Coordination Mechanisms for Integrated Health Campaigns: A Descriptive Review

This descriptive investigation was organized around the coordination structures that programs targeted by HCE will typically apply to integrated campaigns. These structures centered around an overarching national leadership team with subcommittees focused on technical coordination, administration, communications, monitoring, and evaluation including data collection and digitalization, and typical sub-national coordination structures such as those at the regional, provincial, district, and community levels.

Leadership Team

The literature review and interviews revealed a variety of campaign leadership structures, largely involving national coordination committees chaired by high-profile government individuals or program managers. Countries have typically organized a national-level Interagency Coordinating Committee to oversee campaigns, including for integrated immunization campaigns (particularly for polio and Vitamin A), for vertical malaria ITN campaigns, and through the polio elimination initiative in Angola, Chad, and Zambia [4,5,6]. For NTD Control Program covering onchocerciasis, lymphatic filariasis, trachoma, and schistosomiasis, the Director of Disease Control and Prevention chaired coordination leadership [7,8]. The International Coalition for Trachoma Control guidelines recommend a well-functioning National Trachoma Task Force involving governmental and nongovernmental members from such sectors as water, sanitation, and hygiene (WASH), education, agriculture, information, health, and administration to coordinate plans with those of the NTD program [8]. The respondent from Ethiopia revealed that each disease has a specific task force, which serve as technical groups such as those for trachoma and lymphatic filariasis.

The first lady of Honduras has overseen high-level coordination for annual integrated NTD vaccination campaigns, while the Minister of Health in Colombia has taken charge of the national campaign coordination [9]. The directors of Nepal’s Epidemiology and Disease Control and Family Welfare Divisions co-coordinated the lymphatic filariasis elimination and vitamin A supplementation campaign [10]. Nepal’s Ministry of Health created a campaign integration working group that approved the project work plan and guidelines and issued directives for completing preparations before the campaign launch.

Nigeria’s National Measles Technical Coordinating Committee oversaw its 2017-2018 measles vaccination campaign as well as the 2019 integrated measles, meningitis, and yellow fever campaigns. The Committee was created in part to ensure accountability and transparency in implementing the campaign, under a broader national framework to address challenges faced with lack of accountability in previous campaigns. In this context, the Committee established reporting protocols, roles and responsibilities, communications timelines, and oversight of payment of vaccination teams [11]. The Committee was integrated with the Polio Emergency Operations Center to overcome poor high-level political commitment as observed by previous measles vaccination campaigns. The Polio Emergency Operations Center is under a Presidential Task Force chaired by the President. In the Democratic Republic of Congo, the original Interagency Coordination Committee for polio was expanded into a National Coordinating Committee for disease control [4,12].

Guidelines for conducting stand-alone ITN campaigns—whether for targeted populations or for universal coverage—recommend that national malaria programs establish a central coordination committee for campaign planning [5]. This can either be a new coordination structure, or a subcommittee of an existing coordination validated by the Minister of Health [6]. In Ghana’s 2018 vertical ITN campaign, a Mass Campaign Planning Team led by the national malaria program manager provided leadership and direction and was responsible for overseeing and communicating on all aspects of the campaign [13].

The literature and interviewees identified the following general responsibilities of the leadership team:

• Establish campaign strategies
• Oversee all campaign planning, implementation, and evaluation
• Approve technical and operational guidelines to be used in campaign
• Liaise with international partners for resource mobilization
• Convene various actors, donors, and all key stakeholders to coordinate campaign activities
• Oversee coordination sub-committees’ activities, including actual implementation of campaigns
• Allocate donor funds to different programs to implement campaign
• Review campaign progress, prepare and validate the final campaign report

In addition, interviewees emphasized the need for diverse membership within the coordination structures, including health programs managers, national public health institutes leaders, communications heads, donor partners, school management authorities, and community group leaders at national and subnational levels. They also observed that some representatives of departments or sectors were often excluded, such as private sector representatives. Ethiopia’s National Coordinating Committee leadership team missed a representative from a water, sanitation, and hygiene (WASH) program in one campaign, and the subnational coordination mechanism in Cameroon lacked representation of the faith-based organizations despite their significant role in health communication and achieving wide community reach and trust. These oversights highlight the need for inclusive leadership and equitable decision making when determining membership of these coordination structures.

