3.1 Descriptive statistics
A total of 40 KIIs were conducted at national, provincial, district and health facility levels in the three HPV vaccine demonstration district sites in the country (Table 3). Of these study participants, 34 responded to the social network and perceived outcomes surveys. Majority of those interviewed were from the Ministry of Health (MOH) (55%) and the Ministry of Education (MOE) (15%) with a larger proportion (35%) being from the district level
3.2 Gavi FCE partnership framework dimensions’ detailed results
3.2.1 Contextual factors and prerequisites
We found that, Gavi plays a key role in driving Mozambique's HPV vaccination delivery partnership, nevertheless other significant contextual factors also emerged as key drivers of the partnership. These are; the country's first lady's involvement as a champion, Gavi's requirement for the NIP to demonstrate feasibility of its HPV vaccine delivery model and schools as the primary location of HPV vaccine administration.
Gavi’s partnership model, is the main driver of the country’s national immunization collaboration which according to interviewed informants historically stemmed from the country becoming a beneficiary of Gavi grants in 2001. The two core Gavi partners WHO and UNICEF, whose task within the Alliance, are to provide in-country implementation support, were referred to by NIP staff as the “traditional partners”. Each organization is known for specific roles, WHO for technical guidance and UNICEF for logistics and supplies, a fact that we learned has influenced the NIP to adopt the practice of allocating specific roles to potential partner organizations that express interest to collaborate with it.
“We are used to working with WHO for technical guidance. UNICEF they usually support us for vaccine logistics and supply” NIP
Two other organizations, VillageReach an international non-governmental organization (NGO) and Fundação para o Desenvolvimento da Comunidade (FDC) a local organization were also considered as “usual” NIP partners and had supported immunization activities for more than five years prior to the HPV vaccine demonstration project launch. Further investigation revealed that that these two organizations had strong ties to Gavi. VillageReach is an American based organization whose funding comes from the BMGF, a founding partner of Gavi. In addition, one of its founding board members has been Gavi’s chief executive officer for seven years, from 2011 to date. FDC`s founding president had also previously been the chair of Gavi’s board for a decade, from its inception in 2001 until 2009. Results qualitative data triangulation, revealed the importance of these Gavi links, to VillageReach’s and FDC’s participation as NIP’s partners in Mozambique’s HPV vaccine delivery demonstration project implementation.
“Invitation for VillageReach (to be NIP partner) was explicit. Especially after the head of NIP understood VillageReach`s work and its relationship with Gavi. She (NIP head) was initially new. The chief executive officer of Gavi used to be board member of VillageReach from the inception of VillageReach. We were invited when they realized the relationship we had with Gavi and the information that VillageReach possesses about Gavi” (Civil Society Organization)
“….for example FDC was already interested in HPV vaccination introduction, from before because its president Machel was a member of the Gavi board for many years” (Research Institute)
In the year prior to the launch of the HPV vaccine demonstration project, Mozambique’s then first lady assumed leadership of the Forum of African First Ladies Against Breast & Cervical Cancer and hosted a conference in Maputo, the country’s capital(36). This position propelled her to become a HPV vaccination champion in both the continent and in-country, with subsequent impact on HPV vaccination pilot partnership. Her championship position influenced the NIP and MOH to take on a leadership role as opposed to the participatory one that both entities had assumed during HPV vaccine grant application writing. Furthermore, MOH leveraged government funds to carry out demonstration activities in two additional districts, instead of only one district that Gavi was funding. Another outcome of MOH leadership, was the disbursement of HPV vaccine introduction grant (VIG) funds from Gavi through MOH and not to Gavi in-country partners, WHO and UNICEF as had happened previously, with pneumococcal vaccine (PCV) introduction grant. KIs noted that, by assuming a leadership role, the MOH became better placed to negotiate how Gavi funds would be received in-country. The expansion in number of demonstration project sites impacted on the HPV vaccination pilot project partnership because it led to increase number of players.
A couple of other contextual factors unique to HPV vaccine delivery model, led to a partnership which differed compositionally from the one observed during other Gavi funded new vaccine introductions in Mozambique. First was Gavi’s requirement for the inclusion of an assessment component to examine feasibility of the delivery model that would be tested during the demonstration project. For this purpose, two research institutions, the Manhiça Research Center (CISM) and the country’s National Institute of Health (INS) were included in the partnership, to lead assessments in Gavi and Government funded districts respectively. The second factor was the nature of delivering HPV vaccine in schools necessitating the involvement of MOE in the partnership. MOE personnel had to carry out specific HPV vaccination activities at all levels from national to provinces, districts and schools.
3.2.2 Partnership Structure
The SNA results for reachability, distance, centralization, betweenness, density, structural holes, redundancy, homophily and average trust are shown in table 4. The network structure was found to contain a total of 50 actors (nodes) and 164 ties.
The reachability score is 100% meaning that there is at least one path connecting all actors in the network and each can be reached from whichever point one starts from (figure 3). The distance score, which is defined as the average number of edges in the shortest path between pairs, at 2.52 is short. Shorter distance in SNA is commensurate with faster and more accurate information flow. Combining the two SNA metrics scores with our first WHO health system governance characteristic hypotheses (Table 2) we can infer a partnership that has the capacity to effectively engage with and handle multiple
scales. The perceived outcome survey scores corroborate this finding (Table 5). At 97.6%, the effectiveness average score was the highest of all outcome survey mean scores. Furthermore, we noted
100% partners’ agreement to three perceived outcome questions; 1) HPV vaccination partnerships ability for better execution, 2) better quality and improved response to challenges when they worked with multiple types of entities and 3) organizational hierarchical levels.
