Attaining quality immunization services in Nigeria through effective capacity development for health workers

Immunization has been proven to be one of the most successful and cost effective health intervention of modern day medicine. Over the years, Immunization has successfully prevented millions of deaths and disabilities globally especially amongst children.

Effective vaccines stimulate the body’s immune system to produce anti-bodies (natural protecting substances) which prepares the body to fight off infectious agents that causes diseases.

Due to advancement in medicine, effective vaccines against diseases like measles, pneumonia, hepatitis B, polio, tuberculosis, pertussis (whooping cough), yellow fever and Rota virus (diarrhea causing agent) have now become readily available.

Following a global immunization campaign, small pox infection which is caused by a highly contagious virus was eradicated in 1979. Polio is also on the verge being eradicated as a result of availability of an effective vaccine and massive global effort to ‘kick it’ out.

Also, vaccine against the deadly Ebola virus will soon become available following successful trials in some west African countries and there are lost of success stories coming out from the malaria vaccine trials as well.

Besides conferring individual protection against diseases, vaccines are also capable of conferring community protection through the concept of “herd immunity” if a significant number of individuals in the community are immunized against those diseases. This reduces the possibility of disease outbreaks and the incidence of such disease in the community.

Immunization also comes with a lot of economic benefits especially for developing countries like Nigeria and other countries with emerging economies like India and Brazil. When immunization coverage is scaled up, high costs of medical treatment, hospitalizations, and loss of productivity due to time spent taking care of sick children can be averted. With immunization, the population is healthier and children have a higher possibility of reaching their full potential and contribute to the nation’s economic growth.

In order to deliver immunization effectively, skilled health personnel are required to give the right quality and quantity of vaccines at the right time. Health workers also need to possess or acquire the skills required to manage the whole immunization process which includes, carrying out community outreaches to create demand, client education, recognizing and managing some of the adverse effects associated with immunization, disease surveillance and very importantly, immunization data management.

Without skilled health workers to carry out immunization services, national immunization coverage will be low and the threat of disease outbreak will still loom even though these vaccines are available. Therefore, its imperative for health workers to receive the necessary training that will equip them with the knowledge and skills needed to carry out immunization confidently and manage the whole process.

As with other medical professionals, health workers in the field of immunization need to continuously update their skills and knowledge to meet current professional standards (after their initial pre-service training) by undergoing effective in-service training regularly.

By effective, I mean training that is conducted in a very conducive environment using the appropriate curriculum that is designed to achieve the objectives of the training exercise. Having the right blend of facilitators who are skilled in adult learning methodologies and have an understanding of the training curriculum will also make training effective. It doesn’t stop there, as effective training also entails some form of evaluation, regular supportive supervision and on the job mentoring to ensure that the training has led to a change in behavior geared towards increased performance and quality on the part of the health workers.

Following the introduction of some new vaccines into the routine immunization schedule in the last four years, a lot of funds have been invested into capacity development of health workers providing immunization services and as result, a lot of trainings have been conducted. It is estimated that about 20,000 health workers across the country would have been trained by government and partners after this exercise is completed. While this can be said to an achievement, it is also important for stakeholders to view this as an opportunity to effect a paradigm shift by addressing some of the inherent challenges associated with the way health workers are trained in order to ensure quality and effective trainings in the future.

Some of the challenges fall into the following categories:
Training Needs Assessment (TNA) – Research has shown that carrying out a training needs assessment before trainings, can boost trainee’s productivity as it ensures that the training exercise is targeted and tailored to address the needs of the health workers. This has not really been the case for health workers providing routine immunization services in the country as a lot of trainings are carried without conducting a proper TNA. By carrying out a proper TNA, stakeholders can determine those who actually need to be trained, what they should be trained on, how and what is needed for the training to be successful and impactful.

Training content and curriculum – over the years the training curriculum have shown to contain more of theoretical content and less practical exercises which health workers really need to be able to carry out their work which has reduced the impact of the training and led to poor productivity.

Also, very little or no emphasis have been given to some very important topics such as attitude of health workers to clients, interpersonal communication skills, continuous quality improvement, management, and emotional intelligence all of which enables health workers relate better with their clients in the course of rendering services and improving the overall quality of service members of the public are receiving.

Use of unstandardized and poorly designed instructional materials have also contributed to inconsistencies and poor quality in health worker trainings.

Facilitation and training logistics -Use of facilitators who have little or no adult learning or facilitation skills and selection of facilitators based on the position they occupy instead of their skills or facilitation ability is also another challenge that needs to be addressed very quickly in order to reduce inefficiency and conserve resources.

