Socio-demographic Characteristics of Participants
A total of 40 healthcare workers across Ekiti state were selected to participate in this study. The majority (87%) of the participants were females while a little over one-tenth (13%) were males. About 38% of the study participants had post-secondary certificates from nursing school and community health institutions, while 52% were first-degree (BSc) holders. The mean age of the study participants is 46.4 years. (Please see Table 1)
Table 1
Socio-demographics Characteristics of Participants
Characteristics | Frequency | Percent |
Gender | | |
Male | 5 | 13 |
Female | 35 | 87 |
Age Group | | |
31–37 | 2 | 5 |
38–44 | 15 | 37 |
45–51 | 13 | 33 |
52–58 | 10 | 25 |
Educational Attainment | | |
Post-Secondary | 15 | 38 |
University | 21 | 52 |
Postgraduate | 4 | 10 |
| 40 | 100 |
Participants’ Knowledge of COVID-19 Vaccination and Routine Immunization Integrated Approach
Health Workers’ Description of Integration
In exploring the integration of COVID-19 vaccination and routine immunization (RI) within health facilities in Ekiti, it was highly pivotal that we assess the participants’ understanding of integrating COVID-19 vaccination and RI services in the state, particularly at the health facility level. Therefore, the study participants were asked to express their interpretation of intersecting COVID-19 and RI services in the state. All the participants believed and mentioned that it is the combination of two services to make one achieve similar goals. The following are feedback from the study participants:
Thank you. Integration is the joining together of small bodies to become a whole. For example, the different departments that are in primary healthcare. The integration of COVID and RI is how we administer COVID-19 vaccination and routine immunization together. When we first began COVID vaccination, we noticed that there was no RI there, so we figured that if we could integrate it, it would help us, and our patients would flow better ( IDI/Routine Immunization Focal Person/Ikole Ekiti LGA)
Well, with the word integration, the two services and other services were provided together. And with the COVID-19 and the RI vaccination, it's really increasing the coverage for RI and for the COVID vaccination in Ekiti ( IDI/LGA Immunization Officer/IKERE LGA/)
One of the thematic areas was the integration part, which was integrating COVID-19 into the routine immunization services at the facility level, and how it played out was the fact that it played out in two parts, we had the outreach team and the fixed team. Outreach teams were charged with the duty of visiting various settlements, especially hard-to-reach environments, and tracking those who have been defaulting on taking their first dose, … while the facility teams were charged with the duty of vaccinating those who come into the facility to do something or get treatment for one ailment or the other. ( IDI/Assistant Technical Adviser/Ekiti State)
Perceived Benefits of the Integration
Findings from the study revealed that participants expressed their opinions on the benefit of the integrated approach adopted for the optimization of COVID-19 vaccination and routine immunization. Participants aligned on the fact that the benefits of the adopted strategy improved vaccination coverage for both exercises. The following excerpts provide more context:
The benefit of integration has improved the uptake of the COVID-19 vaccine such that it has increased women’s uptake of the vaccine, and it has helped in opening the mind of our patients to the importance of vaccination. ( IDI/Recorder/Ikere LGA)
The benefits I considered are that the program assisted us to reach the unreached and through that, it also assisted us to have more coverage in all our antigens. Before the program in these areas, we have been experiencing dropouts ... But during that program, we were able to cover those areas, to reach all those children and we were able to vaccinate them. (IDI/LGA Immunization Officer/Ifelodun LGA)
The benefit is that it increased the coverage, and then it allowed the defaulter to be tracked at the health facility level. During the integration, we used to track defaulters. We also monitor and complete the doses received during the campaign, and conduct house-to-house visitations. The elderly interested in taking the COVID-19 vaccine are told of its availability at the facilities. ( IDI/M&E/ESPHCDA)
Integration as a Facilitator of Improved Coverage
Participants said the adopted integration strategy influenced the increased coverage of COVID-19 and routine immunization through leveraging opportunities associated with the integration. In other words, the availability of a child for immunization ensures the availability of the caregiver/mother for vaccination, depending on the caregiver’s vaccination status, and vice-versa (that is if the adult has an eligible child). In essence, participants stated that:
The way it has helped is how it makes people come out of their houses because, for a lot of people, it is burdensome for them to bring their children for immunization at the facility. So, it has helped our immunization work increase and that of COVID-19. (IDI/Recorder/Emure LGA)
In Emure local government, the integration of COVID-19 with RI has really helped in coverage because initially with COVID-19 coverage we can see that we have specific days or maybe programs organized to capture people for COVID-19. But since it has been integrated, even when a mother brings her child to the facility, she has access to the COVID-19 vaccine. So, they have access to the vaccine when they need it. ( IDI/LHEO/Emure LGA)
