All values formula-driven. Updated as missions progress.
Active Priorities
Mission 1 · Identify
Investigation requested — find out why coverage is declining
Open Briefing
Mission 2 · Reach
Response planning required
Locked
Mission 3 · Monitor
Awaiting implementation
Locked
Key Contacts
Supervisor Ibrahim
District Supervisor · Awaiting review
👨🏾💼
Laila Musa
Community Health Worker · Latest update available
👩🏾⚕️
Chairman Tanko
District Leadership · Meeting requested
👨🏾⚖️
Five missions · District Review Board · Field Guide
District Briefing · Kwara North
Coverage is declining in three wards.
The reports don't agree on the cause. Before resources can be deployed, district leadership needs a clear understanding of what is happening. Find out why coverage is falling.
Supervisor Ibrahim
We've confirmed declining coverage in three wards.
The reports don't agree on the cause.
Before we can act, we need to understand what's really happening.
Find out why coverage is falling.
What is a zero-dose child?
A zero-dose child is a child who has not received DTP1 and therefore has not entered the routine immunization schedule.
Some may have received vaccines given at birth, such as BCG or OPV0. However, without DTP1 they remain outside the routine vaccination pathway.
Zero-dose children are often among the most vulnerable in a district, disproportionately concentrated in underserved communities and populations facing persistent barriers to care.
The calculation: Zero-dose children = Surviving Infants − DTP1 Doses Administered. For the purposes of this simulation, estimates are derived from surviving infants and DTP1 coverage data. In practice, zero-dose estimates draw on multiple sources including surveys and administrative datasets.
📍 Kwara North Reality
Facility records report 72% DTP1 coverage. Applying the zero-dose formula suggests that approximately 2,500 children have not received DTP1 and have therefore not entered the routine immunization schedule.
Some may appear in birth-dose registers for BCG or OPV0. However, the operational definition of zero-dose is based on the absence of DTP1, not the absence of every vaccine.
Most of these children live in the district's poorest households and most underserved wards. Reaching them is your primary responsibility.
14.3M
Global zero-dose children
67%
Live in 10 countries
50%
In conflict-affected areas
Why implementation science?
Vaccines work. The challenge is not whether vaccines are effective, but whether they reach the people who need them.
Implementation science examines why proven interventions succeed in some settings and fail in others. It helps practitioners understand how context shapes results and how delivery systems can be strengthened to improve outcomes.
Examines the gap between efficacy and real-world performance
Explains why the same intervention can succeed in one setting and fail in another
Provides structured frameworks for diagnosis, design, implementation, and evaluation
Grounds decision-making in evidence rather than assumptions
Alignment with the Immunization Agenda 2030
DISTRICT is aligned with the Immunization Agenda 2030 (IA2030) — the global strategy endorsed by the 73rd World Health Assembly. Its overarching vision: "A world where everyone, everywhere, at every age, fully benefits from vaccines for good health and well-being."
IA2030's three impact goals
🛡
Prevent Disease— Reduce mortality and morbidity from vaccine-preventable diseases throughout the life course
⚖
Promote Equity— Leave no one behind; reduce zero-dose children by 50% by 2030
🏗
Build Strong Programmes— Strengthen immunization within primary health care and universal health coverage
Every mission in DISTRICT connects to a specific IA2030 strategic priority. The mapping is shown in the mission completion screens as you progress through the course.
Source: WHO Immunization Agenda 2030 (WHA73/9, 2020).
Quick check — before you proceed
Your district shows 72% immunization coverage. A colleague says: "We're doing well — let's focus on improving the cold chain." What is the most important concern with this recommendation?
✓ Exactly right.
Coverage numbers mask who is unreached and why. Before any intervention is designed, the nature and location of the gap must be understood. This is the foundational logic of the Identify stage — and the first principle of implementation science.
Look past the cold chain.
Cold chain quality matters — but assuming it is the priority assumes the 72% figure is accurate and that all missed children have access barriers solved. The prior question is: who are the 28%? Where do they live? Why has the system not reached them? Diagnosis must precede any intervention choice.
Coverage does not reach equally — that is the problem.
