Assessment of preparedness of COVID-19 vaccination Programme at local government level in Nepal

Abstract

Executive Summary Background: Vaccination against COVID-19 in Nepal began on January 27, 2021, achieving an 83% coverage rate, second in the WHO South-East Asia Region. However, there were several enablers and barriers to achieve this success at central level and at local implementation level. This study focuses on the local-level implementation of COVID-19 vaccination, examining decision-making processes and challenges faced by local governments in managing vaccine distribution and public health responses. Methods: A mixed-methods convergent parallel study was conducted involving 617 individuals across 14 districts of seven provinces in Nepal, selected based on COVID-19 vaccine coverage; rural municipality for low vaccine coverage and urban municipality for high coverage. The study aimed to assess the preparedness of local health facilities for vaccination and identify strategies for implementation, incorporating both health professionals and general people. Quantitative data were collected from health workers and COVID-19 vaccine focal persons from the local health facilities, and community people through interview using semi-structured questionnaire. Qualitative data were collected through key informant interviews (KIIs) with vaccination program’s focal person of from local health facility and Municipality office, former chairpersons of rural and urban municipalities, and focus group discussions (FGDs) with Female Community Health Volunteers using interview guidelines. Informed consent was secured from the participants, and data were entered into Microsoft Excel 2010 before analysis using SPSS 23.0 for descriptive statistics. Qualitative data underwent thematic analysis with RQDA software. Monitoring and follow-up mechanisms were established throughout the research to ensure data integrity. Results: The sample of community people was mainly within the 21-30 and 41-50 age groups, with females 42.7%. It was found that 27% of the participants had a morbidity, with hypertension being the most common condition (46%). Vaccination coverage was found 91.7% with 45.2% having received two doses of vaccine, and 41.7% at least one booster dose. Health workers were the primary source of vaccination information (30.5%), news portals (18.5%), and social media (17.6%) are the most common sources of information. Most participants rated the vaccination campaign positively, though unvaccinated individuals expressed concerns about side effects (45%) and safety (50%). Despite these hesitations, a large majority believe vaccines are essential for controlling disease spread (95.4%) and feel they are safe (nearly 90%). Most vaccinated individuals reported no significant side effects, with 54.3% experiencing no pain and 87.8% reporting no itching. The study aimed to explore the participation and willingness of local health workers for COVID-19 vaccination, revealing that all health workers interviewed were fully vaccinated, with 70.9% receiving a booster dose. Information sources for vaccination of health workers included other health workers (27.0%) and television (43.7%). A remarkable 94.9% rated the vaccination campaign positively, with 62.0% describing it as "very good," and 64.6% strongly agreeing on the vaccine's essential role in controlling COVID-19. Minimal side effects were reported, with 42.4% experiencing no pain postvaccination. Health workers mentioned that there was strong community support and effective communication regarding the campaign. Findings revealed that 98.8% of the participants had experience as vaccinators at the time of vaccination against COVID-19, with 92.7% willing to continue in vaccination programs. During COVID-19 vaccination, community engagement was found strong, with 90.3% were having strategies to inform local communities, primarily through individual contact, social media, and community members. However, vaccine availability was inconsistent, particularly with 41.8% rating the supply was irregular. Training programs were attended by 87.9% and only 1.2% used electronic data management systems. While 95.8% of health workers received incentives, payment delays of six to twelve months were common. Additionally, while 90.3% of sites had a vaccine list, only 1.2% had safety boxes for waste disposal, with many facilities rely on manual recording systems and faced challenges with electronic ones. Community people primarily received official information from government agencies and community health workers, such as Female Community Health Volunteers (FCHVs). Effective planning and communication were vital for vaccine delivery, although challenges arose with the availability of personal protective equipment (PPE). While health workers received training, support staff often lacked adequate training, impacting capacity during the initial roll out. Key challenges included vaccine supply shortages, hesitancy, logistical issues, and geographical barriers, especially for general public, Vaccine distribution relied on district health offices for storage and delivery, but cold chain facilities faced limitations. Coordination across government levels was crucial, with monitoring by organizations like WHO and UNICEF ensuring effective vaccination efforts. Local authorities adapted strategies to meet community needs but lacked formal written protocols. Participants emphasized the need for additional resources and highlighted strategies for future pandemic preparedness, including early detection, capacity building, and community engagement. Conclusion: There was a high level of participation and support for COVID-19 vaccination among both community people and health workers. A significant majority of the community people were vaccinated, demonstrating a strong belief in the importance and safety of vaccines, despite some concerns about side effects. Health workers also had positive attitude toward vaccination, with nearly all fully vaccinated and actively engaging in community outreach. However, challenges persisted, including inconsistent vaccine availability and delays in incentive payments for health workers. Training and data management practices need improvement, as most facilities still rely on manual systems of reporting vaccine information. The positive and enabling factors for achieving high vaccination coverage against COVID-19, and improving the identified barriers/challenges from this study could be the lessons to improve the immunization programmes and disease control efforts in pandemic situation. Key words: Pandemic, COVID-19 vaccination, community engagement, enablers, barriers