An illustration that we want to give towards improved coverage is that there are people who find it difficult to come into the facility probably because they have one challenge or another thinking they will actually pay before they can get vaccinated and some because they are not even interested in COVID-19 vaccination but because there are some other vaccines that their child have to take and, in the process, they are already being informed. They will then explain to the caregiver and give the child and caregiver their vaccines (IDI/Assistant Technical Adviser/Ekiti State)
Enablers of COVID-19 and Routine Immunization Integration
To effectively assess the drivers of the integration approach (that is, the optimization of COVID-19 vaccination and routine immunization), we employed the WHO Health System Building Blocks Framework, utilizing the six components for easy disaggregation of the health system structure.
Service Delivery
In a bid to ensure a good understanding of how service delivery has aided the integration of COVID-19 and routine immunization, the service delivery component was further divided into sub-themes that comprehensively address the provision of health services in the immunization unit of primary healthcare.
(i) Demand Generation and Social Mobilization
The study participants (health workers) explained that their demand generation activities are dichotomized into two major areas to ensure reaching the people in the rural communities. The following are the steps adopted by the team when engaging community stakeholders.
a.) Stakeholders Engagement
Responses from the study revealed that the team commenced their activities with community entry through the establishment of adequate connections with stakeholders at the community levels. They obtain the buy-in of all community leaders to facilitate easy access to community members. Participants enunciated that:
First of all, we started with advocacy, a high level of advocacy, we paid advocacy visits to influential people in Ekiti state, and we involved all the chairmen in Ekiti state and all the traditional leaders in Ekiti state. We normally hold meetings with them to sensitize them in their palace. … we leveraged their monthly meeting and Iyaloja’s (Women Market leaders). We paid advocacy visits to religious leaders and then civil society organizations such as the Rotary Club. (IDI/SHE/EKITI)
The demand and awareness generation campaign started with traditional leaders because the mode of entry into any community is very important. After that, we held a town hall meeting, an age group meeting, and compound meeting. (IDI/LHE/IFELODUN LGA)
b.) Awareness Creation/Community Sensitization
The second step that health workers across the state and LGA levels took is the step to create awareness and sensitize the community members on the importance of receiving COVID-19 vaccination and routine immunization. The goal of this action was to ensure that residents of the communities willingly accept to receive either the routine immunization for their children or the COVID-19 vaccination for themselves (especially if they have not accepted their first dose and/or have missed subsequent doses). Therefore, participants expressed that:
We did radio jingles and media chats. We did live workshop programmes on both TV and radio stations. Apart from this, we have our platforms where we normally share all the information. If we produce a jingle, we share it on this platform for everybody and we also encourage all these our leaders, religious leaders, and the Iyalojas that when we throw it to their platform, they will help us to also send it to all the platforms they belong ( IDI/State Health Education Officer/Ekiti State)
During antenatal clinic, any clinic whatsoever, or any gathering of the community we sensitize people about it, that now you can bring your child to the facility and receive your COVID-19 vaccination. It really helped and supported the system. (IDI/LHE/IDO LGA)
We announced to people through radio jingles, and phone calls telling them that vaccination is now available at the center and the mobilizer also goes around to inform people. (IDI/RECORDER/IFELODUN LGA)
(ii) Health Education
Participants expressed that, residents of the state across various communities, particularly those who visited the health facilities, such as the caregivers, were significantly educated on COVID-19 vaccination (including the significance, and potency, amongst others). The participants added that the residents were not only educated but were also provided with IEC materials, as this is evident in their statement:
We had various IEC materials talking about the COVID-19 pandemic, how it can be contracted, and even talking about the vaccines, the potency, and the safety of the vaccines. (IDI/State Immunization Officer/Ekiti State)
Yes, like I have rightly said during our clinic sessions, we leverage these sessions to speak about the integration, then during any community meetings we have access to, and speak about it, especially about the COVID-19 vaccination then about the integration of the two. Also, during one-on-one discussions, we discuss it with the people. (IDI/LGA Health Education Officer/Ido LGA)
In our facility, we carry out health education, we explain the benefits of immunization and how to take precautions such as no shaking of hands, and using of nose mask, and we tell them about the things they should do and not engage in that can have consequence on their health (IDI/Recorder/Ijero LGA)
(iii) Vaccine Accessibility
The healthcare workers interviewed for the study emphasized that the eligible populations had access to vaccines throughout the entirety of the program. Ease of access was ensured through the running of fixed-post and mobile outreach teams. The fixed post teams are located in the facility where community residents could visit to get immunized or vaccinated. On the other hand, the outreach sessions involve healthcare workers moving around the communities where the facilities are situated to take immunizations and COVID-19 vaccinations to the doorsteps of the residents.
