We conducted a mixed methods study with qualitative and quantitative methods including 10 semi-structured KIIs, a FGD during the SWOT analysis, and a budget impact analysis of the implementation of JHAVP campaigns based on the health district accounting system and the previous JHAVP reports.
The main questions asked were:
What are the main strengths and weaknesses of the JHAVP, how was it coordinated, what are the provided services and was it adapted to the nomads’ context?
What are the main lessons learned from the JHAVP and how was it perceived by the local population?
What are the main financial and implementation challenges facing the JHAVP and does it have a future?
The feasibility of the programme was analysed with regard to acceptability, implementation and adaptation to the local context (22).
Acceptability
The acceptability of this approach has been the subject of on-going assessments by immunization campaign teams. Meetings were regularly held to evaluate the JHAVP activities to which the representatives of the nomads were invited.
"Indeed, during the implementation of the JHAVP, we did an evaluation meeting of the activities we had to organize and the reaction of this community is that this kind of activities should be repeated more often, because they think it’s good to bring an additional package of services that is often goes beyond vaccination". (Head of an NGO)
This tendency among nomads to prefer the JHAVP was confirmed by a regional health official in the province of Moyen-Chari.
"I think this programme was much appreciated by the nomads, because after the activities we tried to hold meetings with the various actors to determine the bottleneck that prevents the children of the nomads to come to vaccination. And they (nomads) have spoken in favour of joint vaccination which is an opportunity for them to benefit from its activities. "
Unlike other vaccination campaigns (outreach strategy and routine immunization), the JHAVP starts with an official gathering where high authorities, the Minister in charge of Public Health and the Ministry in charge of Livestock, participates and advocate for vaccination. The presence of these authorities provides an incentive effect since they represent a mark of consideration which the nomadic populations generally find lacking.
The acceptance of the JHAVP by nomadic populations was confirmed by officials and nomads’ representatives.
"The joint vaccination approach has paid off, as long as it has mobilized resources. Seeing the results, we have never reached this coverage level in our routine immunization activities. I do not have the number in mind, but the approach has allowed us to reach nomadic children who have never been vaccinated since they were born until the age of five ". (Delegate, province of Moyen-Chari)
A representative of the nomads participating in the workshop agreed in the same direction confirming that:
"On the side of the nomads where I am the representative, everyone is on the same wavelength as this joint vaccination operation is beneficial and everyone wants it to happen every year."
Implementation
The coordination between the public health and veterinary services at central and decentralized level was found to be a key element in the success of the implementation of the JHAVP.
"There are many consultations between the two ministries during the implementation of this approach. I wanted to say that when it comes to a disease that is common between humans and animals, the two ministries always meet to think about the strategies to adopt". (Delegate, province of Moyen-Chari)
The strategy of organising the vaccination campaigns for humans and animals combined into one single activity in a central place brought positive effects according to nomadic communities. This gives the nomads the opportunity to interact with other communities and to trade goods which was an efficient way to motivate these communities to participate in such activities. This was noted by a health service worker who took part in the JHAVP held in 2013 in the Danamadji health district.
"It was a great joy, a great reunion. Breeders who have separated from each other for a long time have found themselves together again. (….), nomads often like these kinds of opportunities because it allowed them to access health services to their children, their pregnant women (....)".
Adaptation
Involving social mobilization teams from within the nomadic communities is one of the strategies used to adapt the JHAVP to the socio-cultural and health context of these communities. The report of the last JHAVP stated that a total of 36 social mobilizers were identified among nomads’ representatives and trained in the Danamdji and Kyabe health districts.
It is well-known that one of the basic characteristics of nomadic communities in the Danamadji health district is the low access to health services in general and immunization in particular (10). Depending on the severity of the conditions, nomads would consider attending public health facilities to seek care. However, as reported by Abakar et al. [ref] they were discouraged either by the cost of care, or the possibility of facing discrimination (8). Therefore, providing joint human and animal health services in an additional package of health services beyond vaccination is a mean to adapt the JHAVP to the specific needs of nomads.