High participant to facilitator ratio, lack of adequate training materials and use of training venues that are not conducive can cause lots of distraction and reduces the quality of the training. On some occasions, the time allocated to the various modules and number of days to complete the training are not sufficient to make the training effective.

Evaluation- This is also as important as the training, because without regular evaluations, we will never be able to assess if the training had any impact. The non availability of a national and standardized evaluation method or tool to evaluate all trainings carried out by the various partners is also another cause for concern as its difficult to compare the impact of trainings carried by different stakeholders using similar curriculum and content. Poorly coordinated and in some cases absence of proper routine immunization supportive supervision for health workers makes it difficult to confirm if they are applying the knowledge acquired during the training in their daily activities.

Coordination –Poor coordination of trainings between the various agencies and partners happens in some cases leading to duplication of some trainings and waste of resources.
Data management- Dormant and in some instances, complete absence of a functional data base to track health workers that have been trained in the different competency areas and how long they have been in service has led to waste and duplication as it becomes difficult to know who should be trained and how resources should be allocated.

Recommendations
It is still possible to address some of challenges and reverse this trend if some of the following recommendations are taken in to consideration by the relevant stakeholders and authorities. In order to overcome some of these challenges and successfully develop the capacity of health workers providing immunization services, it will be recommended first and foremost that we look at what actually happens at the pre-service training stage when these health workers are still in the institutions and see how their curriculum can be reviewed to align with current realities on ground based on the feedback from those already in service and the public.

This can be achieved through strong collaboration between the regulatory bodies of these institutions and the relevant government agencies such as the Ministry of Health and the National Primary Health Care Development Agency.

Carrying out a thorough Training Needs Assessment before trainings are done and use of instructional materials that place more emphasis on practical demonstration rather than theory will help make trainings effective.

Including topics or expanding content on interpersonal communication skills, attitudinal change, continuous quality improvement and emotional intelligence for better management of clients should also be considered in order to ensure high quality and impactful trainings.

Only facilitators that are experienced and skilled in the adult learning methods and facilitation skills should be selected to conduct trainings.

Having in place a functional database for both trainees and facilitators and developing a national evaluation protocol to evaluate all trainings by different partners and will help manage available resources and ensure consistency in evaluating the impact of all trainings conducted. All existing training coordination structures such as the Training Working Groups, the Planning, Research and Statistics departments in the relevant agencies should be continuously strengthened to effectively coordinate all trainings planned by partners and government agencies.

Using a conducive environment for trainings and having the right trainees to facilitator ratio is also very key to have an effective training.

Trying out other innovative learning approaches such as e-learning, on the job learning etc., doing regular supportive supervision exercises after trainings will help consolidate and sustain progress.

Lastly, it is crucial to carry some members of the regulatory bodies along while in-service training is going on, to enable them see what is happening in the field so that they can be guided on how best to revise their institution’s teaching curriculum for the sake of building a strong foundation for those health workers still at the pre-service level.

Future directions
All hope for effective training for immunization in Nigeria is not lost as a couple of new training approaches and learning methods have been or are being tested by different implementing partners like Direct Consulting and Logistics management consultant for Johns Hopkins International Vaccine Access Center (IVAC) who through the Strengthening Training for EPI and PHC in Nigeria (STEP-IN) project are testing the use of a mixture of tutors/lecturers in health institutions and Immunization managers to carry out direct in- service training for health workers instead of the four tier cascade training method usually done by only immunization managers.

In addition, the STEP-IN project are using tutors and lecturers to provide complementary Routine Immunization Supportive Supervision (RISS) for health workers. Another Immunization partner is also trying to make immunization training more hands-on and practical by supporting on the job training and learning since evidence is emerging to show that people learn more if training is done in the work place.

By carrying out a thorough evaluation of some of these new training approaches and learning methods, there will be sufficient evidence for the relevant authorities to make an informed decision on the most suitable training approach the country should adopt.

All Nigerians especially mothers and children, stand to benefit if we make the right investment in immunization and adopt the best training approach for health workers. With better trained health workers, there will be better routine immunization service delivery which will lead to better coverage, better protection for our children and eventually a healthier and more productive country.

Improved health worker knowledge and skills will translate to an improved health system which in turn, will boost public confidence in the system and assure them of more friendly and knowledgeable health workers whose main focus will be to meet the needs of clients and communities they serve.
On a final note, lets not be afraid of change or innovation and doing things different from the norm for change is inevitable. As the saying goes, “you can’t keep doing things the same way and expect a different result”. The most important thing is to take that first step and begin in the right direction!

Written by Dr Linda Arogundade- Public health consultant at Direct Consulting and Logistics