The people around had access to the vaccine because we did fixed post and outreach (sessions) in which case we went to their doorsteps to give them the vaccine. Thanks to the effort of the organizer of the program who funded the outreach we were able to reach a lot of people at their workplace, we went to them and gave them in their market store, people in rural areas instead of asking them to come over to the town we met them at their various villages and settlements then we administered the vaccine. (IDI/LGA Health Education Officer/Ifelodun LGA)
We took it to them, then some came, and we were running both outreach and fixed post (sessions). (IDI/Routine Immunization Focal Person/Emure LGA)
Health Workforce
Subsequently, the study assessed the health workforce component of the health system to understand the contribution of the component to strengthening the immunization health system of the Ekiti State Primary Healthcare Board. Additionally, this component also sheds light on the contribution of the health workforce to the optimization of COVID-19 vaccination and routine immunization. To this end, two key areas were discussed: Training of health workers, and recruitment of ad-hoc staff.
(i) Training
The study participants were able to call out that before the commencement of the integration strategy for the optimization of COVID-19 vaccination and routine immunization, health workers involved in the support were trained across all levels.
We were trained on the integration of COVID and RI. We went for training on how to do everything (hands-on) such that as we’re administering COVID-19 vaccines, we’re doing routine immunization. So, we were trained. ( IDI/Routine Immunization Focal Person/Ikole Ekiti LGA)
There was training, and there was also retraining as part of the success story of the program. Health workers were trained prior to the commencement of the program. We were all trained at different levels, and they trained us equally. We also trained the mobilizers, so that the program could be sustained. So, that they also have adequate knowledge of COVID–19 and RI services. (IDI/LGA Immunization Officer/Ijero LGA)
Yes, we had training. We went to National for training, after which we came down to the state to cascade the training. Afterward, we developed our micro plan that integrates all those services together, and the training was conducted effectively at the state level and down to the local government level. (IDI/M&E/ESPHCDA)
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Ad-hoc Staff Recruitment
In the interview conducted, the study participants expressed that the shortage of manpower influenced the need for additional recruitment of ad-hoc staff to strengthen the workforce for the optimization of COVID-19 vaccination and routine immunization in Ekiti state. The engaged ad-hoc staff are usually residents and/or members of the communities who possess important skills in other areas, particularly technological skills, where the services were needed for the optimization of COVID-19 vaccination and routine immunization.
