Royalty rewards to address Barriers to immunization uptake

Between 2018 and 2019 the Government of Kenya and other stakeholders intensified immunization for Polio and other diseases. During the period there were many reported cases by caregivers for adverse effects following Immunization (AEFIs) on immunized children. They mainly present as high fever, injection site swelling, skin rash, abscesses, convulsions and cough. Due to lack of knowledge regarding the AEFIs from the different vaccines coupled with a bad attitude and arrogance from government health workers , it resulted in a disconnect between health workers and the caregivers. There was a decline in vaccine uptake and immunization apathy. 

As intervention to address this was being planned  Covid-19 emerged and the fear of contracting Covid in health facilities , abrupt closing of clinics translated in missed opportunities for life saving vaccines amongst children increased. With lack of preparedness and lack of a community based vaccines initiatives monitoring system  to check on child vaccines defaults and adherence the research team observed a trend where caregivers would make false entries in their child immunization record  book to show the child had already been immunized. Since there's no coordination amongst clinics offering the service a caregiver could visit a different facility and there was no way of detecting the forged entry.As a result of this the public health problem the missed immunization will translate into  high prevalence of preventable disease, increased morbidity, mortality and disability amongst children in the first 1000 days of life for Kenya vulnerable communities. For Kenya as a country to reduce mortality and morbidity from vaccine-preventable diseases, adoption of innovative strategies will result in high coverage and minimize drop-outs and missed opportunities.

To further quantify the problem , the researcher / lead innovator and a team of community health volunteers  based within the target communities spent six months shadowing a  group of 120 caregivers picked randomly in Nairobi informal settlement and also in Kiambu rural areas as they visited the health facilities and in their day to day activities. The team noted the following as key contributors to vaccine hesitancy.

1. Overstretched and fatigued Health Service Providers in health facilities. With cost cutting measures by Kenya government and private health service providers, the health personnel were overstretched since they had to offer other treatment services apart from administering vaccines. It was observed that many of the health personnel were fatigued and in some instances there was wrong administration of vaccines. This led to AEFs ( after effects following immunization ) , there was uncoordinated and poor counseling strategy for the caregivers (mothers), unsupportive provider-client relationships and the facilities lacked a system that could track vaccine defaulters. The team observed many caregivers feared to ask questions in regards to vaccines and their impact on children for fear of retribution , being embarrassed and rudely treated by health service providers in front of other mothers. This contributed greatly to defaulting of vaccines and forging of record books to avoid harsh words from the nurses who administered the vaccines.

2. Prioritization of child immunization versus livelihood ventures. The majority of target caregivers under observation and study were mostly  casual laborers who eked a living through casual jobs. The team observed that many of the available job opportunities were available between 7 a.m to 1 p.m daily.  It was also observed that the health facilities had strict time for  vaccine administration which was between 8:00 am to 11:00 am Monday to friday due to vaccine potency. Left with no other option, many caregivers gave a priority to job opportunities rather  than the child vaccination. Majority of the infants were exposed and at risk of acquiring infectious diseases that could cause serious illness, disability or death.

3. Misinformation on vaccines and immunization programs. Amongst the poor and vulnerable communities , religious and social cultural beliefs were so prevalent. The being overly religious and belief in social cultural systems that gave unverified information on vaccines potency was observed a key in missing of life saving vaccines. Some of the religious leaders were found to have been giving  wrong messages in regards to vaccines potency like it will cause sterilization and deformities.

Inconsistent rewarding system. As a way of addressing child immunization apathy and increasing vaccine adherence , the Kenya government mobilized  stakeholders and initiated rewarding schemes for caregivers. Parents would get mosquito nets , soap and washing basins whenever they took children for routine immunization. There was a huge increase in vaccine uptake but clearly the initiative lacked a strategy that was  sustainable , was inconsistent , lacked specific target rewards and had no monitoring system to know who got what and where. The team observed a lot of double counting of immunization of infants as caregivers. Some Caregivers had two to three immunization record booklets for one child and each would be used in different clinics in order to  acquire as many free items as possible for each vaccine taken in different clinics. There was no coordinated  process to check if a caregiver had received the rewards item at a different clinic.  This exposed infants to dangerous levels of pathogens resulting in high levels of AEFIs. There was no vaccine monitoring system that could detect anomalies and remedy them in real time and no one wanted to be held responsible

Community Health Rewards System.

