Country of focus:

Somalia, South Central Region

Transformative investment of focus:

Strategies to Reach: per the GRISP Guideline, this, particular to the Somalia context, will focus on tailored strategies and technologies that identify under vaccinated and unvaccinated persons and regularly provide them with the vaccines they need. It will encompass delivering immunization services in an integrated manner using opportunities that present themselves and will have key components including staff capacity building and provision of vaccines.

The strategies related to the “Strategies to Reach” transformative investment:

Identify and examine reasons for unvaccinated and undervaccinated populations

Investigate and address cultural, societal and behavioral barriers or confidence gaps in immunization

Explore health worker-client interactions, perceptions and practices

Improve the friendliness, convenience, efficiency and quality of services at health facilities

Use VPD surveillance and campaign monitoring opportunities to identify unvaccinated and undervaccinated children

Find “invisible children” left out of any system

Update microplans to ensure that all communities are included and targeted within session plans

Prioritize services to reach the largest number of unvaccinated

Revitalize and provide adequate resources for outreach services

Apply Periodic Intensification of Routine Immunization (PIRI) in settings requiring rapid, short-term coverage improvement or “catch up” missed vaccinations

Expand target age groups for routine immunization to cover the life-course and increase opportunities to vaccinate

The three strategies prioritized specific to the Somali context:

Identify and examine reasons for unvaccinated and undervaccinated populations

Use VPD surveillance and campaign monitoring opportunities to identify unvaccinated and undervacinated children

Update microplans to ensure that all communities are included and targeted within session plans.

Reasons for selection of the above strategies:

Summary:

For the past three decades, protracted armed conflict in Somalia along with drought and famine, has resulted in mass displacement and a crippled health system. In urban Mogadishu, home to more than 369,000 internally displaced Somalis, only a small percentage of women and children present at a facility for immunization and family planning services. Those that do arrive may not receive the health benefit of the service if they are required to return for follow-up visits. As a result, children are at increased risk of sickness or death from vaccine-preventable diseases.

Context in Somalia:

Somalia remains one of the largest humanitarian crises in the world. Civilians in Somalia, enduring abuses by warring parties and dire conditions, continue to bear the brunt of the country’s long-running conflict. As a result, more than 1,029,000 people have been displaced since November 2016[1], with 174,603 residing in Mogadishu. The country is also currently in the midst of severe drought, and 6.2 million people – half the country’s population – are now facing acute food insecurity and impending famine.

The absence of coherent government and security over almost three decades has left the country at the low extreme of global rankings on child and reproductive health indicators. It is estimated that one in every seven children dies before their fifth birthday, with a higher number in south and central Somalia where Mogadishu is located. In addition, the current immunization coverage is extremely low: 42% for the third dose of pentavalent vaccine, and 46% for measles.

Problem rationale:

Like in many other contexts, health workers in Somalia are only able to serve patients directly in front of them; in other words, only those people who arrive at health facilities receive care. In fragile and crisis-affected contexts, only a small percentage of the population seeks out the health services they need, regardless of accessibility. Even if people do come for a curative or preventive health intervention, they may not receive the benefit of the full service if they are required to return for follow-up visits. This results in serious inefficiencies and leaves populations highly vulnerable to preventable diseases and deaths. The heart of this problem is two-fold:

1) Facility-based health workers have a poor understanding of their catchment population and cumbersome paper-based tools do not allow them to identify and track individual patients for follow-up.

2) Facilities have weak linkages to the wider population. Community engagement through community health workers (CHWs) is crucial to encourage people to seek and complete the full scope of health services, from the initial visit to any necessary follow-up visits. In contexts like Mogadishu, CHWs have difficulty locating their clients lost to follow-up.

Measuring coverage and equity:

Measuring immunization coverage – or the extent to which people in need of services actually receive care – is key in implementing comprehensive immunization services. This data helps to guide program design, decision-making around resource allocation during implementation and can assist in measuring impact. Similarly, measuring equity in health service coverage is integral to ensuring that vulnerable populations, such as the many internally-displaced persons in settlements throughout Mogadishu, are reached effectively. However, accurate assessments of both health service coverage and equity can be quite challenging, particularly in fragile contexts.

Through the selected strategies, particularly use of VPD surveillance and campaign monitoring opportunities to identify unvaccinated and undervacinated children, and updating microplans to ensure that all communities are included and targeted within session plans, can address some of the challenges faced in measuring immunization coverage as well as the timeliness of access to each service. Through use of innovative technologies, plus codes (associated with mobile data entry) can be used to help populate user-friendly maps, enabling program managers, health providers and CHWs to understand which geographic areas and populations are being underserved or lack access. Directing community mobilization and targeting service outreach based on accurate coverage data can then in turn help to narrow both these disparities.

Snapshot of the catchment population areas served by the IRC in Mogadishu:

Facility	Total population served	Immunization eligible children
Arif	70,000	2,100
Karaan	80,000	2,400
Korsan	36,000	1,080
K8	38,423	1,153
K12	30312	909
Total	254,735	7,642

Helping clients lost to follow-up return for care:

Maintaining continuity of care for immunization is critical to ensuring protection from vaccine-preventable illness and death in infants. However, too often mothers and their children miss their follow-up appointments for a number of different reasons. CHWs play an important role in helping health facilities track down clients who miss their follow-up appointment, reminding them to return to the facility for care.

In urban and densely populated settings like Mogadishu, it can be difficult for CHWs to track down clients lost to follow-up. Seasonal movements into and out of residential areas renders tracing of clients requiring vaccination and family planning, including those who have defaulted, difficult. Mogadishu lacks proper urban planning, further complicating efforts geared towards mapping the locations of clients. Within the urban context, community leaders are at a greater disadvantage than their rural counterparts in the identification of defaulters, since they report having less time to devote to voluntary services and have less influence on community behavior. Competing priorities and high migration rates of urban families also tend to reduce the utilization of health services. Furthermore, some clients use different names in the facility and at the community level, thus making it difficult to identify them within the community. There is also unwillingness of some clients to be followed up at home due to stigma associated with being perceived as sick, making it even more critical that a community health worker does not have to engage other community members to locate the client. Defaulter tracing information can also be affected by the poor quality of existing information systems which often lack crucial identifying or health information. Ongoing conflict in Mogadishu limits access to some locations, further complicating CHWs' efforts to conduct defaulter tracing and household visits.

The integration of and updating microplans into existing technologies and leveraging these, such as the extensive and functional mobile network in Somalia would be part of using the VPD surveillance to identify unvaccinated and undervaccinated children, including immunization clients lost to follow up and refer them back to the facility for continuation of care.

[1] UNHCR Somalia- Drought displacements in period 1 Nov 2016 to Sept 2017

3 OCHA humanitarian Bulletin March 31