Cold chain improvements do help all children who access services — but the 28% who have never been vaccinated are not accessing services at all. Improving infrastructure for the 72% already using it does not close the gap for the 2,500 who are completely outside the system. Equity requires understanding why some populations are unreached before deciding what to fix.
Targeted and universal approaches both depend on diagnosis first.
Whether the response is targeted or universal is a design question that comes after context assessment — not before. At 72% coverage with 2,500 unreached children, the first step is understanding which communities are missed and why, so that any approach — targeted or mass — is designed to reach them specifically.
Mission 1 · IDENTIFY
Why is coverage declining?
Coverage is falling in three wards. The reports don't agree on the cause. Your task is to find out why — before any resources are deployed.
From the field — CHW Laila Musa, Kpako Settlement
"I have been walking through this settlement for four months. I know which houses have children; I can hear them inside. But when I knock, the doors stay closed.
Last week, a woman looked at me through a crack in the wall and said, 'We do not deal with government people.'
I am not government. But to her, I am."
Field journal entry, Week 14
Encounter — The Coverage Paradox
Your coverage report reads 72%. That means 4,320 of 6,000 under-1 children received DTP1 — according to facility registers. But a household survey finds only 58% real coverage. The gap represents approximately 2,500 children who have not entered the routine DTP schedule. Most live in the district's poorest households and the communities furthest from routine services.
The question is not "why is coverage low?"
The more important question is: which children are being missed? Where do they live? And what is preventing the health system from reaching them?
Coverage Map — Kwara North
Each cell represents a ward. Click to inspect.
High (85%+)
Medium (60–84%)
Low (<60%)
No data
First Decision
Based on what you see, what is the most important first action?
✓ Correct.
Effective implementation begins with understanding who is missed and why. Interventions introduced before diagnosis often improve performance for populations already reached while leaving the hardest-to-reach communities behind.
Not quite.
Before any intervention is designed, you need to understand which communities are missed, where they live, and why the system does not reach them.
Implementation Science Concept Unlocked
Context Assessment — Using CFIR
Context assessment is the systematic process of understanding the social, geographic, cultural, political, and health system factors that influence implementation. Interventions that perform well in one setting may perform poorly in another if contextual differences are not recognised and addressed. The Consolidated Framework for Implementation Research (CFIR) structures this diagnosis across five domains. In Kwara North, the three missed wards each represent a different CFIR failure:
Tudun Wada → Outer Setting (structural migration patterns beyond the health system's control) and Implementation Process (session scheduling ignores the community's calendar)
Kpako Settlement → Individuals (deep caregiver distrust rooted in legal vulnerability) and Outer Setting (absence from government registers)
Rafin Zuwo → Inner Setting (health system placed too far from the population) and Outer Setting (economic barriers create structural exclusion)
CFIR's value is that it prevents you from treating all context problems as the same type of problem — which leads to applying the same solution to fundamentally different barriers.
Source: Damschroder LJ et al. (2009). Implementation Science 4:50. Revised: Damschroder LJ et al. (2022). Implementation Science 17:75.
Ward Sorting Investigation
Your community health workers have gathered field reports from three low-coverage wards. Click a ward name, then click its barrier type to match them.
📍 Ward Field Reports — read carefully before classifying
Kpako Settlement: Road access deteriorates during the rainy season — travel to the nearest vaccination site takes more than two hours. Two outreach sessions were cancelled due to road access problems last quarter. CHWs note high concentration of under-1 children with no vaccination records.
Tudun Wada: A densely populated peri-urban ward. CHW Laila Musa reports that several caregivers have expressed concerns after hearing rumours about vaccine safety circulating in the community. Attendance at community meetings has declined over the past two months.
Sabon Gida: Families frequently move between settlements and are difficult to follow up. CHW records show many children who received DTP1 could not be located for DTP2 or DTP3. There is no tracking system in place for mobile households.
Rafin Zuwo: The facility in-charge reports that vaccination sessions are frequently delayed because staff are assigned to multiple services simultaneously. Several missed opportunity events were documented last month — eligible children attending the facility for other reasons left without vaccination.
Community Co-Diagnosis: Who Knows the Context Best?
