Understanding Community and Health Worker Perceptions of Integrated Health Services with Routine Immunizations in Mali Open Access

Abstract

Understanding Community and Health Worker Perceptions of Integrated Health Services
with Routine Immunizations in Mali

Author: Kelli Cappelier

Thesis Advisor: Saad B. Omer, MBBS, MPH, PhD

Background: There has been great success in addressing vaccine preventable diseases
through the Expanded Programme on Immunizations (EPI); however, this success has not
translated into the delivery of other cost-effective interventions that can contribute to
reducing child morbidity and mortality. There is increasing interest to build upon the
expansive routine immunization (RI) network to increase the reach of other health
services through integration into the routine immunization program.

Objective: This study was conducted to better understand community preferences and
perceptions for integrated health services at the health facility level through community
and health worker perceptions of integrated service delivery using immunizations as a
platform in Mali.

Methods: A qualitative cross-sectional study in seven urban and rural sites in three regions, comprising 16 in-depth interviews with health workers and key informants;12 focus group discussions with mothers, fathers, and paternal grandmothers; and 25 exit interviews with mothers leaving the health facility.

Results: Community members and health workers support an integrated delivery
structure, with preferred interventions including: vitamin A supplements, Insecticide
Treated Nets, growth monitoring, educational discussions, Ante- and post- natal
consultations, and cooking demonstrations. Services preferred to be separated include
HIV/AIDS related services and family planning.

Discussion: The integration of additional health services should not negatively impact
the EPI programme, but work to strengthen both the interventions and routine
immunizations. The research confirms RI is the primary reason women visit the health
facility, reinforcing the use of RI as a suggested platform for integrated services. The lack
of human resources, training and supervision, stock-out, and poor service delivery
structure are major barriers to efficiently and consistently delivering the services
provided. Access to services through consistently maintaining supply and expanding
outreach programmes is an important component to ensure equal distribution of services.
Availability of services and the quality of service delivery are important to
ensure the number of services integrated and how they are integrated are not
compromising the quality of service delivery by offering too many services.

Table of Contents

TABLE OF CONTENTS

1.0 INTRODUCTION ......................................................................................................................................................1

2.0 BACKGROUND.........................................................................................................................................................3

2.1 Mali .......................................................................................................................................................................3

2.1.1 Mali Health Profile.................................................................................................................................................. 4

2.1.2 Mali Health System Profile .......................................................................................................................................6

2.2 Expanded Programme on Immunizations........................................................................................................................ 9

2.3 Millennium Development Goals ...................................................................................................................................13

2.4 Child Survival .........................................................................................................................................................13

2.5 Vertical and Horizontal Health Delivery Structures .........................................................................................................14

2.5.1 Vertical Health Delivery Structure ...........................................................................................................................15

2.5.2 Horizontal Health Delivery Structure ........................................................................................................................16

2.5.3 Vertical vs. Horizontal ..........................................................................................................................................16

3.0 LITERATURE REVIEW .............................................................................................................................................18

3.1 Integration ............................................................................................................................................................18

3.1.1 Integration Platforms ...........................................................................................................................................19

3.1.2 Potential Integration Benefits .................................................................................................................................22

3.1.3 Potential Integration Challenges .............................................................................................................................24

3.1.4 Key Considerations for Integration ..........................................................................................................................28

3.1 Integration in Africa ................................................................................................................................................28

3.2.1Integrated Management of Childhood Illness ..............................................................................................................30

3.2.2 Accelerated Child Survival & Development Programmes ..............................................................................................31

3.3 Integration in Mali ..................................................................................................................................................31

4.0 DATA AND METHODS ............................................................................................................................................36

4.1 Overview .............................................................................................................................................................36

4.2 Site Selection .......................................................................................................................................................36

4.3 Data Collection .....................................................................................................................................................37

4.4 Data Analysis ........................................................................................................................................................41

5.0 RESULTS ..............................................................................................................................................................42

5.1.1 Integration in Bamako, Kayes and Sikasso ................................................................................................................44

5.1.2 Vaccine and Integration Perceptions .......................................................................................................................46

5.1.3 Vaccine and Integration Benefits............................................................................................................................ 47

5.1.4 Vaccine and Integration Concerns: Access ...............................................................................................................48

5.1.5 Vaccine and Integration Concerns: Supply ...............................................................................................................49

5.1.6 Vaccine and Integration Concerns: Service Delivery ..................................................................................................50

5.1.7 Vaccine and Integration Concerns: Human Resources and Health Worker Capacity..........................................................54

5.1.8 Vaccine and Integration Concerns: Incentives ..........................................................................................................57

5.1.9 Integration Preferences........................................................................................................................................ 57

5.1.10 Support to Separate Services............................................................................................................................... 60

5.1.11 Making Integration Decisions ................................................................................................................................64

6.0 DISCUSSION ........................................................................................................................................................65

7.0 PUBLIC HEALTH IMPLICATIONS .............................................................................................................................70

8.0 RECOMMENDATIONS .............................................................................................................................................71

9.0 REFERENCES ........................................................................................................................................................73

10.0 APPENDICES ........................................................................................................................................................I

10.1 Verbal Informed Consent Script: Service Providers ........................................................................................................V

10.2 Interviews at National Level ....................................................................................................................................VI

10.3 Integration at District Level ...................................................................................................................................VII

10.4 Integration with nurses at the health facility level....................................................................................................... IX

10.5 Verbal Informed Consent Script: In-depth Interviews/Exit Interviews...............................................................................XI

10.6 Interviews with Key Informants at Community Level ....................................................................................................XII

10.7 Exit Interview with Mothers ...................................................................................................................................XIII

10.8 Verbal Informed Consent Script: Focus Groups ..........................................................................................................XIV

10.9 Focus Groups at Community Level ...........................................................................................................................XV

10.10 Note Taker Form ...............................................................................................................................................XVI

10.11 Focus Group Debriefing Form ..............................................................................................................................XVIII

10.12 Archival Information Sheet ....................................................................................................................................XI

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Integration, Routine Immunizations, Mali
Committee Chair / Thesis Advisor	Omer, Saad B, Emory University
Partnering Agencies	CDC

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