Health Systems Constraints and Facilitators of Human Papillomavirus Immunization Programmes in Sub-Saharan Africa: A Systematic Review

"...to accelerate universal access to the HPV vaccine for adolescent populations in low- and middle-income regions..., it is important to provide decision-makers with robust systematic evidence of what works (and what does not work) for HPV immunization programmes in sub-Saharan Africa, especially where health systems are concerned."

Some of the major challenges experienced in scaling up the performance of national immunisation programmes (NIPs) in low- and middle-income countries (LMICs) are not necessarily programme specific but, rather, reflect issues with wider health systems functioning. This systematic review provides the evidence of how NIPs and health systems interact by reporting on the health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus (HPV) immunisation programmes as a proxy. HPV vaccines are not widely accessible through NIPs in most sub-Saharan African countries, as compared with other regions of the world.

The 54 full-text articles included in this review reported on studies published between 2008 and 2018 and conducted in 20 countries in sub-Saharan Africa. Six cross-cutting themes are addressed in the analytical model used for the investigation: (i) the governance and policy landscape, (ii) the capacity of the health workforce, (iii) the availability of potent vaccines, cold chain, and logistics systems, (iv) the quality of health service delivery, (v) the state of health information systems and community partnerships, and (vi) the availability of equitable and sustainable health financing.

Most studies (33/54) were primarily concerned with assessing knowledge, awareness, and acceptability of the HPV vaccine among key populations such as adolescents, parents and caregivers, health workers, teachers, and religious leaders (see Table 1 in the paper). The articles also reported on the availability of the HPV vaccine in the relevant countries at the time each study was conducted.

The researchers considered findings pertaining to health systems constraints and facilitators to (i) HPV vaccine introduction into NIPs, (ii) HPV vaccine acceptance and uptake, and (iii) the overall performance of HPV immunisation programmes, including existing nationwide programmes or demonstration projects and future HPV immunisation programmes. Some of the key findings related to communication include:

• The governance and policy landscape - The available evidence highlights the importance of clear governance and management structures, the involvement of political champions, the support of policy influencers (including governmental and non-governmental organisations - NGOs), and the role of strong and inclusive partnerships to the optimal performance of HPV immunisation programmes in sub-Saharan Africa.
• The capacity of the health workforce - Health workers' limited knowledge about the safety of the HPV vaccine was reported to negatively impact on their acceptance of the vaccine for their adolescent daughters, as well as their ability to recommend the vaccine to their clients. In contrast, where health workers received adequate training, it was reported they were capable of providing sound recommendations about the HPV vaccine to clients, thereby positively influencing the acceptance and uptake of the vaccine. Additional facilitators of HPV immunisation programmes included the involvement of well-trained school health teams as well as community health workers, who were reported to play a key role in health promotion and social mobilisation for HPV immunisation programmes.
• The quality of health service delivery - To mitigate challenges, a mixed vaccine delivery model that involves coupling the school-based strategy with community outreach immunisation campaigns is recommended in the literature. Availability of well-functioning NIPs can instil trust in immunisation and improve vaccine acceptance and uptake.
• The state of health information systems and community partnerships - Some constraints include:
  • Inadequate sensitisation campaigns, leading to low level of awareness about the HPV vaccine and the vaccination programme;
  • Weak or absent engagement with fathers and male teachers;
  • Poor access to information about HPV, cervical cancer, and HPV vaccine for individuals living in hard-to-reach communities and among populations with low literacy levels;
  • Low level of knowledge about safety and effectiveness of the HPV vaccine;
  • Misinformation about the side effects, safety, and benefits of the HPV vaccine;
  • Misconceptions about other vaccines;
  • Negative media reports and interference; and
  • Exclusive reliance on paper-based vaccine records.

  Some facilitators on this front:

  • Evidence-based health promotion strategies involving intensive community mobilisation and sensitisation;
  • Effective community engagement involving key stakeholders: adolescents, parents (including fathers), teachers, and municipal and religious leaders;
  • Adequate information, education, and communication (IEC), especially on vaccine safety and efficacy issues, with a priority on hard-to-reach communities;
  • Consideration for culturally appropriate communication about HPV, cervical cancer, and HPV vaccination;
  • Adequate communication about all vaccines; and
  • Strong surveillance of adverse events following immunisation (AEFIs).
• The availability of equitable and sustainable health financing - It was reported that a substantial cost component was required to train health workers, organise effective social mobilisation and community sensitisation campaigns, and deliver the vaccine through the school-based strategy.

Reflecting on the review, the researchers note that there is evidence "to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success." However, "significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts....While these health systems facilitators (strong political endorsement, clear governance structures and partnerships with global partners) have achieved some progress for HPV immunization programmes in sub-Saharan Africa, the region continues to fall short in meeting global targets for implementing HPV immunization programmes."

Although this systematic review assessed health systems constraints and facilitators to HPV immunisation programmes, the researchers assert that the findings could be relevant for scaling up NIPs in general. For example, barriers to accessing vaccines due to ineffective service delivery, staff shortages, lack of awareness about vaccines, weak engagement with key stakeholders, and poor governance and policy structures have been suggested to negatively impact on the performance of NIPs in most LMICs, and the findings of this review are in support of this.

In conclusion, the researchers call for an expansion of the research agenda to include a comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa. "By providing a better understanding of what works - and does not work - for NIPs, health systems strengthening initiatives could be better designed to adequately respond to the burden of vaccine-preventable diseases in sub-Saharan Africa."