"We intervened by bringing a joint package of human and animal vaccination and taking care of the mothers at the camps level. Our teams have nurses within them to make rapid consultations for the sick people. Also, our teams have some drug supply to take care of the minor health problems". (An NGO representative)
This is also confirmed by a delegate from the province of Moyen Chari who adds:
"The joint vaccination strategy is not just about vaccination. We take advantage of this approach to do primary prevention against malaria, deworming of nomadic children and vitamin A supplementation. We also do pre-natal consultation. In short, we were able to reach these communities with activities that, without this approach, would be difficult to achieve".
SWOT analysis
Table 3. summarizes the main findings of the SWOT analysis realized during our study.
Table 3
| Opportunities - Political stability - Political good willingness with regard to JHAVP - Funders adherence to the approach | Threats - Security - Scarcity of funds - Natural catastrophes - Breeders agricultures conflict |
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Strengths - Existence of framework - Availability of personnel - Coordination at all levels | SO strategies - Establishment of inter-sectoral dialogue framework - Holding donors meetings for mobilization of additional funding | ST strategies - Establishment of inter-sectoral platform for collecting and analysing information needed to anticipate potential threats - Promotion of dialogue between communities (sedentary and nomads) |
Weaknesses - Absence of legal basis - Insufficient funds - Absence of additional health intervention (rabies, CBPP, etc.) | WO strategies - Establishment of inter-ministerial entity for the implementation of JHAVP - Advocacy for resources mobilization | WT strategies - Establishment of a legal basis to the JHAVP - Advocacy for resources mobilization |
Strengths
Although JHAVP is implemented informally (it does not yet have a formal institutional framework that can guarantee its sustainability), it still has strengths that allow it to survive and continue to provide a number of services to nomadic populations and their livestock.
Existence of financial support from donors
One of the conditions for the sustainability of any health programme, such as the JHAVP, is the availability of financial resources. Indeed, such a health programme requires substantial financial resources. "Yes, there is funding", a delegate from the province of Moyen-Chari said. The delegate further added "When there is a strong political will, it means that the finances will follow as well".
Even though there is not yet a substantial governmental funding for the programme because a special service for this purpose is still lacking, there are some NGOs working in this field for more than a decade. Additionnaly, other NGOs and UN agencies can provide financial support for the JHAVP, although this may not be enough to ensure its regularity.
"(...). Because I know that there is now in Moyen-Chari, many projects like the Programme d’appui aux districts sanitaires au Tchad (PADS), there is also the project led by IRED (AHPSR) and the health project of the mobile pastoralists in Central Africa lodges at the CSSI. There is also the MSF who is intervening". (An NGO representative)
Existence of a reference framework document
The existence of a reference framework document adopted by the Government of Chad to define inter-sectoral support programmes to nomadic communities was considered as strength. Although the various objectives and recommendations contained in this document are not yet translated into practice, this document constitutes a reference framework to which the various actors working in support of nomadic populations can refer for the implementation of health approaches and other integrated activities for the benefit of nomadic populations and their livestock.
Existence of the programme of health of nomads (PNSN)
This institution is created to serve as a framework for reflection, orientation, and planning of health activities for nomadic populations and, in a broad sense, hard to reach populations.
"Well, if I have one last thing to add, it may be a suggestion. It is to advocate with the Ministry of Health so that all actors involved in the nomadic health sector can get around this programme, work in synergy. The interventions of certain partners, notably the NGOs, must not be allowed to escape the national coordination of the PNSN, which is today the nomadic health programme which is for us a key partner and which already shows the good will of the government to appropriate the thing. (…)" (An NGO representative).
Availability of qualified vaccinators and supervisors
Indeed, although the logistics and per diem was always financed by NGOs, the management of these vaccines is largely the responsibility of the health and veterinary officers. Apart from the few people recruited as community health workers responsible mainly for communication, most vaccinating agents are qualified government personnel.