Yes, there was recruitment, because not all those that supported outreach were health workers. For the facility, which is the fixed team, we ensure that, for the sake of the integration, it is only the RI officer and the recorder of the facility that is allowed to work as part of the team for the fixed team. While for the outreach team, to complete the number of personnel needed for the team, we have cases whereby the recorder or the EMID, and paper recorder is not a health worker. Also, the validator and mobilizer are not a health worker but for vaccinators, we ensure that each team is led by a health worker, and this is usually the vaccinator 1 ( IDI/Assistant Technical Adviser/Ekiti State)
Yes, because in Ekiti State, presently, we all know that we have a shortage of staff. As a result of that, our staff will not be enough to cover all the communities. So, we had to recruit some ad hoc staff, in which they were also trained along with our staff, to be able to carry out the activity. (IDI/LGA Immunization Officer/Ifelodun LGA)
Yes, we employed ad-hoc staff. The likes of the mobilizers and those who are conversant with the communities who know the in -and - out of the communities, people that were given to us to help us mobilize people ( IDI/Recorder/Ikere LGA)
The likes of the mobilizers and those who are conversant with the communities who know the in and - out of the communities were available to help us mobilize people ( IDI/Recorder/Ikere LGA)
Commodities and Vaccines
In discussing the measures taken to ensure the availability of commodities and vaccines for the seamless operation of the intervention geared towards the optimization of vaccination services in the state, participants emphasized that they structured their micro plan with an adequate standard, and adhered to the micro plan developed, as this aided management of commodities and vaccines across the state.
We used what was developed in the micro plan to supply all the materials required. So, in that area, since they are given all the micro plans that are robust and cover every resource, then from that micro plan, that's where we supply. And then we ensure that no area lacks all those resources that they need from our end. So, what they have, we firstly get it and then we do the needful to submit what they have before the micro plan is updated. So, they give us what they have and then we compare it with the target population. Then, what we cover, we make available to supply through the cold store to ensure that those commodities, the syringe, then the vaccine carrier, everything was provided. ( IDI/M&E/ESPHCDA)
We have something we call bundling; it is like a package deal. When you get a vaccine dose, you also get all the necessary supplies like syringes, needles, cards, and cotton wool. It ensures that everything needed for the vaccination is provided together. So, it's not just about counting the doses but also making sure you have all the materials required for a smooth vaccination process. (IDI/LGA Health Education Officer/Ido LGA)
We had a plan that we used to provide everything that we would need for the program. There has never been a time we ran out of supplies, injections, safety boxes and everything. So we just monitor the supplies to know when it is running out. And most times it's LIO that gets it for us. ( IDI/RECORDER/GBONYIN LGA)
Health Information System
Quality and reliable immunization data is the lifeline of sound and informed decision-making in healthcare interventions. To generate high-quality data from the integrated program, a robust data reporting structure was put in place. Subsequently, to ensure adequate electronic reporting, a skilled and technologically inclined health worker was reporting at the facility level, while technologically skilled individuals, usually hired as ad-hoc staff were utilized for outreach teams. Their roles were to report and record data. Regular data validation and verification meetings were held at all levels of operation. Participants expressed the following:
(i) Data Recording and Reporting
At the facility level, we have the recorder and the RIO. At the end of the month, even prior to the project, what they do is collate their reports. The RIO reports to the CCO and the LIO. Why the CCO was brought into the picture was because of the vaccine. Vaccine utilization must be checked across the board to tally with the number of people that have been immunized for the month, while the RIO is reporting to the CCO and the LIO the recorder also reports to the M&E and thereafter the LGA level, at that LGA level the M&E, the LGA M&E, the LIO, and the CCO will now look at those data also again before uploading to the DHIS but, when we also came on board we actually requested that they maintain the reporting structure and made some little improvements. ( IDI/Assistant Technical Adviser/Ekiti State)
Yes, using Kobo Collect and all other platforms on a daily basis even immediately they are vaccinating, they are capturing all this data and sending it to the appropriate person, and the M&E for the LGA usually does the summary and sends it to the appropriate person. ( IDI/LGA Health Education Officer/Emure LGA)
When the patient comes to the facility, I will take the paper record and request for their name, and their telephone number. After that, will pick up my phone to collect all the information and I will ask the person to go and get vaccinated. After vaccination, I will record on DHIS 2 stating if it is the first time or second time of vaccination. I will then collect all the data from both immunization and COVID-19 and record it on Kobo Collect one after the other ( IDI/Recorder/Ado LGA)
(ii) Data Validation
