• For the latest case count in Angola please click here.
• Angola had reported only 5 polio cases in 2011, compared to 33 in 2010. The 2011 cases have been clustered in Kuando Kubango in the south, and a single case confirmed in Uige in July, on the northern border with DR Congo.
• Hard to reach border areas pose logistical and social challenges that will need stronger coordination with DR Congo in 2012.
• Although there have been no cases reported in Luanda, campaign quality continues to be a concern. The 4 cases reported in Kuando Kubango in early 2011 were linked to poliovirus transmission in Luanda.
• The most critical challenges in the programme are service delivery problems, but up to 22% of missed children nationally could be missed due to social reasons, largely masked under the category of “other’.

• Spotlight on missed children
• Service delivery
• Refusals
• “Other” social issues
• High-risk interventions

Spotlight on missed children

Although there has been a significant decrease in the number of polio cases this year - only 5 cases reported compared to 33 in 2010 - the continued poor quality of campaigns, particularly in densely populated areas of Luanda, continues to be a significant concern. While improvements in campaign quality have been made over the past quarter in rural areas, post-campaign monitoring data in Luanda shows an increase in the proportion of missed children, rising from 11% in July to 19% during the November campaign. Worryingly the November LQAS survey conducted in 10 municipalities of Luanda found that the teams missed households in 9 out of the 10 selected areas.

Why are we missing children?

Service delivery

Independent monitoring data confirms that the most significant reason for missed children nationally continues to be the failure of teams to visit every household (see Figure ANG1). During the November campaign, 59% of missed children were missed nationally due to unvisited houses. In Luanda, as many as 65% of missed children were not vaccinated due to this failure in team performance, including the challenge of using young vaccinators.

Although there were improvements in the capital early in 2011, thanks to the involvement of the municipal authorities, this commitment has weakened or even evaporated due to the restructuring of municipalities (from 9 to 5) with changes in boundaries and new leadership at both provincial and municipal levels. In addition, health staff are simply overloaded with work and underpaid, which impacts negatively on motivation, further reducing the time available to strengthen planning between campaigns.

The other significant reason for missed children is that children are not at home when vaccinators arrive. A recent study1 suggests that parents often don’t know exactly when vaccinators will visit the household, mostly due to poor planning, and the lack of an efficient system for interpersonal communication. Overall in 2011, 33% of children were missed due to child absence, although there was some improvement during the most recent campaigns – 22% in November. It is hoped that the recently updated independent monitoring form will be introduced during campaigns in 2012 to provide more detailed analysis of missed children to aid micro-planning.

A deeper understanding of which children are being missed is urgently needed, as well as information on where 1 Community research on Polio immunization and effectiveness of communication and social mobilization interventions, SINFICUNICEF, June 2011 children are when they are not at home during team visits. An in-depth qualitative study looking at reasons for missed children is underway in high-risk areas of the country, including Cabinda and other provinces bordering DR Congo, as well as parts of Luanda.

Refusals

Refusals remain low nationally, with only 2.9% of missed children due to refusal. A three-fold increase in refusals during the October campaign was a concern with a rise to 6%, although this fell again to 2% in November, and this needs to be better understood (see Figure ANG2).

Refusals are higher than the national average in high-risk areas like Cabinda, which saw 12% of refusals in October. Uige province with 6% of refusals in October, reported the most recent case in a hard to reach area near the border with DR Congo. Resistance here could be linked to similar cultural issues influencing resistant communities in DR Congo.

“Other” social issues

In the last quarter, about 4% of caregivers nationally were afraid to give OPV to their sick child, rising to 9.5% in high risk areas like Cabinda.

When combined with the percentage of parents who actively refused OPV, the percentage of missed children due to ‘hard’ or ‘soft’ refusals rose to 8% in the past quarter nationally, and to 18% in Cabinda.

An additional 17.5% of missed children nationally were missed due to “mother unaware”, which, as was noted last quarter, does not adequately explain why the child did not receive OPV.

With this figure at 24% in high risk areas like Uige, and as high as 36% in other provinces, it is critical that this category be revised in the independent monitoring classifications. This will enable both operational and communication strategies to be designed to reach and vaccinate these missing children.

High-risk interventions

Since the November campaign, increased focus is being placed on specific interventions in the high risk areas of Zaire, Uige, Malange, Lunda Norte, Lunda Sul and Cabinda, with promising results. Many areas in these provinces are hard to reach, especially during the rainy season. Internal and external migration from these areas also needs to be better understood. UNICEF has entered a cooperative partnership with the Red Cross to build social mobilization capacity in these regions, including enhancing interpersonal communications and undertaking social mapping of high-risk populations and micro planning. In 2012, UNICEF intends to scale up this partnership in the high-risk border areas and densely populated slums of Luanda, expanding an existing alliance to promote essential household practices with the largest faith based groups in the country.

Awareness of campaigns decreased slightly in the last few months of 2011, from 86% in the third quarter to 84% – still below the global target of 90% (see figure ANG3). Throughout 2011 there has been an intense focus on the use of mass media, which has contributed to improvements in awareness among areas with better media access. In spite of this, however, caregivers are not aware of the importance of taking multiple doses of polio vaccine.

With the ongoing operational challenges, awareness of campaign dates does not always translate into coverage, in spite of clear community acceptance, and in many areas, even active demand for the vaccine. In Luanda for example, where the overall level of awareness has been the highest throughout 2011, the number of missed children has also remained consistently high. The operations and communications teams must work much closer together in the coming year to harmonize their efforts, and to improve the quality of campaigns.

At the same time it is important to highlight improvements in awareness in some of the high-risk areas including Cabinda, Malange and Zaire. This could be due to the recent initiatives to implement more locally appropriate social mobilization approaches, and enhanced interpersonal communications to supplement mass media in the border areas where communities have very limited or no access to mass media. For example during the November campaign, with the increased focus on interpersonal communications in partnership with the Red Cross, a significantly increased proportion of people were aware of the campaign through mobilizers in several of the intervention areas, including Uige. The focus on inter-personal communications and local approaches must now be scaled up in all high-risk areas to ensure this success is replicated more broadly (see Figure ANG4).

Recommendations

• Finalize the qualitative study on reasons for missed children, ensuring that the data helps guide programming refinements in high risk populations and areas.
• Implement the revised independent monitoring form, and ensure the independent monitors are trained to accurately report on the
  communications data.
• Include communications indicators, including reasons for missed children, in the ongoing roll-out of LQAS, which is currently being piloted in Luanda.
• Scale up the high risk strategy in the 6 border provinces, and 5 high risk municipalities of Luanda to ensure more locally appropriate mobilization approaches tailored to the unique situation on the ground. It will be critical to involve local leaders, including religious leaders, to strengthen social and personal commitment to the immunization programme, given the lack of trust in the health system. This will also require increased technical support to build local capacity and to intensify monitoring and supervision.