The field reports above were gathered by community health workers — people with direct relationships inside the three wards. This is not incidental. It is the foundation of collaborative implementation.
Community members often possess contextual knowledge that programme managers do not routinely access. Co-diagnosis combines community experience with programme expertise to improve problem definition and strategy design.
Co-diagnosis — structured processes where communities, CHWs, and programme staff jointly identify barriers and design solutions — produces implementation strategies with better fit, higher community acceptance, and lower dropout rates. IA2030 Strategic Priority 2 (Commitment and Demand) explicitly names community engagement as a prerequisite for achieving equitable coverage, not an optional add-on.
In practice, co-diagnosis tools include: community mapping sessions, participatory rapid appraisals, village health committee consultations, and CHW-led household surveys. The barrier classification you are about to do should, in a real programme, be done with the community — not about them.
Ward — select first
Kpako Settlement Not yet classified
Tudun Wada Not yet classified
Sabon Gida Not yet classified
Rafin Zuwo Not yet classified
Barrier type — select second
✓ Classification complete.
Each ward faces a different dominant barrier. Geographic access limits outreach to Kpako. Community trust concerns drive avoidance in Tudun Wada. Population mobility breaks the follow-up chain in Sabon Gida. Service delivery constraints create missed opportunities in Rafin Zuwo. Getting the classification right is the foundation of effective strategy selection.
Implementation Science Concept — Dynamic Context
Context Varies Across Place
The three wards you just classified are within the same district — yet each requires a fundamentally different implementation strategy. This is the core insight of context sensitivity in implementation science: context is not a single background condition but a multidimensional configuration that differs from community to community, ward to ward, and household to household.
The CFIR outer setting factors operating in Kpako (legal vulnerability, exclusion from government systems) are entirely absent in Rafin Zuwo, where the outer setting challenge is purely geographic. Applying a single "district strategy" would fail both communities in different ways. Effective implementation demands granular, local diagnosis — not aggregate planning.
Implementation Science Concept
Equity Analysis
Equity in immunization means understanding not just who is left behind, but why. Structural barriers — geography, migration status, poverty, seasonal movement — systematically exclude specific populations. Programs that don't classify and directly address these barriers keep missing the same children year after year.
Missed Opportunities for Vaccination (MOV)
A Missed Opportunity for Vaccination (MOV) occurs when an eligible child or person comes into contact with a health service but does not receive one or more vaccines for which they are eligible and for which there is no valid contraindication. MOVs are distinct from zero-dose children: a zero-dose child has not received DTP1 and is not on the DTP immunization schedule (though they may appear in birth-dose registers for BCG or OPV0); a MOV child had a health system contact but was not vaccinated despite being eligible.
Types of contact where MOVs occur
The WHO MOV framework classifies missed opportunities by the type of health system contact where the opportunity was missed. Its core premise is that immunization services should be provided at every contact with the health system, regardless of the reason for that contact.
Immunization contact— the child attends a session to receive one vaccine but is not given all eligible vaccines due to provider knowledge gaps, false contraindications, or multi-dose vial policy concerns
Sick-child / treatment contact— the child attends a facility for illness (outpatient, inpatient, or emergency) and vaccination status is not checked or acted upon
Other preventive service contact— the child attends for growth monitoring, nutrition, ANC, or another preventive service and is not screened for vaccination eligibility
Community outreach contact— the child is present when a vaccination team visits but is not vaccinated due to stock-out, equipment failure, or provider absence
Note on defaulters: Children who started the schedule but did not return for subsequent doses are a dropout problem — they had a prior contact and were vaccinated — not a MOV in themselves. However, a child who defaults may experience a missed opportunity during a subsequent contact with the health system. Defaulter tracing is a strategy for improving schedule completion, which is distinct from MOV reduction.
Scale and significance
Studies across multiple LMIC settings report that a substantial proportion of undervaccinated children have had prior contact with the health system — in some facility-based assessments, more than 30% of children presenting at health facilities were eligible for vaccination but were not vaccinated. In Kwara North, this means a significant proportion of your 2,500 zero-dose children may have already been seen by a health worker — and left without a vaccine. A recent individual-level meta-analysis of DHS and MICS data across 23,557 children in sub-Saharan Africa estimated a pooled crude MOV prevalence of 34% (Tamuzi et al., 2025). MOV reduction is among the highest-yield, lowest-cost strategies for improving coverage because the contact has already been established.