At the facility level, we have the recorder and the RI. At the end of the month, what they do is, collate their reports, both of them. The RI and the recorder report to the M&E, the LGA M&E. The RI reports to the CCO and the LIO. Why the CCO was brought into the picture was because of vaccine, vaccine utilization must be checked across the board to tally with the number of people that have been immunized for the month … the LGA M&E, the LIO, and the CCO will now look at those data also again before now uploading to the DHIS…(IDI/Assistant Technical Adviser/Ekiti State)
They have an OPD register, tally sheet, and immunization register which they work on … immediately a child is brought to the facility and that child is being attended to the record it immediately, and when they have collected all their data they bring it together and come for the validation meeting where they will look at what they have done, the M&E officer will be there, the CCO will be there too if the number of vaccines collected correspond with what they used. (IDI/LIO/Gbonyin LGA)
We ensure our work tallies, if our work does not tally we won't be able to present quality data. (IDI/Recorder/Ifelodun LGA)
PHC Financing
Participants believe that the financial support offered to health workers was highly commendable, as that was a major agent of encouragement for health workers to remain dedicated and committed to their work. Additionally, participants emphasized that payments were made to all healthcare workers who were involved in the intervention across all levels to ensure the optimization of COVID-19 vaccination and routine immunization, yielding a subsequent seamless implementation and operation of the intervention. As such, participants state that:
They tried. You know I explained earlier that they motivated us—the financial support is part of it. Because it helps to make transport convenient, and even minor things like getting water when you’re thirsty. So, these help to keep us motivated ( IDI/Routine Immunization Focal Person/Ikole Ekiti LGA)
Sydani Group as I’ve said, has really done well because I can see that they are the ones that have really sponsored and really spent much on this integration. All the teams that are working—both the facility teams, and even at the LGA levels, have stipends that are being given at the end of the month, to all the team members that are working. Even the EMID and the Validators, as Sydani paid for their data and everything that they are using. So, this aids in the effectiveness of the program. ( IDI/LGA Health Education Officer/Emure LGA)
Sydani actually supported them with some stipends and the stipend was based on target. There was a daily target for the teams, including the outreach and the fixed-post teams. For the fixed-post team, they have a daily target of 7 people at least getting vaccinated before they can lay claim to the financial aspect of it for the day. ( IDI/Assistant Technical Adviser/Ekiti State)
Leadership and Governance
Responses from the participants indicated that there was a structured leadership system that was employed for accountability and transparency in the implementation of the intervention. In doing so, there were supervisory roles at different levels to ensure standard and adequate supervision of the provider of the immunization and vaccination services (i.e. the facility health workers). In other words, participants expressed that:
Well with the planning, we had LGA, state, and National level supervisors. Based on that organization, national supervisors available in the state were distributed to different local governments, along with state supervisors. At the LGA level the MOH, LGA health secretaries, deputy program officers, and the M&E are all the supervisors. And then at the ward level, health management–chairman, and health management committee of that facilities are part of them. So, we distribute ourselves across the teams for supervision. Then we use the ODK app for supervision. So, the supervisor, each LGA from the facilities, the health facility OIC, along with program officer, are distributed according to the schedule that has been verified at the state level before we continue the implementation. ( IDI/M&E Officer/ESPHCDA)
The LGA team tried because we were doing on-the-job supervision and training for them, they indeed went for training but we still guided them and corrected them with love,, we show them how they ought to do it if need be and about data entry, we asked them “why have all these data not been entered?” and if she said “it’s because of the network”, as there are some communities with poor networks actually, we would encourage them that immediately they get to the town they should upload the data and we follow up if they have uploaded it. ( IDI/LGA Immunization Officer/EMURE LGA)
The supervisory role I can describe is that they tried. Because there is a proverb that says that one who must catch a monkey must act like a monkey. All of us that are here, it’s not like we’re all perfect people, but I’m grateful that our bosses play leadership roles. When they see that we seem to be tired, they call us themselves and encourage us. So that leadership role that they carried out, I see that they tried for us. ( IDI/Routine Immunization Focal Person/Ikole Ekiti LGA)
Barriers to the Integration of COVID-19 and Routine Immunization
This study assessed the barriers to the integration of COVID-19 vaccination and routine immunization using the WHO Health System Building Blocks framework. Specifically, the study utilized the WHO framework to understand some of the challenges experienced during the implementation of the intervention in Ekiti state.