To address the identified problem , the lead researcher/ innovator together with a group of caregivers and community health volunteers through a caregiver centered design process  designed a Royalty rewards scheme to address Barriers to effective uptake and provision of immunization for the target caregivers in the informal settlements and rural areas. This was an incentive for caregivers to increase immunization and address immunization apathy due to AEFIs ( after effects following immunization ). The royalty rewards program better aligned caregivers incentives and needs, with the goal of addressing the unique cultural barriers to immunization uptake and the lack of accessible, trusted health information in Kiambu and urban slums of Nairobi. 

A platform was designed and it digitized the immunization booklet  enabling the Community health volunteers keys in the data through a platform installed in their smartphones and supported by salesforce software on a real time basis.The system had an integrated algorithm that as data was entered it would acal;culate and populate royalty points for vaccines taken and training attended by caregivers. It would also create alerts for default and remind caregivers a few days before to plan to visit the clinic and get their children immunized. The platform connected caregivers to a  health system and importantly monitored and tracked childhood immunization adherence in real time. The Innovative community-led caregiver royalty reward system strengthened the participating community-owned immunization advocacy processes which resulted in a transformative approach to immunization and vaccine adherence. The program's intention was to benefit children aged 0-12 months and their caregivers, by addressing the unique barriers to immunization uptake due to lack of accessible, trusted health information in rural Kiambu and Nairobi informal settlements, especially during the COVID-19 pandemic. The royalty rewards program bridged the gap for health information and services and created trust, knowledge and trust in health systems. The royalty rewards program solution has continued to better align caregiver incentives and needs with the goal of addressing •The unique barriers to immunization uptake in vulnerable settings •The lack of accessible, trusted health information in Kiambu rural areas and urban slums of Nairobi

Gates foundation and Openideo funded the initial  pilot of the innovative royalty rewards program. There was a great success and with co-creation design process with caregivers and the Community Health volunteers the program attained high levels of sustainability and ownership. Currently the caregivers are grouped in peer to peer groups made up of ten caregivers. They are then paired with each other within the group. Rather than the caregiver earning individual bonus points only like before , they now earn points both as an individual and extra  bonus Royalty points collectively as a group. Each caregiver monitors a partner within the peer group within the group in relation to vaccine adherence, attendance of education forums and child health at home. In case a peer in the group doesn't adhere to the immunization schedule, the peer group loses Royalty points collectively which in turn affects their reward standing. This has created a healthy competition amongst the peer groups and has enabled them to become innovative and strategic in order to maintain their standing and earn bragging rights. It has also increased sustainability, ownership and improved adherence of vaccines uptake by 75% within target areas. 

 We do hope to improve the system so that more community health volunteers and caregivers in future can upload data and monitor adherence and Royalty points in real time themselves. We are also testing a process whereby the peer groups agree on what reward they will give to the winning team monthly through their own resource. This way we will focus on monitoring and the caregivers will develop their own pathways in the Royalty program.

The solution currently serves caregivers with children aged 0-12 months and who are in need of live saving vaccines. The target communities are in Nairobi urban informal settlements and surrounding Rural areas that have very high poverty levels. Studies have shown  the target  caregivers are the highest defaulters of child vaccines which in essence depletes their little income when seeking treatment for diseases that would have been easily been addressed by uptake of vaccines.

The ways the innovation is and will continue impacting them is

1.  The uniqueness of the royalty program is the community involvement in design work, capturing of the child development, data is captured and responses done using a commonly understood language by each caregiver. Photos enable health service providers to have a pictorial view of immunization (AEFIs  and health bio data for quick interventions. The program enables caregivers to get discounts for services and products in a royalty kiosk owned and managed collectively or by a business person within their area. Caregivers with higher points have chances of becoming community health champions and be trained as Community Health volunteers earning them an extra income from Community serving organizations in their locality.  They also  get recognition certificates as health champions. 

2.      The Royalty program as an intervention presents an opportunity to record additional information related to the health of the families/mothers of the children being immunized e.g. on ARVs for HIV management. Increased adherence to immunization schedules, up-to-date Health management information system ( HMIS) , reduced health costs, and low morbidity among children will contribute to. improved HH wellbeing and secured livelihoods. 