"At the level of the health districts, there is the District Medical Officer (DMO) who coordinates activities at the district level. When we go out here and we go for the vaccination, he knows that in such a place it is such person who goes to vaccinate. There is an implementation plan. At the regional level, the delegate coordinates. I remember when I was in Danamadji, it was the DMO who was in charge of coordinating our activities at Danamadji level. "
Weaknesses
Although its regularity is not assured (since its first implementation in 2000, it has only been executed two or three times), the JHAVP benefited from factors which guaranteed its survival. However, it has some weaknesses such as lack of a proper institutional framework, insufficient financial support, lack of implementation infrastructure and lack of socio-anthropological study among nomads to improve the performance of this approach.
The non-institutionalization of JHAVP
Although JHAVP seems to be well appreciated by nomadic populations, this initiative suffers from several disabilities which could undermine its regularity and sustainability. One of the weaknesses is the non-institutionalization of the programme. Indeed, the programme is a transverse health operation between the Ministry of Health and the Ministry of Livestock, but there is a lack of a transverse institution with a legal basis capable of managing the integrated health of nomads and their livestock, as a regional delegate rightly observed:
"There is no proper framework for managing this integrated human and animal health operation. Until then, now the things worked based on the good relationships between the human and animal health authorities that we are"
This concern is widely shared by the relevant service officers in, human health and animal health, such as a regional delegate who offered this suggestion:
"And here I think it is necessary to think about creating a formal framework of consultation in order to manage this issue of human health and animal health, for example an inter-ministerial decree"
Insufficient financial resources
As there is not yet an institutional service within the districts implementing JHAVP, there are not sufficient financial resources from the government. Most of the operational costs are covered by external donor’ contributions.
"Now, the weaknesses are insufficient funding especially from the government. It is an activity that should be consistently applied, because interrupting it for a year or two is a handicap". (Provincial delegate, province of Moyen-Chari)
Construction of fences for livestock vaccination is a bottleneck
The nomadic populations in Chad including those in Danamadji are very invested in their livestock, as confirmed by a vaccination programme officer in the region:
"Yes indeed, the statement of nomadic communities better vaccinates their cattle than their children are true. This can be justified by the absence of nomads in the immunization service. Everywhere in the health centres, we do not notice the presence of the nomads."
Therefore, the success of JHAVP depends on the success of animal vaccination, as one NGO official states. Animal vaccination is set up as a gate of entrance to the nomadic populations who are looking for any initiative for the health of their livestock. Thus, it was thought that by offering them the opportunity to come to vaccinate their cattle, human health workers could vaccinate their children. Meanwhile, the success of animal vaccination depends on the availability of vaccination fence (park or enclosure) which creates some problems:
"Among the challenges, there is the question of the enclosure (...). You know at the bush there, if you want to make an enclosure with the woods, you will have problems with the agents of waters and forests. Not long ago, the Livestock Delegate told me to do an enclosure and as soon as it was done with the woods, we had problems with water and forest agents. (…) and I ended up paying something to solve problem". (A nomads’ representative)
Budget impact analysis (BIA)
The main budget characteristics of the mixed campaign are represented in Table 4 and Table 5 in USD (1 USD = 616 FCFA, January 2017). Table 4 presents resource consumption in natural units and the corresponding unit costs for a mixed vaccination campaign realized in 2016 in the study district. The total cost of the outreach event was 17’328 USD with 1684 children vaccinated. Table 5 shows an overview of the main cost categories: transportation is the budget category with the greatest weight followed by personnel and logistics (e.g., basic equipment including chairs, tents, and refreshments for participants). Considering costs incurred only at the district level (excluding personnel costs at regional and national level), the total cost was 14’384 USD.