Technical Coordinating Committees or Subcommittees

Technical coordinating committees (TCCs) or subcommittees typically provide technical assistance nationally for planning, training, logistics, data management, supervision, communication and social mobilization, and monitoring and evaluation. These responsibilities were identified for TCCs supporting immunization campaigns (i.e., measles and polio in Nigeria, polio and vitamin A in Ghana), ITN distribution (Nigeria, Ghana, Mozambique), and NTDs in Mali [6,7,12,13,14]. Depending on the country or region, the TCCs also supported logistics and data management. For the NTDs campaign in Mali, the Chief of the Division of Disease Prevention and Control chaired the TCC, which consisted of four national coordinators of the disease-specific control programs, the head of the Nutrition Division, and representatives from the National Public Health Research Institute, the National Center for Information, Education and Communication, and the representative of the nongovernmental development organization grantee [7]. Meeting intervals for the TCC and subcommittees varied from weekly, monthly, and mostly quarterly intervals for planning, budgeting, with targets set according to campaign timelines, and campaign activities reported to the Interagency Coordination Committee or National Coordinating Committee [5,7,12,13,14].

Administration

While country governments assume administrative responsibilities for coordination mechanisms, donor partners appear to provide the most funding to implement the coordination structures. The governments (largely the ministries of health) allocate operational funds, and organized training and supervision-for both the vertical and integrated campaigns in coordination with the campaign partners such as the World Health Organization (WHO), the Bill & Melinda Gates Foundation, United Nations Children’s Fund (UNICEF), and Population Services International. Mali’s Ministry of Health worked with the United States Agency for International Development in administrative coordination of NTD campaigns, and the Governors’ Forum was responsible for allocating funds to endemic regions [7]. This review could not clarify meeting intervals and forms of reporting for these administrative activities.

Most interviewees noted that donors alone funded most coordination operations including per diem or transportation costs for attendees at coordination meetings. One interviewee highlighted this dependency on donor funding for these coordination mechanisms, noting that they would be called “advocacy meetings,” which qualified for donor-eligible funding, versus “coordination meetings,” which donors saw as a government responsibility. In Nigeria and Nepal, governments provided meeting facilities or jointly covered the cost of meetings with donor partners. In decentralized country structures such as in Nigeria, the state-level joint program subnational committees allocated the administrative funds for the coordinating body. The literature reviewed on campaigns did not describe funding specifically allocated for coordination mechanisms.

Communication

Social and behavioral change interventions are integral to all types of health promotion, improving behaviors, and ensuring strong outcomes in response to health campaigns. In integrated campaigns conducted in India (for immunizations) and Ghana (vitamin A and polio), the Ministry of Information’s Information Service Department coordinated social and behavioral change interventions along with health partners, while social and behavioral change subcommittees were prominent in both vertical and integrated ITN campaigns [5]. The scope of work included pre-publicity and social mobilization using a variety of channels such as mass media and the use of artists and influencers. Details from this review were limited on how they functioned, how often they met, and how they reported on their activities.

Monitoring and Evaluation (Including Data Collection and Digitalization)

As noted earlier, this review found that technical coordinating committees or subcommittees often oversee monitoring and evaluation, which include data collection and digitalization for various aspects of campaigns. The interviewees in all five countries reported to have integrated data collection tools and digitalization, which included surveys, tally sheets, and monitoring and evaluation forms, directed by either the technical coordinating committees or program focal persons. Data from the integrated services was electronically transmitted from the district health information system in place, then transmitted to the national information system. This review could not generate further details on successes and challenges specific to integrated monitoring and evaluation including data collection.

Subnational Coordination Mechanisms

The subnational levels include the state, county, regional, provincial, district, and the village/community as the lowest level.

• State, county, regional, and/or provincial coordination structures: At these levels, regional health teams in some countries coordinate planning activities, training and supervision of district health teams, and reporting to the National Coordinating Committee or Interagency Coordination Committee [4,15]. In Nigeria (particularly the polio campaigns and non-polio supplemental immunization activities), the National Emergency Operations Centers and a State Task Force led by Director/ Chairman and Deputy Chairman, and the state polio incident managers took the lead in managing and coordinating the campaigns in their respective states [12]. Executive secretaries of the State Primary Health Care Development Agency oversaw clusters of local government authorities in all states, from planning through implementation of the campaigns [6].
• District and community-level coordination structures: District health management teams—the District Coordinating Council in Ghana’s vitamin A and polio campaign and the District Task Force for Immunization in India’s immunization campaign—coordinated most district-level campaign operations including planning, supervision, training of community health campaign workers, and reporting to the regional health teams [4,5,6,12]. At the subdistrict level for Mali’s NTDs integrated campaigns, community health workers were paramount to coordination in their catchment areas, including campaign planning, supervision, and selecting and training of community-directed drug distributors in villages. In Nigeria’s ITN and measles campaigns, community members provided coordination with household mobilizers and community drug distributors, ward supervisors, and distribution point supervisors overseeing activities including ITN inventory [5].