3.      Missed and double vaccinations due to  lack of records exposed children to preventable viral and bacterial infections. The community identified the cost of treatment of children costly and resulted in death in some instances yet this was preventable if vaccinations were administered correctly. The health cost depleted their assets and livelihoods exposing them to shocks. Encouraging immunization will  reduce child mortality and morbidity. This would mean more income, increased wellbeing, reduced vulnerability, and improved food security and a more sustainable use of natural resource base.

4.  Caregivers expressed misgiving with the current government of Kenya immunization process which was closed and non-responsive when questions arose through defending flaws. Involvement and suggestions on community education, mobilization is vital and response from health service providers to address apathy towards immunization was lacking. The pilot observed a community that close, have a localized coded language that's not understood easily by outsiders. They also have diverse cultural, religious, social and family beliefs. These lessons have informed greatly the intervention, future expansion and sustainability. The team will record and use emerging issues to improve the process and have the team conduct scientific studies on the same.

Our innovative project was a result of addressing a pain and was designed through a collaborative process that involved the caregivers, community health volunteers and stakeholder working in the communities. Over the course of the program, we’ve piloted in four communities, trained and on boarded 4 volunteer doctors, 10 Community health volunteers, volunteer IT and data analyst's and reached to over 323 caregivers during their initial pilot phase, in addition to on- boarding an additional 200 caregivers registered not included in the initial pilot.The project is able to mobilize Quickly and build distributed teams of community champions and healthcare workers, creatively pushing successful project implementation despite staff resource constraints. The community and caregivers' ownership of the project and feedback on what is working and what can be improved in real time has created trust and belief in the process. 

The team is led by Keneth Ndua award winning global innovator in health and social impact and advises. He has continuously led the community design process and design thinking processes. He is a Program Manager with extensive knowledge in water, health, advocacy, energy access and livelihoods in Urban and Rural areas. 

The program has an advisory team made up of caregivers , community health volunteers , health professionals working in the area and an IT team that spends time voluntarily in the community.

The team of volunteers underwent training from Openideo, IDEO and Gates foundation vaccines initiative and is well versed on the problem they are solving for their community which is

1.Missing and disjointed health and immunization data across communities they live in.

2. A gap in knowledge, trust , and access to the immunization process.

3. A lack of caregiver agency to control their children’s health data.

4.  How does community-led, personalized support further encourage caregivers to join a health program that includes rewards and what type of rewards would caregivers be most interested in

The team  worked with assumptions and we tested and verified them through a process with the target caregivers and stakeholders on how a community-led , personalized support further encourages caregivers to join a health program that includes rewards.

The project graduates’ caregivers who are dedicated and adhered to their immunization schedules into super mentors in their community. We train them, equip them with skills and tools and they are able to cascade the model within their villages. By pairing them with elderly caregivers whom they trust more the project is bound to grow and be sustainable. We allow the caregivers to innovate and grow their initiatives through support of the innovation team, volunteer doctors and community health volunteers. Our team believes in our pathway and is from within the communities where the challenge is.

From using our platform to run education campaigns, we intend to reach thousands through a creative safe way to protect and expand health services, support the community while facing rapid shifts.

Our pride is that we have managed to train elderly caregivers on using smartphones in data collection, breaking the barriers of technology access for populations with low literacy levels.

1. Enhance skills in health design and innovating for community transformation through peer learning and support from experts in the field.
2. Improving on the project delivery and impact measurement.
3. Learn more on community led initiatives and sustainability
4. Learn scaling up the model through collaboration with other health service providers serving the ultra poor and vulnerable communities. 
5. Get technical support in integrating the smart royalty bungle with the tracking platform and how offgrid wifi can be used to relay data on real time.

The innovative project was a result of addressing a pain and was designed through a collaborative process that involved the caregivers, community health volunteers and stakeholder working in the communities. The community and caregivers' ownership of the project and feedback on what is working and what can be improved in real time has created trust and belief in the process. 

