HPV vaccine introduction in Mozambique: Generating knowledge from the demonstration project for national roll-out decision making and planning

Abstract

Abstract HPV vaccine introduction in Mozambique: Generating knowledge from the demonstration project for national roll-out decision making and planning The studies in this dissertation describe an evaluation of the implementation of a HPV vaccination delivery demonstration project in Mozambique. Specifically, this work identifies the drivers of heterogeneous implementation performance during the 2-year project, by employing the Consolidated Framework for Implementation Research (CFIR) for analysis (Aim 1); tests the contribution of network structure on the added value of the project’s implementation partnership (Aim 2); and describes the implementation strategy and cost estimates for the project and a fully immunized girl (FIG) (Aim 3). In Aim 1 we found that 18 CFIR constructs emerged from informants’ responses as implementation influencers. Adaptability was identified as an important construct because delivery models needed to be adjustable to differing levels of girl school attendance. Expanding outside of school-based delivery was necessary in the lower performing district and was challenging. Available resources varied across the three sites, with one site receiving direct donor support, whilst others received primarily state-based support. These latter sites reported considerably more implementation bottlenecks, manifested in the examples of weaker structural characteristics and insufficient organizational incentives. Health workers beliefs in vaccines’ relative priority and organizational culture of personal sacrifice to undertake program activities drove performance. The positive drivers of implementation success can be capitalized on during country wide expansion of HPV vaccination. In Aim 2 Social Network Analysis (SNA) measures for partnership structure corroborated the perceived outcome survey results. They revealed a partnership network characterized by high overall connectivity scores of reachability 100% and average distance 2.5, features that are favorable for rapid and widespread diffusion of information, and also necessary for engaging and handling multiple implementation scales. High SNA effectiveness and efficiency measures for structural holes (85%) and low redundancy (30%) coupled with high mean perceived effectiveness (97.6%) and efficiency (79.5%) outcome scores were observed. Disparate institutions and organizations worked in a collaborative environment in which the comparative advantage of each entity was leveraged, thereby producing an effective and efficient partnership model that can be adapted during national scale up of HPV vaccination. In Aim 3 we found that total implementation costs for the whole project in the three pilot districts were $523,601, 99.4% of which were direct medical costs. Annual patterns and cost compositions of the aggregated costs provided insight into the factors contributing to changes in costs. They showed that important cost determinants were high vaccine price, number of administered doses, program startup costs and the necessity for rigorous demand generation. The cost per fully immunised girl of $54, amounts to more than 50% of Mozambique’s current estimated health spending per capita of $92 making the vaccine extremely expensive to introduce. The country will need to consider strategies where savings can be achieved in order for national roll out of the HPV vaccine to be both feasible and sustainable. The goal of the research in this dissertation, is to inform decision and policy making for national expansion of HPV vaccination in Mozambique, other low and middle-income countries, and global donors and implementing partner organizations.