The interviewees noted that the organization of sub-national coordination structures mirrored the national-level structure and adopted the guidelines established at the national level. However, the federal system of government in countries such as Ethiopia decentralized organization of campaign coordination to the district levels.

Enablers of Coordination

The following factors were found to support integrated coordination mechanisms:

• Government support and political will. The interviewee describing Sierra Leone’s experiences highlighted the country-level ownership of the malaria program—including the direct interface between the President, the Ministry of Health, and the integrated campaign National Coordinating Committee leadership team—as a factor that strengthened integrated campaign coordination. When the government actively leads the coordinating mechanism, integrated campaigns can benefit from more rational planning and allocation of resources. Ultimately, such strong leadership can help ensure the potential for replicating that coordination structure for future campaigns and even for general health service delivery.
• Strong and effective leadership; working in harmony with the same objective. Across different campaign meetings and activities, well-positioned leaders (or champions of integrated campaign activities) are critical facilitators of convergence, as they can draw together siloed campaign domains.
• Global Campaign Integration Working Groups as models for countries: Working groups at the international level that bring together programs to identify opportunities for campaign integration or coordination incentivize coordinating mechanisms at the country level. Several global strategy and guidance documents describe these working groups, for example:
  • Measles and Rubella Strategic Framework 2021–2030:
    “Governance structures and coordination mechanisms that facilitate joint programming, promote integration between different health programs and foster intersectoral collaboration (such as between the health and education sectors or the public and private health sectors) should be strengthened or established to facilitate life course vaccination.” [16]
  • Considerations for Planning Integrated Campaigns–Immunization and Beyond (forthcoming)
• Conducting a stakeholder analysis at the outset of campaign planning: The interviews identified such an analysis as an important enabler of effective campaign integration, as it ensures engagement of key, influential partners with shared objectives and critical functions.
• Diverse partners and donors for the programs. Since 2017 in Nigeria, a global Country Working Group supports coordination of measles and non-polio supplementary immunization activities. The Country Working Group links representatives of the US Centers for Disease Control and Prevention, Gavi the Vaccine Alliance, WHO, and UNICEF at the global level and meets regularly with the country coordinating team to ensure timelines are met while preparing for campaigns. They also help issues such as vaccine availability and accountability. In the same vein, both the public and private sectors were engaged for their contributions toward programs.

“The private sectors are allowed to bring their own areas of strength, where they support for a partnership and collaborate in implementing programs. For instance, the private sector played a key role in provision of network services to facilitate communication.” —Key informant

• Clear mandates to members of the coordination teams. On Sierra Leone’s experience:

“One of the things that made the most difference was having minutes and action points assigned to different people or programs to say who needs to do this because you’re behind or its EPI [Expanded Program on Immunization] that needs to do this because you’re behind.” —Key informant

• Availability of global guidelines on and high-level support for campaign coordination through such documents as the London Declaration 2012 on NTDs, which stated:

“Enhance collaboration and coordination on NTDs at national and international levels through public and private multilateral organizations to work more efficiently and effectively together.” [17]

• Community ownership of and trust in the services being provided through integrated campaigns.
• Promoting a joint funding basket for integrated campaigns to provide more flexibility and efficiency to the coordination mechanism in implementing the campaign.

Barriers to Coordination

The respondents interviewed from different countries suggested that the following factors posed a challenge to country-level integrated coordination mechanisms:

• Challenges in accounting of funds designated for campaigns by individual donors. Most donors of different programs required specific reporting on how their funds were used, but program integration made this a challenge. In addition, according to one of the Nigerian respondents:

“We have an accountability framework, but the implementation is not as it should be, hindering coordination. Accountability problems arise because sometimes some of the partners are not forthcoming, about how to spend their money.”

• Funding restrictions by donor and donor dependency, as some donors restricted use of their funds to specific program areas. Establishing a joint funding basket was mentioned as an alternative. The Ethiopian respondent stated:

“Each donor provides funding for each specific disease/program in that the money can never be used for any other program even if it’s accessible. For instance, funds for trachoma cannot be channeled to onchocerciasis.”