The uniqueness of the royalty program is the community involvement in design work, capturing of the child development, data is captured and responses done using a commonly understood language by each caregiver. Photos enable health service provider have a pictorial view of immunization after effects and health bio data. Caregivers earn points becoming community health champions, caregivers get recognition certificates as health champions. 

The adaptability and ease of use by different communities and stakeholders in addressing a common challenge that's prevelant globally makes it an important program. Its able to create immediate impact and will contribute to the health of children in the future.

The Royalty program as an intervention presents an opportunity to record additional information related to the health of the families/mothers of the children being immunized e.g. on ARVs for HIV management , increased adherence to immunization schedule up-to-date HMIS, reduced health costs, low morbidity among children. Improved HH wellbeing and secured livelihoods. From initial 25% to 75% acceptance rates was an achievement. 

Its hoped in the next five yeras through collaboration with Kenya Government and devolved units the following will be achieved.

1. At least 500,000 thousands children and caregivers enrolled in the system and real time monitoring of immunisation process digitised.
2. Over 100 community led Royalty rewards programs established and run sustainably by communities through collaboration with stakeholders in the health sectors.
3. Reduced healthy cost for Kenya health ministry and devolved units since children vulnerability to communicable and non communicable diseases will be reduced.
4. Better data for health planning and resource distribution.

The primary KPI’s are

1. No  of caregiver with knowledge on maternal child health and any serious adverse events related to vaccination. 
2. No of caregivers adhering to immunization schedule as a result of the different reward schemes/packages.

Indicators 

1. No of caregiver’s information, royalty points and baseline information and Children basic information and vaccine adherence data updated on real time
2. Household Visits/Training collected by community health volunteers during household visits and training provided records Child Health Card that digitally Stores immunization information that have been administered to the child

3. No of caregivers enrolled and how community led rewarding  for immunizing their children reduces apathy and influence other caregivers in urban informal settlements in Kenya to immunize their children.

4. No of caregivers and health service provider’s with knwoledge in relation to the royalty programand if theres any increase in uptake of immunization. 

5. No of stakeholders and collaborators adopting the  royalty program thus making it sustainable and result in improved well being of caregivers.
   

Theoretical approach

Understanding   the ecosystem components in immunization evolution in urban informal settlements and rural areas in Kenya to broadly reveal the important support mechanism which forms and influences formation of specific barriers to the health, social impact, actualization of sustainable and transformative immunization strategies in urban informal settlements. This is done through an in-depth understanding of immunisation rewards programs and social innovation in relation to addressing barriers towards effective uptake of immunization.  Our theory of change Involves  health service providers financial and non-health support measures/services, stakeholders, implementing agencies). Gap Analysis – Identifying the gaps in the current support system for immunization, knowledge, feedback and non-financial support measures/services currently in place to       encourage immunization uptake and reduce apathy. 

The project is powered through saleforce and previously was using Taroworks for data collection. Currently exploring of Google suite and intergrate it into the saleforce system. This system enabled Interactive collection of data on real time, maping challenges on real time and enabling interventions to be designed and implemented on time. This also helps on mapping of households on GPS for each of tracking. Aggregation of caregivers and children using various parameters.

• Digitized Child immunization health records making it easy to track adherence and inform on next vaccines clinic visit dates

• Real time flagging of defaulters which is Immediate mentorship / follow up
• Limitless data collection, ease of replication by other organization 
• Adaptability to monitor other Health crisis like Covid-19. The system is currently tracking reported COVID-19 cases in caregiver’s communities and current preventive intervention’s

The project does not dicriminate caregivers or stakeholders by the ethinicity , social cultural or religious beliefs or their sexual orientation. We are inclusive and embrace diversity

Our business model currently has two components illustrated by the following business model canvas https://canvanizer.com/canvas/...

1. B2B. Government , NGOs who will act as agents and implement the project to help them track their project geared towards child immunisation.
2. B2C. Where caregivers will own a sale point for smart Bungle's and royalty redemption points for royalty rewards

1. Charging for SMS SERVICES

• Licensing NGOs and government institutions at a cost to derive data for fundraising and planning service's

Received two grants from Openideo and Gates foundation

We are working on getting impact investors to invest in the program and commercialise the process. The expansion will target government and NGos sector in adopting and paying for the services.

Theres is interest with devolved untits in Kenya in adopting our system