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‘Last-Mile’ vaccine initiative increases immunization coverage in Uganda

By Justine Landegger, IRC health technical adviser

During the last two decades, substantial improvements in immunisation coverage have occurred due to vaccine technology, cold chain equipment, and targeted global financing. But the job is not finished: total vaccine coverage in developing countries has stagnated around 80 percent. Recognising this gap, the International Rescue Committee (IRC) is working to introduce user-friendly technology to facilitate monitoring and follow-up for children—particularly in the most remote areas—who may have not yet received the critical vaccines to protect them. The IRC is rolling out its project, “Reaching the Fifth Child,” across three districts in rural northern Uganda where the IRC has been active since 2000. The project aims to empower both facility- and community-based health workers (CHWs) with the tools they need to increase immunisation coverage.

In June 2015, the IRC selected one sub-county comprising three health facility catchment areas to pilot this ‘last mile’ strategy as a sub-set of the larger immunisation project. The IRC introduced a smartphone application, or mHealth tool, using tailored CommCare software. The application developed a localised immunisation information platform to allow facility-based health care workers to more easily identify and follow up those children that may have missed (or defaulted on) one or more of their vaccination.

Before this pilot, facility-based immunisation service providers did not have actualised/accurate denominators, or targets, of the children under the age of one year that needed to be reached in their catchment areas. Moreover, if they wanted to identify and follow-up with defaulting children, facility-based immunisation service providers had only one option: to go through the cumbersome paper-based immunisation register, line by line, and potentially leave the facility to search for the children and neglect their other responsibilities.

Not only is mHealth based on an accurate denominator, but it also auto-generates lists of children both due for vaccinations in the coming week and those that already defaulted. The larger strategy that the IRC is piloting formally involves CHWs in defaulter tracing and follow-up, enabling 1) CHWs, as trusted members of their communities, to meet with the caregivers of defaulting children, and 2) facility-based staff to remain at their post to provide other life-saving services. CHWs receive lists of children due for vaccination or that have defaulted by the facility-based staff. They then visit these children and their families at their home and refer them to the closest health facility and also inform them of the date of next immunisation outreach session in their village.

Initial evidence from this pilot shows that both facility-based health workers and CHWs find the new strategy to be feasible and acceptable for integration into the broader health system. As of December 2015, 106 of the 111 children identified as defaulters—or 95.5%—of a total 613 children targeted in the pilot area were successfully followed up, had their caregivers counselled by CHWs as needed and based on the given reason for default, and received the necessary vaccinations to be protected and remain on-track with their immunisation schedule.

“This [study] is helping to decrease the number of children in my village without vaccination,” said CHW member Alex Okumu during a round of qualitative evaluation. “When I track a defaulter child, I give the caregiver a referral form so the child can get vaccinated. The caregiver takes this very seriously.

Quantitative results from the end line data collection of this pilot study will be available by mid-May 2016, after the coverage survey ends in April.

This project was funded with UK aid from the UK government.