In Cameroon, the interviewee cited issues with compensation of individuals who attended the coordination meetings:

“There is need to compensate the people attending meetings, in either in cash or in kind; for instance, T-shirts or caps as a way to motivate them even though compensation mode may differ as you go down to different levels.”

• Competing health priorities restricting budgets for integrated campaigns. In Nigeria, the national and state government prioritized campaign integration differently. For example, some state governments chose not to incorporate vitamin A supplementation and soil-transmitted helminths treatment with albendazole into a planned maternal, newborn, and child health week, despite national interest and directives.
• Different target groups for the campaign services: for example, health workers in Nepal may have challenges to address different target ages for vitamin A supplementation (children ages 6 months to 5 years), and mass drug administration for lymphatic filariasis (children ages 2 years and older).
• Interference from the COVID-19 pandemic, which led to lockdown or otherwise halted health campaigns in some countries, such as in Ethiopia during its acute period of COVID-19 in April 2021.
• Narrow specialization of health workers, for example, requiring coordination of additional training of immunization staff for other program services.
• Inadequate briefing to members of the coordinating body due to missed meetings, hindering effective coordination.

Campaign Coordination in Complex Operating Environments

A complex operating environment is defined by the Alliance for Malaria Prevention as:

“a country or part of a country in a situation of disrupted livelihoods and threats to life produced by warfare, civil disturbance, natural disaster and large-scale movements of people, which have led to or exacerbated weak governance, poor access to health services, mass famine or food shortage, fragile or failing economic, political and social institutions and created an operating environment with high risks, insecurity and threats to delivery of health care services and to health care workers” [18].

The need to provide multiple health services quickly in these settings can make campaign integration essential. Coordination mechanisms must be in place to address multiple funding streams and timelines for receiving funding. To avoid delays, the Alliance for Malaria Prevention recommends that coordination mechanisms for health cluster partners in emergencies establish “a joint timeline…with key milestones that will allow for early warning of delays to ensure timely communication with beneficiaries and donors” [18].

Similarly, the United Nations Refugee Agency (UNHCR) recommends the delivery of health and social services using standardized coordination mechanisms such as camp coordination and camp management cluster mechanism for operations in settings for internally displaced persons, and a refugee coordination model for refugee operations. In all operations, UNHCR advocates for strong governmental support and cross-sectoral partnerships for effective and efficient service delivery. It also proposes the use of designated mobile teams or community-based organizations to ensure continuity of services including health and nutrition interventions for clusters or areas with long distance and security challenges.

Key informants cited the following challenges for establishing integrated campaign coordination mechanisms in these settings, which mirror those of stand-alone campaigns:

• Poor infrastructure, which made it difficult to reach populations in remote areas. This necessitated microplanning to establish fixed sites in these areas to ensure access.
• Natural disasters including drought and famine posed great challenges for providing integrated services in semi-arid regions, as with mobile populations in Ethiopia. The country campaign coordinators designed specific outreach to these communities.
• Lockdowns due to the COVID-19 pandemic, which halted campaigns. The campaign coordination team in Lagos state, Nigeria, developed a plan to “routinize” campaign services to reach beneficiaries and avoid overcrowding. In other words, services were provided through routine services rather than attracting crowds at campaign sites.
• Political instability and insecurity in war-affected regions that posed insecurity. In Cameroon, the campaign coordination team organized temporary posts to provide services.

Coordination with COVID-19

Coordination teams for campaigns implemented during the emergence of COVID-19 referred to the pandemic-related adapted guidelines developed by countries’ COVID-19 Task Forces [5]. For South Sudan’s vertical ITN distribution campaign, the National Malaria Control Program coordinated its COVID-19 adaptations with international partners such as the Alliance for Malaria Prevention, Global Fund, the Malaria Consortium, Population Services International, and WHO. In Comoros, the central coordination committee comprising staff from different offices of the national malaria program worked with the National Commission for the Fight Against COVID-19 to design and implement its vertical ITN campaign [5].

The key informants all mentioned the presence of a national task force that provided guidance to the campaign coordination bodies, as in Nigeria. In Ethiopia, the NTD campaign coordination team referenced program-specific guidelines developed by WHO for COVID-19 adaptations. Programs also adhered to state-level guidelines on COVID-19, with some campaign programs suspending all activities from March 2020 and resuming services at various times depending on country strategies.