Service Delivery
Under the service delivery components, responses from the study participants indicated that there were three key issues experienced during the program implementation. These include; rumors, demand for palliatives, and complaints about adverse events following immunization.
(i) Rumors
Participants emphasized that a fundamental barrier they experienced among community residents was rumors about COVID-19 vaccination e in the state and the country at large. The study participants reported that the propagating rumors slightly influenced their coverage, believing that their recorded coverage could have been higher except for the presence of rumors among people at the grassroots level. However, efforts were made by the team to debunk some of these rumors.
The major challenge that we faced at that time with the issue of service delivery was the issue of rumor. It really affected our service delivery. Because some people have heard rumors about the vaccines, especially the COVID-19 vaccine, that those that are taking it, may be taking it to cause one problem or the other. Some even said that after two years, those who took the vaccine may die from it. ( IDI/LGA Immunization Officer/Ifelodun LGA)
When we had almost finished the process, different rumors began to fly around, and people did not want to take the vaccine anymore. We had to explain the concept of the spaced doses to them and dispel the rumor to help people to continue coming for their doses. ( IDI/Routine Immunization Focal Person/Ikole Ekiti LGA)
(ii) Demand for Palliatives
Participants further shared their experiences with the caregivers and in some cases, reports from the outreach teams on the demand of community residents. According to the participants, community dwellers believed that health workers had received their share of the palliatives, while community dwellers were abandoned to their fates. This was evident from the following responses:
We are just sacrificing our time and everything, when the VC/supervisor of health can be saying that, think of so many that will be happening in the field, many insulting words saying we did not give them palliatives that we and our families have finished the palliative, and we are now bringing vaccines to them ( IDI/LGA Immunization Officer/EMURE LGA)
the caregiver always insults us saying we only give them injections, we don’t give them food and whenever we go for awareness they always ask us if we will give them money, the people we want to give vaccines to help their health, they ask for money for food, these are the challenges we are facing. ( IDI/Recorder/Ikere LGA)
(iii) Adverse Events Following Immunization
The study participants also revealed that the complaint of Adverse Events Following Immunization (AEFI) either by a resident who had received one dose or by some of the community residents acted as a deterrent to other residents in the community. This affected the optimization of COVID-19 vaccination and routine immunization in the visited communities.
The challenge we faced was that some patients refused to take the vaccine because of the adverse effect of the first dose and we enlightened them on the benefit of completing the dosage, some even said they wouldn’t take it because they had seen someone who got vaccinated and had a severe temperature and the likes, but we keep educating them and many end up taking the vaccine. (IDI/Recorder/Ijero LGA)
Some people said they don't want to be vaccinated because they heard rumors that the vaccine is affecting some people in the community, and they too do not want to start complaining. ( IDI/Recorder/Ido LGA)
To address the challenges experienced under service delivery by the team the following activities were deployed:
i. Persuasion through the support of the community leaders, and
ii. Health Education
Generally, participants emphasized that to address their challenges in service delivery, they had to persuade community members and educate them where necessary. Participants also added that in some cases, they worked with the community leaders who aided the persuasion given to the community residents before they could eventually go ahead to get them vaccinated or immunize their children.
We then begin to persuade them and let them know that we did not benefit from any palliative needless to say to give people. We also let them know that even if they are being given palliatives, it will finish in days, and we encourage them to receive the vaccine that can enable them live a healthy life. We educate them on how these vaccines can prevent some diseases from affecting their health. And we also tell them that since they have been advocating for adult vaccination saying it is only children and women that we care for, now COVID-19 vaccination is here, they should come and receive it. (IDI/LGA Immunization Officer/EMURE LGA)
We did a lot of work before we could convince our people. That was why I said we involved all the leaders in the community. They really are the ones who assisted us to be able to talk to our people in this area. At the end of everything, we were able to convince them, and they all took it. Most of them took the vaccine ( IDI/LGA Immunization Officer/IGbonyin LGA)
Health Workforce
Participants reported in their interviews that the major barrier they experienced under the health workforce component was the shortage of health workers. According to the interviewees, the lack of manpower resulted in an increased burden of workload amongst the available health workers in the facilities. This is evident in the following expressions by the health workers interviewed.
