77 - How to evaluate COVID-19 vaccine service integration into routine immunization and primary health care? Featuring one story based on a mixed-methods evaluation from DRC

Abstract Information: While the integration of COVID-19 vaccination into primary health care (PHC) and routine immunization (RI) offers the promise of increased efficiencies, additional resources, and increased access to health services it also poses several challenges including the potential for COVID-19 vaccine hesitancy to turn people off of critical RI and PHCs, the increased workload for those supporting vaccination efforts, and the additional strain to supply vaccine chains and health information systems. This roundtable will aim to answer the primary question: what approaches, methods, and frameworkers are most appropriate to evaluating integration of COVID-19 vaccination into PHC and RI? The presenter will briefly describe relevant integration frameworks from literature such as that described by Grépin and Reich in 2008 and share the story of using co-creation and human-centered design approaches to integrate COVID-19 vaccination services in six demonstration sites in the Democratic Republic of Congo (DRC) as a means of prompting discussion with a concrete example.
There is little research and experience on how to integrate COVID-19 vaccination into PHC and RI without compromising vaccination coverage and the utilization of other services. Dudley and Garnder’s 2011 systematic review found that integrating vertical programs into PHC actually decreased patient utilization of and patient satisfaction with vertical health services. There are also few guidelines for monitoring and evaluating this integration apart from preliminary WHO guidance. In this sense, COVID-19 presents a novel challenge for health systems that funneled resources away from PHC and RI to prioritize COVID-19 services. For these reasons, a discussion is warranted on what evaluation approaches and frameworks are relevant to the current integration challenge. Evaluations can take several angles. For example, just how integrated is a service into PHC when considering communication, colocation of services, and practice? At what level is the integration taking place within a health system and what functional component domains of the system are being integrated? How have integration activities changed the structure or the processes of service delivery, whether intended or not?
Participants will be invited to discuss key questions relevant to monitoring and evaluating integration of COVID-19 services in low- and middle-income country (LMIC) contexts such as: what health integration frameworks are most relevant to such interventions? What structural and procedural aspects of integration should be highlighted? How might the interventions and therefore measurement approaches differ across LMIC contexts?

Relevance Statement: Three years after the COVID-19 pandemic began, public health systems around the world are still grappling with how to integrate preventive COVID-19 services into primary health care and routine immunization. At the time of writing, the WHO’s preliminary guidance on the subject is less than a year old. While this guidance is helpful, it is not complete with studies that document effective integration approaches in the “post-pandemic” context. Given that integrating vertical programs into primary care may actually decrease patient utilization of and patient satisfaction with vertical health services (Dudley and Gardner, 2011), sharing knowledge of how to avoid the risks associated with COVID-19 integration and capitalize on possible synergies plays a critical role in informing other COVID-19 integration work around the globe. A discussion is warranted on what evaluation approaches and frameworks are relevant to the current integration challenge. Evaluations can take several angles. For example, just how integrated is a service into PHC when considering communication, colocation of services, and practice? At what level is the integration taking place within a health system and what functional component domains of the system are being integrated? How have integration activities changed the structure or the processes of service delivery, whether intended or not?
In this context, the case study of integration from the Democratic Republic of Congo’s Program for Expanded Immunization (EPI) and the USAID-funded MOMENTUM Transformation and Equity of Routine Immunization (M-RITE) project team will be a valuable contribution to the shared knowledge of evaluating assessments of COVID-19 integration into PHC and RI. In addition, it will serve as means of launching a broader conversation about appropriate evaluation approaches for such interventions. Starting in early 2023, DRC’s EPI process included RI planning integration at national and local levels (e.g., national strategy, microplanning), delivering integrated RI services (e.g., fixed-site and mobile outreach vaccination activities), investing in partner MOH health staff, and investing in streamlining COVID-19 data collection through RI channels. A mixed-methods approach, using both survey and interview data, was used to monitor and evaluate this co-creation process in demonstration health facilities. Perspectives of patient communities as well as the narratives of frontline health workers were gathered to understand how integration strategies were adapted across various demonstration sites and what approaches were most successful in restoring gains in immunization and maintaining the pace of COVID-19 vaccination.

Data for this abstract is underway at the time of submission and will be completed before September 2023 as EPI refines its national strategy in collaboration with M-RITE and the integration approach is adapted to different health contexts.