Spotlight on missed children
The proportion of missed children in DR Congo continues to rise, with an average of 9% children missed in the last 3 campaigns in the fourth quarter (See Figure DRC1)). Extrapolating figures from independent monitoring, this could mean as many as 1.14 million children are missed during a National Immunization Day (NID) Campaign. Rising trends in both Bas Congo and Katanga are of particular concern, and explain the increased caseload emerging from these two provinces. At the same time, as many as 178,691 children could continue to go unvaccinated in the capital, Kinshasa, on average each round, in spite of access here being less challenging than elsewhere in the country.
The presidential elections in late November significantly disrupted preparations for the planned December campaign, with the Health Ministry distracted by pressing political developments. Following the elections, the movement of polio workers was substantially limited due to fears of violence in response to the results. This led to several delays, although the campaign eventually took place on 19 December.
Why are we missing children?
Children absent when vaccination teams visit remains the highest reported reason for missed children (see Figure DRC2). Between 30% and 40% of children nationally were missed for this reason in the fourth quarter, and 37% across the entire year. Both operational and social mobilization strategies need to be refined.
“Other reasons” comes second, a catch-all category that could reflect anything from a child being sick to a house not visited. With on average 30% of missed children being classified in the “other” category throughout the year, this is the largest proportion globally. Urgent action is needed to improve the forms, as well as the way the data is collected and classified, so that strategies can be refined.
In spite of intensified communication efforts, the fourth quarter continued to display high levels of resistance. Campaign activities have focused on areas with the highest concentration of opposing religious groups, geographic access constraints, and media challenges. Between NIDs in July and localized campaigns in August, refusals shot up from 13% to 23%, demonstrating that refusals are much higher in the virus epicenters than in the rest of the country (see Figure DRC3).
Findings from a recent study on missed children (see Box ) suggest that these elevated rates may even be an underestimation of the refusal problem in some areas. Many social reasons for non-vaccination are being classified into the ‘other’ category in Independent Monitoring forms (see Box DRC1).
Tackling institutionalized resistance
One specific challenge emerging in DR Congo is the hardcore organized resistance associated with particular religious groups, such as l’Eglise des Noirs, Mpeve ya Longo, Bundu Dia Kongo (BDK), Postolo, Kimbangu Rouge, Mwakwidi and Nsangu Sala.
The recently revised strategy of increasing the duration and quality of time spent engaging with religious groups and traditional authorities is starting to show results.
Since April, the number of groups collectively resisting vaccination has been reduced across the country from 61 to 20 as of December 2011 (see Figure DRC4). In the capital city of Kinshasa, 7 out of 8 previously resistant groups now support vaccination. There is no more organized resistance in Bandundu, and only one remaining group in each of the other provinces.
However, in Katanga, institutionalized opposition to the vaccine is much more widespread, particularly among the Kitawala followers, who have the largest religious base in Katanga. Here, only one religious group has been persuaded to accept polio vaccine since April, with 7 continuing to refuse.
Understanding Katanga – critical for success
Gaining a deeper understanding of both the social and religious dynamics in Katanga is critical. Virus transmission has never been interrupted in this province, and the programme’s inability to gain the trust of hardcore resistant groups is likely to be a key reason for this failure.
Significant efforts have been made during the last quarter to reduce resistance in Katanga. Religious groups were mapped in detail, with leaders and influencers – both positive and negative – identified at village level across 10 Zones de Sante’ in the North Katanga district of Tanganyika. In spite of this, Katanga still proves to be a special challenge. Not only has it been extremely difficult to gain the trust of most opposing groups in the Province; but even when breakthroughs are made with influential leaders or spiritual chiefs, it does not take long for them to be denounced as too ‘liberal’, and new allegiances pledged by their previous constituencies.
Nonetheless, efforts continue and progress has been made. Three representatives of Postolo and Filadelfie have been enlisted as advocates for vaccination in Katanga, and over the last quarter, they have held debates and discussions with religious groups and organized village tours for vaccination teams.
Successful lessons from other areas are also being applied in Katanga, although lack of trust in this province is also mixed in with a general lack of satisfaction with local development. A more sophisticated and multipronged engagement strategy will need to be developed specifically for Katanga in 2012.
Forced vaccination, broken trust
Active social mobilization with trusted mobilizers remains a key strategy in DR Congo, particularly in the ongoing political turmoil. The lack of trust in government services stems not only from a lack of amenities, but also from the behavior of local health staff and vaccination teams. The recent study found that in almost every province surveyed (with the exception of Bas- Congo), caregivers who refused to vaccinate their children were threatened with imprisonment or fines up to $100 USD per household.
Whilst coercion might be seen by some as a valid means to raise coverage, such a serious breakdown of trust between community and the health system is likely to have long-term negative consequences. Firstly, it makes it very difficult to identify and locate children when caregivers fear fines or imprisonment if they admit to non-vaccination. This affects the quality of coverage and independent monitoring data.
Equally serious, people associated with the programme quickly become regarded with suspicion, perceived to be investigators or even police. Local influencers are then needed to vouch for the credibility of vaccinators, which does not make for a favorable environment within to receive a vaccination team each month.