For the second WHO health system governance characteristic hypotheses, the centralization score was found to be neither low nor high at 48%, and average betweenness was 37.24 with a large standard deviation of 110.1. These scores are consistent with the network’s outdegree statistics that revealed
three outlier actors numbers 2, 5 and 24 (figure 3), around which the network is centralized. While actor number 2 had the highest outdegree score, this centralization value, means that the partnership is not highly centralized around 1 focal actor (e.g. EPI program). In addition, the network structure connectivity
scores support the existence of effective relationships between these three key actors, indicating that the partnership could coordinate and respond rapidly to challenges. When triangulated with perceived
outcomes survey results, we found a concordance as 100% of respondents, answered affirmatively for the question on their perception of HPV vaccination partnership’s capacity to respond to challenges which had arisen during project implementation processes (Table 5). Qualitative data further supported the finding (see quotation below).
“The involvement of many organizations was very advantageous because we as the district directorate of health would not have been able to undertake all the activities within the short time that we had to prepare. The partners and their support helped us to reach where we would not have reached, for example sometimes they gave us fuel when we didn’t have and even one hired a boat to reach some islands” (District Health Directorate)
The third WHO health system governance characteristic is the capacity to combine and integrate different forms of knowledge whose hypotheses (Table 2) are based on density and reachability across different spheres and entities. According to SNA diffusion theory, actors in very dense networks have difficulty in accessing diverse forms of knowledge; however density is important for the effective transfer of complex knowledge(37). This network has a low density score of 0.1338, which taken together with the observed diversity of types of entities in the network, distinguished by different colors in figure 3, and the 100% reachability score, mean that actors in this partnership are well positioned to receive new types of information. Further support for this finding comes from contextual qualitative data. KII respondents talked of the implementing partnership for HPV vaccine, being compositionally different from implementing partnerships for traditional NIP vaccines which target children below 22 months of age compared to HPV vaccine’s novel target age group of 9-13 years.
“The target group for HPV vaccine is different so we have to work with different collaborators, for example the ministry of education and partners in the community that helped us to pass the message” (District Health Directorate)
3.2.3 Partnership performance, practices and outcomes
The last three dimensions are interpreted here jointly because our conceptual framework postulates that a partnership's structure determines its performance, practices and consequently the outcomes. SNA measures have so far revealed a network characterized by high overall connectivity that is favorable for rapid and widespread diffusion of information. In addition, trust within the partnership is very high as evidenced by the high tie strength average score of 4.056 which is very close to the upper limit of five on the scale that respondents had been asked to rate professional trust on. Network outcome SNA measures (described in table 2) unveiled an efficient network structure characterized by a high number of structural holes and less redundancy. Majority (85%) of the nodes in the network require only 2 or 3 paths to reach them and 70% have only one way to connect with other nodes meaning that redundancy is only 30%. The network was also found to be heterogenous with a homophily E-I index scores of 0.195.
On triangulation with qualitative and perceived outcomes data so as to facilitate interpretation we found that these topological features of the network influenced partnership practices and subsequently the outcomes. The partnership’s structure heterogeneity significantly influenced partnership practices. The avoidance of duplication of activities or partner organizations focusing on the same activities in the same geographical area emerged as very key to the effectiveness and efficiency of this partnership. Respondents at all levels emphasized the role of regular meetings in the form of a formalized NIP technical working group (TWG) at national level and regular meetings chaired by the head of health at provincial and district levels. Specific roles for specific partner organization was another attribute that respondents repeatedly stated. Remarkably each partner organization was known for a specific role in this partnership. Beyond WHO and UNICEF’s earlier stated roles VillageReach was known as a logistical support partner, FDC for community mobilization and GlaxoSmithKline (GSK) usually supported printing of training material and health worker job aids. Perceived outcomes survey scores added strength to these findings with 88% of respondents agreeing that the partnership leveraged each partner organizations’ comparative advantages.
“…….the duplication of activities does not occur because each organization presents its activities to the directorate and the directorate tells them where they can work. Apart from that we have regular coordination meetings” MOH provincial Directorate
Lower agreement perceived outcome scores were noted for the questions on country ownership (79%), reduction in financial cost of process (74%) and better allocation of each organization’s financial resources (62%). Many district level respondents expressed their dissatisfaction in the sufficiency of funding that had been availed to them for HPV vaccination activities, with the situation being worse in the districts that were not funded by Gavi and had to depend on only MOH funds. While some respondents noted that partner organizations had stepped in and helped a lot, especially with in kind donations, many talked of lack of funding for outreach activities for finding non-school attending girls in communities as a major challenge. Correspondingly, the highest perceived outcomes drawbacks score was that of country ownership at 24%. Several issues were mentioned regarding country ownership but featuring prominently was the preference for a country based partner organization. Respondents expressed their unhappiness on the inclusion of a non country-based partner in the HPV implementation partnership. Language barrier and lack of contextual knowledge were mentioned as some of the problems of the specific technical assistance that was provided by the particular partner who was considered foreign. The lack of participation in regular technical working group meetings was also noted as a hindrance to individuals based outside the country contributing effectively to the partnership. This is because TWG meetings was the forum where most of the partnership communication took place with updates on progress on processes being made, important discussions taking place and key decisions being made during the meetings. Short visits to the country to provide technical assistance were said to be ineffective by survey respondents and were even blamed for having largely contributed to the delay in the accomplishment of some HPV vaccination pilot implementation phase deliverables.