How we used people-centred design to improve vaccine service delivery in Nigeria
For a brief period in 2021, the world shared one of Nigeria’s biggest healthcare problems. Governments were grappling with how to get as many people vaccinated as possible. A COVID-19 jab had been developed, but the hurdles were varied, from convincing the public that it was safe to making the process frictionless.
In Nigeria, the threat of under-immunisation stretches well beyond COVID-19. About 2.2 million of our children haven’t received their routine Pentavalent jab, which prevents diphtheria, tetanus, whooping cough, Hepatitis B, and Haemophilus influenzae type b. That’s the highest rate in Africa and among the worst in the world.
The most reported reason for the startlingly high number of zero-dose children is a lack of knowledge. But there is also a huge opportunity to improve service delivery, starting with better use of data. Brooks Insights, an independent consulting firm I lead, ran a project to explore how healthcare workers could harness data to strengthen health systems and boost vaccine uptake through ‘good enough strategies’ — simple, low-cost solutions that are feasible, culturally appropriate, and put communities first. We were supported by the Vaccine Data CoLab, which funds country-led interventions that use hyperlocal data systems for vaccine decision-making.
Our approach embraced human-centred design (HCD) — solving problems by working with users and tailoring the approach to their needs. First, we trained immunisation program managers and healthcare workers on using data to engage local communities and understand vaccination barriers. Then, we used those insights to co-design tailored and targeted solutions to those problems with community members.
Finding solutions by working with the community
The project uncovered three important lessons about improving service delivery and vaccine uptake.
First, local context is critical.
“What we are doing is not looking at any one solution as a silver bullet, but seeing data as a part of a bigger health system where we need several solutions working together to make an impact,” says Dr Sam Agbo, a former senior health officer at the UK Foreign, Commonwealth and Development Office in Nigeria.
That meant creating tailored solutions for each community. For example, one area had an excellent health facility that offered vaccinations, malaria tests, and other primary health care services. However, the data showed that no one used it. When we engaged with the community during the HCD session, it became clear that they thought the centre had been built for one particular ethnic group.
To promote the health facility to those not using it, the healthcare workers and the community put together a grassroots engagement program, including banners telling people that the centre was open and which services it provided. The solution turned out to be highly context-specific — other communities were probably not making the same assumptions about who their health facility was built for — but it took a localised approach to improve vaccine uptake at this particular facility.
“HCD made us identify approaches to different problems as it allowed the locals to come up with solutions to their problems,” says Tanko Chadwafwa, a state routine immunisation desk officer at Nigeria’s Federal Capital Territory Primary Healthcare Board. “It’s a wonderful approach.”
Second, solutions have a better chance of being sustainable if they are directly developed with and for the people you’re trying to support early on. For example, when a new intervention is introduced, the training is often generic and doesn’t consider the knowledge gaps of frontline workers. Instead, we engaged with the workforce and got a much better understanding of the training they needed. We assessed them after the training to measure what they learned and how they applied it in their work. As a result, feedback was overwhelmingly positive among workshop participants: 91% of state program managers, 100% of local government program managers, and 85% of health workers said they were “very satisfied”.
Third, the impact of consistent frontline investment is exponential and will ensure you’re reaching the people who need it most. This is especially true if you develop a dialogue with the people you support. We noticed communications between healthcare workers and the community were very one-sided. Health workers would tell people about the importance of vaccination and give them details on health facility days for immunization services. But there’s no opportunity for the community to voice their views and concerns about vaccination and the services rendered. As a result, important information that impacts vaccine uptake is missed.
For example, if people aren’t able to go to the clinic because they are working at that time, healthcare workers are missing out on an easy and low-cost solution to improve the way vaccination services are offered. As a result of our work, healthcare workers now have the tools they need to create a dialogue with the community. This includes behavioural and social driver questions they can ask to understand how people feel about vaccines, the social processes that encourage or prevent vaccination, individual motivations or hesitancy, and practical factors in seeking and receiving the vaccination.
What all three lessons have in common is how simple the solutions are. Healthcare workers are under a lot of pressure. Teaching them how to take a ‘good enough’ approach can generate effective strategies that help them do their job better without creating more work. It’s also an efficient way of learning. Instead of putting health workers through hours of training, they’re given a lifelong skill that they can apply immediately to all sorts of health programs, not just vaccine programs.
Building on CoLab successes
The CoLab method — working collaboratively and experimentally to test and scale solutions in real-world contexts — has given me a clear idea of what could help us strengthen health systems and boost vaccine uptake even further.
One challenge was that the project was short-term, which meant there wasn’t enough time to assess the impact of our work in improving vaccine uptake. While we know satisfaction with the training was high, and there was interest from the government to do more, we would love more time to measure the effectiveness of the strategies to understand what works and why. This would help us scale our impact more effectively.
More data also needs to be digitalised. Much of our data collection is paper-based, which is prone to errors and quality issues. The main source of digital data — the District Health Information Software (DHIS2) — is also not user-friendly. The government has encouraged the use of DHIS2, but uptake would be much better if it were easier to use.
Finally, we need the right tools in action. For example, we could use geospatial mapping to locate zero-dose children and identify the communities for HCD sessions and targeted interventions. Another issue is people need to be motivated to use these tools. The government should offer non-monetary incentives, such as awards, for program managers and health workers who actively adopt them.
I loved the CoLab way of working, particularly the process of understanding the people, the landscape, and the networks, imagining a radically better future, and realising the future vision through collaboration and experimentation. Now, I hope our health workforce can learn from the work that the Vaccine Data CoLab is doing and design people-centred, bottom-up interventions for primary healthcare interventions beyond immunisation.
The Vaccine Data CoLab in this form ended in October 2023. If you work in the vaccine data ecosystem, we’d love to know what you think about what we’ve learnt and any opportunities you see to apply the approach in other countries or health topics. Get in touch with us at vaccinedata@makingbetterfutures.org.
You can also learn more about Brooks Insights and the portfolio of solutions or read more about our overall learnings.
