Integrated approaches to immunisation and other health services for maternal, newborn and child health in resource-constrained settings

Abstract

Background Integrating immunization and other health services during infancy could dramatically expand access to health care. During the first year after childbirth, immunisation services reach over 115 million families globally, at a point in the life-course where disease prevention, nutrition, and other preventive services can have high impact. Immunisation coverage could also benefit from integration, when catch-up vaccination is incorporated into illness or other care. There is encouraging evidence for malaria, HIV, or family planning programs and many global strategies advocate integrated services, especially for resource-constrained settings. However there are significant unresolved implementation questions, such as how best to link services, avoid staff overload, and maintain quality. Some attempts at integration fail to achieve expected benefits due to difficulties in re-organisation of services, or unexplained gaps in demand for and uptake of new arrangements.

Methods This researched focused on low- and middle-income countries, using methods from health policy and systems research. Firstly, a new systematic review of global evidence examined outcomes and processes in controlled studies attempting integration of other services with infant immunisation. Secondly, in rural Papua New Guinea (PNG), integration questions were nested in a prospective observational cohort study following 699 mother-infant pairs from first antenatal visit until 12 months after childbirth. Repeated assessments examined co-morbidity and preventive care needs, experiences of integrated services, and a unique open exploration of women’s preferences for future integration. Thirdly, a cross-sectional health services assessment, in the same setting, examined integration practices and preferences of health managers and front-line staff. Integration of Immunisation and Other Services

Findings Review of global evidence documented new work integrating family planning, HIV, malaria and nutrition. Most linked services benefited, with mixed outcomes for immunisation. A new typology of integrated services emerged, with richer detail on what determines success. In PNG, need for integrated care is high but provision is low. PNG women’s preferences surpassed current evidence, policy and practice; seeking addition of maternal illness care, comprehensive child illness care, better education on important disease threats, and sexual and reproductive health care. They had many insights for improved implementation of integrated services. Women privilege holistic quality care over savings in time and money, although the latter are valued. Acceptability is not universal, with sensitive topics needing careful management.

The existing immunisation program in PNG offers some integration opportunities, but meeting women’s preferences will require additional investments in planning and staffing. Synergies when strengthening immunisation for integration may also expand routine coverage and capacity to support emergency responses. Priorities include addressing maternal health during immunisation clinics, integration of nutrition, family planning and immunisation in the first and second years of life, and reducing missed opportunities for vaccination during illness care.

Conclusion Integration of other services with immunisation in infancy should be pursued; first because it can offer holistic care for the multiple health needs in families, and then for potential efficiencies. Implementation details, especially addressing users’ preferences, are critical to success. Better understanding of families’ needs and preferences is essential to health planning, as more responsive services offer pathways to system resilience and universal coverage.