Why implementation science is needed
MOVs commonly arise from service delivery processes rather than deliberate decisions by health workers. They are the product of system design failures — no vaccination check at triage, no vaccine carrier at outreach, no defaulter tracing system, no same-day vaccination policy. Implementation science is needed to identify which system failure is generating MOVs in a specific context and to select strategies that address that failure — not generic awareness campaigns directed at caregivers who were already present.
Source: WHO/UNICEF. (2019). Missed Opportunities for Vaccination: A Framework to Identify Missed Opportunities. Geneva: WHO. Scobie HM et al. (2020). Missed Opportunities for Vaccination. MMWR Supplements 69(1). Tamuzi JL et al. (2025). Prevalence of missed opportunities for vaccination (MOV) indicators among children aged 12–23 months in sub-Saharan African countries: An individual-level meta-analysis of DHS and MICS national household data surveys. Human Vaccines & Immunotherapeutics 21(1):2510714. https://doi.org/10.1080/21645515.2025.2510714
Practice Exercise — Data for Decision Making
Your DHIS2 dashboard shows this data for four Kwara North wards. Review the table carefully, then answer the question.
Ward
DTP1
DTP3
Dropout
MOV rate
Tudun Wada
38%
21%
45%
18%
Kpako Settlement
12%
8%
33%
4%
Rafin Zuwo
61%
43%
30%
31%
Sabon Gida
89%
82%
8%
6%
MOV rate = proportion of health facility contacts where an eligible child was not vaccinated
Rafin Zuwo has a high MOV rate (31%) alongside moderate DTP1 coverage (61%). Kpako Settlement has a very low MOV rate (4%) alongside very low DTP1 (12%). What do these two patterns together tell you?
✓ Correct — two different system failures, two different strategies.
Rafin Zuwo's 31% MOV rate means children are reaching the health system but leaving without vaccines — the contact exists, the vaccination does not. This is a system-design failure: no vaccination check at the contact point, inadequate stock management, or provider practice gaps. The strategy is MOV reduction: same-day vaccination, triage screening, stock protocols.
Kpako's 4% MOV rate alongside 12% DTP1 means almost nobody reaches the system at all — so there are almost no MOVs to count. The strategy is access and trust-building, not MOV reduction. Applying MOV interventions to Kpako would be the wrong solution to the wrong problem.
Read the two patterns together.
Rafin Zuwo has moderate DTP1 (61%) but a high MOV rate (31%) — many children contact the system without being vaccinated. Kpako has very low DTP1 (12%) and very low MOV (4%) — almost no children contact the system at all. These are fundamentally different problems requiring different strategies. Treating them the same wastes resources on both wards.
Implementation Science Concept
Data for Decision Making
Data should inform action, not simply reporting.
DTP1 reflects access DTP1-to-DTP3 dropout reflects retention MOV rate reflects service quality Administrative vs survey differences may signal data-quality concerns
Each indicator highlights a different implementation challenge and may require a different response.
Mission 1 Assessment
Your district shows 85% DTP1 in administrative data but only 65% in a recent household survey. A colleague argues for commissioning a new household survey to get a definitive figure before acting. Another argues for immediately deploying CHWs to the three lowest-coverage areas. Which approach is more consistent with implementation science?
Mission 1 Complete.
Both options have merit but commissioning a new survey takes weeks. Deploying CHWs without diagnosis risks effort in wrong communities. The implementation science approach is to use existing data first: DHIS2 rates, CHW registers, and ward headcounts reveal denominator problems and barrier types within days. Act on available evidence; refine as you gather more.
A substantial gap between administrative and survey estimates warrants investigation. Possible explanations include denominator error, reporting practices, population movement, numerator quality, or survey limitations. Understanding the source of the discrepancy is a core context-assessment task.
Think about what the gap reveals.
A 20-point gap between administrative and survey data suggests that one or more population, reporting, or measurement assumptions require further investigation. Adjusting targets or ordering new surveys treats the symptom, not the cause.
