The public health sector has made massive investments in recent years to improve vaccination rates in the 70 poorest countries in the world. Galvanized by the Bill and Melinda Gates Foundation, developed countries now provide free vaccines to these countries for all the basic infectious diseases through the Global Alliance for Vaccines and Immunization.
In addition, organizations such as the World Health Organization, United Nations Children’s Fund, CARE, Save the Children and national foreign aid agencies have worked with health ministries to design, resource and implement more effective vaccine delivery programmes.
While great progress has been made in raising vaccination levels in many countries, these interventions have been unsuccessful in about a dozen countries. In countries such as India, the Democratic Republic of Congo, Nigeria, Ethiopia and Indonesia, vaccination rates often run below 50% in certain regions, compared with the 80% or more needed to achieve a low risk of the disease spreading.
Douglas Holt (left) is L’Oréal professor of marketing at Oxford University’s Saïd Business School. Jacob McKnight is a DPhil student at the same
To help address this problem, we designed a research project which uses marketing techniques to diagnose the systemic barriers to effective vaccine delivery in the problematic countries. Our ultimate goal is to propose alternative interventions that will significantly boost routine vaccination rates in countries that are not on track to achieve immunization goals.
Our research begins with a problem solving framework adapted from marketing strategy. We study vaccine delivery as a complex marketing system and seek to specify why the vaccine delivery system fails to deliver on service goals. This analysis requires two types of data: A nuanced understanding of how our customers—in this case, mothers with infants—understand, value and use vaccine delivery, combined with a close study of how the current system is designed to deliver this service.
We are carrying out this research in Ethiopia’s Jimma zone. In Ethiopia, infant vaccination rates are running at about 57%, with huge variation between regions. Urban areas such as Addis Ababa achieve rates of at least 90%, while rural areas with politically marginalized populations, such as the Somali region, struggle to immunize at least 20% of their infants.
Customer analysis: We completed ethnographic interviews with 80 mothers who had not immunized their infants. Local students carried out the interviews under our supervision, and we then had them translated. Three key findings emerged:
One, Ethiopian mothers generally value vaccination for their children and, all things being equal, would be happy to have the children immunized. Under-vaccination does not result from the mothers’ ignorance or negative perceptions about vaccine efficacy or safety.
Two, mothers are often unable to get their children vaccinated because of the logistical hurdles. In Ethiopia, at least 80% families live in rural areas, of which about 25% are nomadic. The health posts that serve them are often a considerable distance away. Mothers can’t afford to lose a day’s work to get their infants vaccinated, they can’t find care for their other children, and have difficulty arranging transport.
Three, mothers have little trust in the delivery system. They also hold the skills of the health extension workers (Hews), who deliver the vaccines, in low regard.
Channel analysis: Vaccines are perishable and so require a temperature controlled supply chain or cold chain. The cold chain is a major constraint in designing service delivery. For example, to minimize wastage, vaccination in rural areas is organized around monthly vaccination days, and vaccination to reach locations to vaccinate nomadic populations is even more infrequent. Because the supply channel to rural areas runs in an ad hoc manner, with Hews placing orders for vaccines through their contacts at health centres, even this system often breaks down.
These cold chain limitations are exacerbated by financial problems. Hews are paid poorly and often do not receive promised pay for outreach.
Service delivery: Given that mothers point to front-line service provision as the key barrier to vaccination, we are also investigating why it is that the marketing system does not successfully enable the Hews to fulfil their responsibilities. We are finding that the design of the delivery system, seemingly efficient from a supply chain viewpoint, severely impedes vaccination. It is not reasonable to expect mothers living at a subsistence level to organize their lives around a single day a month, to walk 10-20km to get their child vaccinated.
One key component of the Said Business School’s marketing, culture and society initiative is to apply leading edge marketing analysis to create innovative solutions to some of the most challenging social and environmental problems of our day. Vaccine delivery is one area where we feel our approach can bring unique insight.
By analysing the vaccine delivery system from a marketing perspective, we have gained a good idea of the barriers to vaccination from the customers’ perspective, opening the way for a range of innovative solutions, which we are currently exploring.
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