A qualitative evaluation of the immunization program in Papua New Guinea.

OBJECTIVE An in-depth evaluation of rural immunization services in Papua New Guinea was conducted to determine the reasons for poor immunization coverage, as well as to document the impact of recent efforts to strengthen the national immunization program. METHOD A qualitative process was used to complement quantitative monitoring data. An interview process, based on open-ended questions, active listening and observation, was designed whereby a team of program supervisors collected information from rural health staff. The teams interviewed health staff in 30 health centres that were selected to provide examples of contrasting field situations. RESULTS This qualitative review provided valuable detail about why immunization services were failing, encompassing locally specific weaknesses, such as logistic reasons for not conducting outreach, and generic systemic problems such as lack of access to funding. In addition, the information gathered provided details on local solutions developed by better-performing facilities. Both these aspects added significant value to quantitative measures of program performance (derived from national health information system data and analysis of supervision checklists). The review also captured a number of behavioural reasons that will need to be overcome before an improvement in the services can be expected. CONCLUSIONS AND IMPLICATIONS This in-depth evaluation provided valuable information about problems in peripheral immunization clinics and identified local solutions. The high level of detail collected will be important for planning future strengthening of the health system. The study modelled a supportive form of supervision with the potential to improve outcomes from future supervisory visits. Some of the major barriers to improved immunization were locally specific organizational issues, as well as complex human problems. While some issues can be remedied through further strengthening of immunization systems, others lack easy, rapid solutions.