🔍
Zero-Dose Finder
You identified missed communities and applied context assessment and equity analysis to a real district scenario.
Reflect — Before you move on
What assumption about coverage data did this mission challenge? How might that assumption affect programme decisions in your own district?
Expert perspective
Experienced district officers consistently report the same surprise: administrative coverage data is structurally biased toward the visible population. It measures contact with the system, not coverage of the target population. The IA2030 monitoring framework calls for subnational disaggregation and household survey triangulation because facility-based data systematically undercounts the hardest-to-reach. A high coverage figure is not evidence of a strong programme — it may simply evidence a narrow denominator.
Mission 2 · REACH
What should we do about it?
You know which wards are struggling and why. Now select strategies that match what you found — and deploy them where they fit.
From the field — Musa Abdullahi, Village Health Worker, Rafin Zuwo
"Before, vaccinating my child meant paying for transport both ways — almost a day's wage.
I made the trip once.
The second time, I could not afford it.
The third time, I told myself she was probably fine.
She was not.
Years later, when I became a Village Health Worker and started bringing vaccines to this community, the first mother who came to the outreach post said:
'I have been waiting three years for someone to come.'
I thought about my daughter."
Interview, Rafin Zuwo outreach post, Month 3
Encounter — The Implementation Gap
You know who is missed and why. Now the challenge is designing interventions that genuinely fit the context — not just scaling up what works for easier populations.
Key Principle: Implementation Fit
A strategy that works well in one community may fail in another if the barriers are different. Effective implementation depends on fit. The question is not whether a strategy works. The question is whether it works here.
Strategy Deployment Board
Intelligence — District Update
The Government, with support from Gavi, has begun phased deployment of a Digital Immunization Register (DIR) in Kwara North. Sabon Gida PHC is now active. Rafin Zuwo PHC has partial adoption. Kpako PHC deployment is planned. The DIR can generate defaulter lists and support follow-up — but deployment is not the same as adoption.
For each ward, select the strategy that best addresses the identified barrier. Complete one ward to unlock the next.
Kpako Settlement
Remote location — outreach cancelled due to road access
Geographic Access
✓ Correct.
Geographic access barriers require bringing the service to the community — eliminating the travel requirement entirely. When road access is the constraint, the only viable solution is an on-site outreach post. Extended hours and awareness campaigns assume the family can reach the facility; they cannot.
Think about what this community faces physically.
The barrier is distance and road access — not awareness or facility hours. No amount of messaging or extended hours eliminates a two-hour road journey that is impassable in the rainy season. The service must come to the community.
Tudun Wada
Vaccine safety rumours — community attendance declining
Community Trust
✓ Correct.
Trust barriers require trust-based solutions. Where rumours are driving avoidance, visible authority increases suspicion rather than resolving it. Working through trusted community intermediaries — leaders, religious figures, respected mothers — addresses the actual barrier by rebuilding confidence through relationships rather than information.
Think about what builds trust in this context.
Authority and volume don't build trust — they signal power. When communities are avoiding vaccination because of fear and rumour, the response must come from people the community already trusts. Government presence without that relationship can make avoidance worse.
Sabon Gida
Mobile households — DTP1 children lost to follow-up
Population Mobility
✓ Correct.
Population mobility breaks the follow-up chain because records are tied to a single facility. The solution is a record system that follows the child — not the facility. Birth registration linked to DIR with cross-facility record access means the child is never "new" at any vaccination point, and defaulter tracing can cross administrative boundaries.
Think about what breaks the chain.
Mobile households don't disappear — they reappear at different sites. The problem is that records don't follow them. Home visits and static defaulter lists only work if you can find the household again. The system needs to track the child, not the address.
Rafin Zuwo
Missed opportunities — eligible children attending facility left unvaccinated
Service Delivery
✓ Correct.
This is a missed opportunity problem — children are reaching the facility but leaving without vaccination. The barrier is not access or awareness. It is a service delivery failure: no system exists to check vaccination status at contact. Same-day vaccination and triage screening fix the system failure directly.
Think about where in the system the failure occurs.
