Engagement of Private/Nongovernmental Health Providers in Immunization Service Delivery

In 2012, the World Health Assembly adopted the Global Vaccine Action Plan (GVAP), with the goal of providing equitable access to vaccines by 2020. The GVAP sets ambitious targets that may only be attainable through shared responsibility and partnerships of the various groups involved in providing health care. Engagement with non-governmental (private) providers to achieve optimal vaccination services has the potential to help improve programme performance and increase coverage, but only if their respective roles are clearly defined. Available in 3 languages, this World Health Organization (WHO) guidance note for national immunisation programmes (NIPs) explores these roles and relationships, providing recommendations to support optimal engagement of private providers in the effective delivery of NIPs.

Non-governmental vaccination providers come from a diverse range of sectors that include both for-profit and not-for-profit civil society organisations (CSOs), non-governmental organisations (NGOs), and faith-based organisations (FBOs). They have varying roles in the delivery of vaccination by NIPs and in the provision of other immunisation-related services - e.g. health education, advocacy, awareness raising, demand creation, resource mobilisation, and vaccine-preventable disease (VPD) surveillance.

Private sector engagement (PSE) has been shown to add value in the health system at various levels, including by increasing access to skills and expertise, boosting operational efficiencies, increased innovation, sharing risk, and allowing the government to focus on its core competencies. PSE is particularly important in low- and middle-income countries (LMICs) or in areas of civil strife, where governments may lack the capacity to achieve national health and vaccination goals.

WHO explains that, regardless of whether the government sector proactively engages with the non-governmental sector, it is likely that NGOs and non-governmental providers are already playing a role in immunisation services in most, if not all, countries. Yet information exchange between government and non-governmental sectors, particularly for-profit providers, is weak in many countries. In LMICs and in some high-income countries (HICs), mechanisms for reporting of adverse events following immunisation (AEFIs) are limited in the non-governmental sector due to human and financial resource constraints and limited competencies.

In that context, the WHO guidance note looks at various considerations concerning the engagement of the private sector in NIPs. For instance, in order to overcome preconceived misconceptions and biases between the public and private sectors, PSE should be approached in a way that encourages maximum trust and predictability. To build trust and foster dialogue, WHO suggests building engagement step by step through transparency and shared visions and long-term goals, with realistic expectations about relative contributions, capacities, and timelines. Starting with small collaborative projects and building relationships over time, with opportunities for short-term successes to demonstrate progress, is part of this relationship-building process and allows partners to demonstrate commitment. Opportunities for structured dialogue include facilitating the private sector to participate in task forces, leadership committees, information sharing, and policy changes and prioritisation. It is essential for all parties to enter into contracts with clear expectations on performance, including performance measurement and consequences. Practical toolkits are available to assist governments with the process of contracting.

With regard to advocacy, if a provider, private or public, is unable to communicate the need for vaccination or lacks pertinent information, this will likely have a negative impact on vaccine uptake. In addition, divergent messaging about vaccination by public and private providers can contribute to a loss of public confidence and to vaccine hesitancy. It has been noted that improper knowledge among private providers and vaccine hesitancy are greatest for new vaccines, the administration of multiple vaccines in one visit, conjugate vaccines, and where more than one vaccine type - e.g., oral polio vaccine (OPV) versus inactivated polio vaccine (IPV) - is currently in use. It is therefore important to build healthcare worker knowledge and to study and manage vaccine hesitancy among healthcare providers in both the private and public sectors.

When a high proportion of curative services is provided through the private sector, the latter becomes an important source of data on both VPDs and AEFIs. Even if private providers do not directly deliver vaccines, their engagement in surveillance of VPDs and reporting of adverse events is needed. Lack of knowledge about the value of post-marketing vigilance, reporting mechanisms, and a "blame" culture could contribute to underreporting of AEFIs. Engaging private providers through professional associations, provision of professional development support, immunisation forums, and health-information communication linkages can support a collaborative relationship and build understanding between the sectors.

A universal standard approach to engaging the non-governmental sector is neither realistic nor appropriate, given the varying situations in individual countries. However, WHO's overall recommendation is that NIPs should optimise collaboration and communication with non-governmental providers regardless of the relative contribution of non-governmental providers to the delivery of vaccination. Specific recommendations are provided in the guidance note with respect to activities to:

• Assess non-governmental providers' contribution to immunisation service delivery.
• Determine the optimal model of public-private engagement and optimisation of service delivery.
• Facilitate dialogue and establish agreements and contracts for collaborative activities, including for decision-making. Good practice in policy and dialogue:
  • government policy to work with the private sector as a partner in the delivery of services
  • formally instituted dialogue mechanisms
  • ongoing dialogue between the government and the private sector
  • ongoing implementation of engagement policy
• Ensure adequate data management and reporting.
• Provide adequate training and capacity building.
• Support accountability and performance oversight.

Such exercises can be useful to foster conversations with private sector participation in the engagement process and to flag major system challenges relevant to the private sector - allowing identification of policy reforms, system changes, and potential solutions that could address these challenges. The aim is to encourage closer collaboration between the public and private/non-governmental sectors and hence a more effective engagement of the private sector in supporting NIP priorities.

Click here for the 33-page document in PDF format (French).
Click here for the 33-page document in PDF format (Russian).