Appreciative inquiry: Nepal uses new approach to achieve full immunization for children

STORY HIGHLIGHTS

  • The appreciative inquiry (AI) approach was initiated by WHO in coordination with the Government of Nepal in 2012 to mobilize local communities and resources and build ownership among local communities towards the national immunization programme and ensure vaccination of every child in the country.
  • The underlying principle of AI is to focus on existing strengths and achievements rather than on analysis and criticism of unmet goals. This strength-based management tool is geared toward triggering an inner transformation within individuals who begin to see themselves as catalysts for change. Thus motivated, they take more responsibility and need less external support, supervision and monitoring to achieve their goals.
  • Other countries, including Afghanistan and Bangladesh, are interested to learn from Nepal’s success in using AI to achieve improvement of maternal and child health goals, including immunization.

Forty-one-year-old Nara Bahadur Karki was luckier than many in Kathmandu. The recent earthquake damaged his house. He slept out in the open for eight days. But no one died or was injured in his family. Now, he is back home, and has come to terms with the reality that he has lost many friends in the quake that devastated large parts of Nepal.

Now is the time for “healing and restoration,” says Mr Karki, a public health professional, who is a well-known appreciative inquiry practitioner and coach, and has conducted over 40 AI workshops in districts across Nepal. Perhaps it is the transformational nature of AI that lies behind his optimism.

“The underlying principle of appreciative inquiry is to focus on existing strengths and achievements rather than on analysis and criticism of unmet goals. After a three-day training session, this strength-based management tool helps to trigger a transformation within individuals who begin to see themselves as catalysts for change. Thus motivated, they take more responsibility and need less external support, supervision and monitoring to achieve their goals. This has been used very successfully in Nepal for social mobilization to ensure full immunization for every child,” adds Mr Karki.

Doing the same thing but in a different way

The national immunization programme is a top priority for Nepal. Currently the government provides 12 antigens – BCG, DPT-HepB-Hib, OPV, IPV, MR, PCV and JE (high-risk districts)–free of cost to children mainly through 16 000 outreach services. The vaccination coverage has increased over the years. The reported national coverage for the pentavalent (DPT-Hib-HepB) vaccine is more than 90% and that of the measles-rubella is about 88% but the overage is not uniform throughout the country. It varies due to many reasons – geography, sociocultural factors, ethnicity, mother’s education and family income.

Despite the government’s efforts to strengthen routine immunization over the years, 15% of children in this small, land-locked nation do not receive full immunization and 3% of children never receive any vaccines, according to the Multiple Indicator Cluster Surveys (MICS), 2014.

“The idea of using appreciative inquiry for full immunization was initiated by WHO in coordination with the Government of Nepal in November 2012. The AI facilitator, who works with WHO, facilitates AI-based workshops at the district level in addition to assisting in national reviews and monitoring,” says Dr Rajendra Bohara, National Coordinator, Programme for Immunization Preventable Diseases, WHO, Nepal.

How does AI help in ramping up immunization?

The process starts with a three-day AI workshop in the districts. The participants of the workshop include village development committee (VDC) secretaries, executives of municipalities, heads of health facilities, district-level officials, political leaders, media and local representatives of social organizations. During the workshop, participants make a commitment to ensure vaccination of every child. This is a transformative experience. After returning from the workshop, participants hold a series of meetings at the local level and take necessary action to ensure that every child eligible for vaccinations gets them. The AI session acts as an energizer.

In several places, there has been a palpable impact soon after the workshop. Vaccinators have been recruited. Additional incentives have been given to female community health workers to get every child vaccinated. Local leaders, media and teachers have pitched in for the initial verification process to certify that every child is vaccinated.

Once the community is sure that all children below one year of age have been vaccinated,they invite the district coordination committee to verify the results, and request the VDC, municipality and district officials to go for a full immunization declaration.

The district coordination committee carries out a random survey to ascertain that no child is left unvaccinated. Then it gives permission for the declaration ceremony to take place to declare the district fully immunized for under-5-year-old children.

Goal achieved, there is a public ceremony that is attended by senior officials of the Ministry of Health including the minister, political leaders, partner agencies, the local community, schools, the media, mothers’ groups and female community health workers. In the ceremony, which takes the colour of a festival, the community workers and people who helped achieve the goal are felicitated for their hard work. In 2014, a village committee provided bicycles to the female community health workers for their contribution towards full immunization during the declaration ceremony in the Nawalparasi district.

“Being a part of the AI-based full immunization initiative has bought a sense of responsibility and commitment within us. The realization of potential within us has made us creators of new realities in our community through mobilization of local resources, ownership and participation,” says Lok Darshan Koirala Ward Secretary, Pokhara Sub-metropolitan City-9.

Mahendra Bista, Chairperson of the Federation of Nepalese Journalists, Morang, eastern Nepal, says that his involvement with the AI-based full immunization programme led him to recognize the constructive role that the media can play in bringing about social change by inspiring, empowering and motivating the community towards a shared dream.

Results

Since its inception in 2012, more than 900 VDCs, 35 municipalities and 8 districts have been declared fully immunized. The full immunization declaration process exemplifies successful coordination and cooperation between various line ministries (education, local development, women and child welfare, etc.). Nepal has set itself a goal – Declaration of a Fully Immunized Country by 2017.

Nepal’s experience in using AI to achieve public health goals such as improvement of maternal and child health and now full immunization has evoked interest by other countries. A delegation from the Ministries of Health from Afghanistan and Bangladesh visited Nepal to observe and participate in the AI training and declaration ceremonies.

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