These children are already in the facility. The barrier is not distance, cost, or knowledge — it is that no one checks whether they are due for vaccination. Transport and education solve access problems. This is a delivery process problem that requires a delivery process solution.
Implementation Strategies for MOV Reduction
Acting on Missed Opportunities
Rafin Zuwo's MOV rate shows that many children reach the health system but leave without vaccination. The problem is not access. The problem is that existing opportunities are being missed. This requires different ERIC strategies from Kpako, where almost no contact exists at all:
Same-day vaccination — vaccinate at any facility contact regardless of the reason for the visit (sick child, ANC, growth monitoring). Every contact is an opportunity. This is the single highest-yield MOV strategy where vaccination registers and stock are co-located with other services.
Vaccination screening at triage — check vaccination status at every triage encounter and flag eligible children before they see the clinician. Requires a brief training for triage staff and a visual flag system on patient cards.
Stock-out prevention protocol — Ibrahim's case in Rafin Zuwo was a MOV caused by a stock-out: the child was present at an outreach contact and was not vaccinated. The response is supply chain redesign — consumption-based reorder triggers, minimum stock buffers, and emergency resupply pathways.
Defaulter tracing — following up children who received DTP1 but did not return for DPT2/3 is a dropout reduction strategy, not a MOV strategy. These children had prior vaccination contacts; the problem is schedule completion, not a missed contact. Both matter for coverage, but they require different system responses and should not be conflated.
The ERIC cluster for MOV reduction is Change Infrastructure — redesigning the delivery system so that vaccination status is checked and acted upon at every contact point. No amount of community education eliminates a MOV caused by a system that never screens for eligibility.
Implementation Science Concepts Unlocked
Implementation Strategies — What They Are and How to Choose
You already know the barriers. The next question is what to do about them.
Implementation strategies are the actions used to overcome identified barriers and support delivery of an effective intervention. In immunization, the vaccine is the intervention; mobile outreach, community mobilisation, and documentation-free registration are implementation strategies. Without the right strategies, even a proven vaccine will not reach the children who need it most.
The ERIC compilation (Powell et al., 2015) organises 73 implementation strategies into nine clusters. The three most relevant to zero-dose programmes are:
Engage consumers — build demand and remove access barriers through community leaders and trusted intermediaries (applied in Kpako)
Change infrastructure — alter the logistical systems that support delivery (outreach posts in Rafin Zuwo; mobile scheduling in Tudun Wada)
Adapt and tailor to context — modify the delivery model to fit local conditions while preserving core components (applied across all three wards)
Feasibility is the final gate: a strategy that cannot be executed with available resources and infrastructure is a plan that will fail silently.
Resource Allocation Exercise
Every strategy competes for limited resources. Choosing what to fund is part of implementation.
Quarterly budget: ₦2,400,000. Allocate across strategy types. Total must not exceed 100%.
Mobile outreach sessions30%
Community mobilisation25%
CHW training & support25%
Fixed facility improvement20%
Total allocated:100%
Total exceeds 100% — adjust before continuing.
Applied Exercise — ERIC Strategy Selection
The ERIC compilation provides 73 discrete implementation strategies across nine clusters. For each Kwara North ward, match the most appropriate ERIC cluster.
Partner with trusted community and religious leaders; community dialogue sessions
Sabon Gida Population mobility — follow-up breaks
Change Infrastructure
DIR-linked birth registration; cross-facility record linkage so vaccination record follows the child
Rafin Zuwo Service delivery — missed opportunities
Change Infrastructure
Same-day vaccination and triage screening at all facility contacts
Now select the ERIC principle that best explains why applying the same implementation strategy to all four wards would fail:
✓ Correct — barrier-specific strategy selection.
ERIC's "Adapt and tailor to context" is the most commonly under-applied cluster in immunization programmes. It requires assessing the CFIR determinants first, then selecting strategies that directly address the identified barriers. A seasonal barrier requires an infrastructure change (schedule); a trust barrier requires consumer engagement (relationship); a geographic/economic barrier requires another infrastructure change (location). Applying a community mobilisation approach to Rafin Zuwo — where the barrier is distance, not awareness or trust — wastes resources while leaving the access barrier untouched. In practice, composite barriers often require strategies from more than one ERIC cluster — the one-to-one mapping in this exercise is a teaching simplification.