We have a shortage of staff in all the health facilities. Not only in my LGA but in all the health facilities across the LGAs in the state. For instance, normally, a health worker who is in a fixed post is expected to take delivery of a pregnant woman, but there should be another staff that will be there because of COVID-19 vaccination, and there is usually a roaster for who will be there in the morning and for RI. However, we will be there in the morning and afternoon with no roaster because of the special assignment. We have to be there from morning till evening. Because you will have a lot of work to do, as there's no staff to fix those gaps ( IDI/LGA Immunization Officer/Oye LGA)
When the process was on, the number of us available did the job well, but if we were more in number, it would have been more efficient. For example, fixed post people like us—a vaccinator and a recorder are at the fixed post, and you know there will be times that the work will be too much, and they’ve told us that our clients must not be kept waiting at the facility. You know that if we were up to four or more of us at different tables, we would be able to attend to the clients faster. Although even those that were available tried, if the staff is increased, the work will be faster. (IDI/Routine Immunization Focal Person/Ikole Ekiti LGA)
Health Information System
Findings from the study interview revealed that, despite the electronically structured reporting system that was developed for them to utilize in reporting the data for COVID-19 vaccination and routine immunization, two major hindrances to this system were a lack of gadgets such as laptops and tablets, and poor network services on the part of the various service providers that operate in the state. The following are the findings from the study:
(i) Poor Network
Participants emphasized that poor network services affected the reporting rate of the data they have acquired, which in some cases may affect their performance. Senior-level health officials highlighted this network issue sometimes results in health workers not entering data properly on the expected platform(s)
The network issue is fundamental. At times, at the state level, they will be calling us, they are expecting our report, but because of the network. We have undulated places, valleys, and other things within my local government here, which affects the network. That was the major challenge. Some work will be sent to the national or state level at midnight, which is not supposed to be like that. ( IDI/LGA Immunization Officer/Ijero LGA)
With the internet service, because most of the time we do evening review meetings. I collected all the template data that was sent manually. But for us to get the EMID data downloaded, it is giving us a big problem... In some areas where they provide the service, the network will not be okay. I know this because sometimes when they ask me to go to some LGA, to find out what is going on, I find that when I collect the Android phone they use, the data is stored in their local server with them. But for them to get the internal network to upload it to the national server, is a big problem... ( IDI/M&E Officer/ESPHCDA)
Leadership and Governance
Participants were equally requested to discuss their challenges in line with the leadership and governance component of the intervention in line with the health building blocks. According to health workers at the supervisory level, bad roads, and lack of designated transportation were two main issues that the team experienced.
(i) Bad Road Networks
Health workers at the supervisory level expressed their worries over the nature of the road network that exists in some of the local government areas across the state. These roads, according to them are not motorable, and evidence from the study is presented below
We have the challenge of mobility for example, if I want to go for supervision I cannot allow anyone to mount the bike with me because the roads are not motorable, especially during the rainy season, there was a day I was going for supervision in Alapoto, I almost fell, and I had to hold on to a tree and I was later helped down, imagine if we were two (2) on the bike, we could have fallen into the water. So the roads are bad and some communities are very far away, I have been injured before when I fell from a bike. ( IDI/LGA Immunization Officer/Emure LGA)
The only challenge is the poor road to get to these health facilities. That is the only challenge that we surely face. ( IDI/LGA Health Education Officer/Ikere LGA)
(ii) Lack of Designated Transportation for Supervision
The participants also expressed their worries over not having a designated transportation system that will aid their supervision visits to the communities and LGAs across the states. Participants equally tied the unavailability of a transportation system to bad roads and the cost of transportation.
There is no vehicle for supervision in Ekiti state. We don't have vehicles for supervision. If I'm going for supervision now, it's either I use my own car or I go in public transport. (IDI/ State Immunization Officer/ESPHCDA)
The only challenge I can think of is that we do not have a transport system in place that can take us to the facilities because transportation is costly, and there are some places where we give COVID-19 vaccinations that are not motorable. ( IDI/Recorder/Oye LGA)