Table 4
Composition of the main cost categories for a mixed vaccination campaign realized in 2016 in the study district
| Unit | Quantity | Unit price | Total cost (% fixed) |
---|
Transportation |
Fuel | Litres | 1750 | 0.97 | 1697.5 (0) |
Car rentals | Days | 52 | 121.75 | 6331 (0) |
Logistics |
Social mobilisation | Lumpsum | NA | NA | 487 (1) |
Tents | Day*quantity | 20 | 8.1 | 162 (0) |
Chairs | Days*quantity | 200 | 0.24 | 48 (0) |
Mats | Lumpsum | NA | NA | 146 (1) |
Blankets | Lumpsum | NA | NA | 156 (1) |
Public adress system | Lumpsum | NA | NA | 81 (1) |
Refreshments | Drinks | 1684 | 0.2 | 336.8 (0) |
Personnel / administration |
Supervisor national program | Person days | 91 | 49 | 4459 (0) |
Supervisor regional program | Person days | 20 | 24 | 480 (0) |
Supervisor district | Person days | 20 | 16 | 320 (0) |
Midwife | Person days | 20 | 16 | 320 (0) |
Community worker | Person days | 40 | 8 | 320 (0) |
Human vaccinator | Person days | 40 | 10 | 400 (0) |
Animal vaccinator | Person days | 40 | 10 | 400 (0) |
Recorder | Person days | 40 | 8 | 320 (0) |
Drivers | Person days | 36 | 24 | 864 (0) |
Total costs | | | | 17'328.3 |
Table 5
Cost characteristics of a joint vaccination campaign in Danamadji
| Total costs (USD) | Total costs district (USD) | Share public health sector | % fixed | Average costs per child (public health sector, USD) | Marginal costs per child(public health sector, USD) |
---|
Transportation | 8028.5 | 8028.5 | 50% | 0% | 2.38 | 2.38 |
Logistics | 1416.8 | 1416.8 | 50% | 57% | 0.42 | 0.16 |
Personnel | 7883 | 2944 | 79% | 0% | 1.28 | 1.28 |
Total | 17’328.3 | 14’384.3 | | | 5.55 | 5.29 |
The allocation of the costs of resources used to the veterinary and public health sector is based on equally divided shares for the transportation and the logistics category assuming comparable utilization of these basic inputs. Personnel costs were distributed proportionally according to health workers present during the campaign, with 79% being allocated to the public health sector. The share of fixed costs was rather low and only applicable to costs related to logistics (57%), which is the budget category with the lowest share in total costs (Table 5). Accordingly, it can be noted that, apart from the logistics category, marginal costs correspond to average costs which indicates little room for economies of scale. Average cost per vaccinated child (without costs of vaccines) was around 5.50 USD.
Table 6 shows the budget impact of realizing one intervention over a one-year time horizon. The district target population was calculated based on the demographic parameters presented in Table 2. Incremental costs were computed by extrapolation, multiplying the marginal cost per child for each cost category (Table 5) with the number of the target population while fixed costs were held constant. The total incremental budget impact was 27% meaning that the realization of one JHAV campaign would use up almost one third of the district’s allocated funds. Assigning the different types of expenditures to their corresponding budget category shows that the burden is especially high with respect to human resources, where costs for personnel exceed the respective budget line by almost half (153%).
Table 6
Incremental budget impact of combined vaccination campaigns for the public health sector at district level
| Incremental costs at district level (USD) | Incremental budget impact | Incremental budget impact per budget category |
---|
Transportation | 4172.6 | 15% | 23% |
Logistics | 1154.1 | 4% | 51% |
Personnel | 2236.3 | 8% | 153% |
Total | 7562.0 | 27% | |
Figure 1 examines the financial consequences over time where a combined vaccination campaign is conducted every year and assuming a constant population growth rate of 3%. More specifically, in Table 6, incremental costs for each year are computed by multiplying the marginal costs with the number of the target population assuming a yearly demographic increase of 3% while fixed costs are held constant. Figure 1 shows that the budget impact of logistic expenditures decreases considerably over time due to the high share of fixed costs as inputs can be reused over the course of time. However, as shown in Table 5, transportation and personnel expenditures are fully variable and therefore increase over time due to higher workloads based on an increasing target population. In total, the impact of the intervention on the district budget decreases slightly from 27–26%. Thus, with the share of fixed costs being relatively low, efficiency gains from scale effects over time are limited.
Deterministic sensitivity analysis was applied to assess uncertainty in key parameters. The upper and lower bounds were defined based on 20% deviation from the baseline value in marginal costs for transportation, logistics and personnel. The tornado diagram (Fig. 2) shows that incremental overall budget impact varies between 3% for variations in transportation costs and 0.2% for variations in logistic cost.