Think about what ERIC is solving.
ERIC strategies are matched to barrier types, not applied uniformly. The principle of "adapt and tailor to context" means the strategy must fit the specific determinant identified through CFIR analysis. Budget constraints, capacity, and LMIC norms are real considerations — but they do not change the fundamental requirement that each distinct barrier type requires a specifically matched strategy.
Implementation Tool Unlocked
ERIC — Expert Recommendations for Implementing Change
The ERIC compilation (Powell et al., 2015; updated Waltz et al., 2015) catalogues 73 discrete implementation strategies grouped into nine clusters: Use evaluative and iterative strategies · Provide interactive assistance · Adapt and tailor to context · Develop stakeholder interrelationships · Train and educate stakeholders · Support clinicians · Engage consumers · Utilise financial strategies · Change infrastructure.
ERIC is used in three ways in practice: (1) as a menu for selecting strategies during implementation planning, (2) as a diagnostic tool for identifying which cluster of strategies is currently absent when programmes are failing, and (3) as a common language for reporting implementation activities so that findings can be compared across settings.
In zero-dose programmes, the most commonly missing ERIC cluster is Engage Consumers — programmes invest heavily in supply-side infrastructure (cold chain, session scheduling, VHW training) while under-investing in the demand-side and trust-building strategies that reach the hardest-to-reach communities.
Source: Powell BJ et al. (2015). A refined compilation of implementation strategies. Implementation Science 10:21. Waltz TJ et al. (2015). Choosing implementation strategies to address contextual barriers. Implementation Science 10:133.
Behavioural Science — The Demand Side
COM-B: Why People Do or Don't Vaccinate
Kpako's problem is ultimately about caregiver behaviour. The COM-B model (Michie, van Stralen & West, 2011) offers a practical lens:
Capability — do caregivers know what to do? Do they know what vaccination is, when it is due, and where to go?
Opportunity — can they realistically do it? Is a session accessible and affordable? Do social norms support vaccination?
Motivation — do they want to do it? Do they trust the health system and believe vaccination is safe and worthwhile?
Applied to the four wards: Kpako — opportunity problem (physical): distance and road access make the facility unreachable Tudun Wada — motivation and social opportunity problem: vaccine safety rumours; declining community trust Sabon Gida — opportunity problem (physical + systemic): household mobility breaks the follow-up chain Rafin Zuwo — opportunity problem (systemic): children reach the facility but the service doesn't screen or act
COM-B explains why the same strategy fails across wards. Trust-building doesn't help Rafin Zuwo if the barrier is a delivery process gap. Same-day vaccination doesn't help Kpako if families can't reach the facility. The framework directs the intervention to the specific deficit.
Community education alone is unlikely to reduce MOVs when the primary failure lies within service delivery processes.
Source: Michie S, van Stralen MM, West R (2011). The behaviour change wheel. Implementation Science 6:42.
Implementation Science Concept
Adaptation and Fidelity — Managing the Tension
Fidelity means preserving the components responsible for effectiveness. Adaptation means modifying delivery to fit context. Effective implementation requires both.
Core components — causally linked to outcomes and not adaptable: cold chain, vaccine schedule, antigen formulation Adaptable elements — delivery features that can be modified without undermining effectiveness: session timing, mobilisation language, documentation process
Changing session timing for a pastoralist community is adaptation. Changing the antigen is not. The discipline is knowing the difference.
The FRAME tool (Stirman et al., 2019) provides a structured way to document adaptations — what changed, why, by whom, and whether the change was planned or reactive. Undocumented adaptations accumulate into programme drift. See the Field Guide for full details.
Source: Stirman SW et al. (2019). Implementation Science 14(1):58.
Allocation feedback
Adjust your allocation above to see feedback.
Mission 2 Assessment
A CHW reports that mobile outreach is failing in Tudun Wada — families are simply not present when the team arrives. From an implementation science perspective, what does this most likely indicate?
✓ Correct — this is an adaptation problem.
When a strategy produces poor results, implementation science asks: what is the mismatch between the intervention design and the context? Poor timing is a design problem — not a community problem, and not a supervision problem. The strategy needs adaptation, not enforcement.
Think about where the failure lies.
When a strategy fails, the first question is not "who failed?" but "what is the mismatch?" The team is arriving when families are absent — a design problem. Supervision and education responses miss the root cause entirely.
🚐
Outreach Planner
You matched barriers to evidence-based strategies, applied implementation fit, and designed a feasible resource allocation plan.
Reflect — Before you move on
Think about the four wards — Kpako, Tudun Wada, Sabon Gida, and Rafin Zuwo. The strategies you selected were context-specific. In your own working context, what is the most common mistake you see when strategies are designed without proper barrier classification?
Expert perspective
The most common error in field programmes is what implementation scientists call "strategy homogeneity" — applying the same delivery model across all communities regardless of context, because it is administratively simpler. This systematically advantages populations already close to services while compounding the disadvantage of the hard-to-reach. IA2030 Strategic Priority 3 (Coverage and Equity) is explicit that subnational tailoring is not optional — it is the mechanism through which equity gaps are closed. The equity-first imperative in IA2030 means the hardest-to-reach populations must receive differentiated strategies, not scaled-down versions of what works elsewhere.
Mission 3 · MONITOR
Is implementation happening as intended?
Strategies were deployed. Three months have passed. Find out whether they are actually being delivered — and what is getting in the way.
Encounter — Three Months Later
Your outreach strategies have been running for 12 weeks. Review the progress data carefully — something is not right. Your job is to find it.
81%
DTP1 Coverage
54%
DTP3 Coverage
33%
Dropout Rate
18
Sessions Held
📍 CHW Field Report — Week 10
"Tudun Wada sessions ran only twice this month. Transport broke down before the third scheduled session. At Rafin Zuwo, the Village Health Worker exhausted DTP-HepB-Hib stock on Day 6 and turned away 31 children. Among them was Ibrahim, nine weeks old — his mother Fatima had walked four kilometres for his second dose. She was told to return next month. She has not returned. In Kpako, community mobilisers remain active, but attendance falls sharply during the second half of each month."
Using Existing Data — Supportive Supervision
Before identifying warning signs, consider the data sources already available. Effective district immunization management does not wait for periodic evaluations — it uses existing routine data systematically for day-to-day programme adaptation.
Data sources available right now in Kwara North
DHIS2 dashboard— DTP1/DTP3 ratios, dropout rates, session counts, stock levels; available in near-real time if data entry is timely
CHW field reports— the Week 10 report above is a structured observation; when systematically compiled, these become a real-time monitoring instrument
Digital Immunization Register (DIR)— Sabon Gida PHC is actively using DIR; defaulter lists generated weekly and follow-up rates improving. Rafin Zuwo PHC has DIR installed but usage is inconsistent — records incomplete, defaulter lists rarely reviewed. The technology is identical. The implementation is not.
Supportive supervision registers— each supervisory visit produces structured observations on cold chain, session quality, staff attendance, community engagement, and stock; these should feed directly into adaptation decisions
Community feedback— attendance registers, caregiver exit interviews, and community committee minutes capture demand-side signals that facility data misses entirely
What makes supervision "supportive"?
Supportive supervision is not inspection. Its purpose is to identify problems, solve them collaboratively, and improve implementation quality. In the activity below, you are playing the role of a data-driven supervisor — using CHW intelligence alongside DHIS2 metrics to jointly diagnose what is going wrong.
Amina Bello — Health Information Officer
Reporting completeness remains high this month.
However, I've flagged discrepancies between session registers and submitted reports in two facilities. High completeness doesn't always mean accurate data.
Worth investigating before the district review.
District Health Information Unit — Month 3 flag
Dashboard Anomaly Hunt
Select all problems requiring immediate corrective action (you should find 3):
✓ Correct — three critical warning signs identified.
High dropout, the Rafin Zuwo stock-out, and the Kpako attendance pattern are all flags requiring action. Strong DTP1 coverage is encouraging but meaningless if a third of those children drop out before completing the schedule.
Look again.
There are 3 correct warning signs: the dropout gap (options 0, 2, 4). Option D (DTP1 at 81%) is actually a distractor — strong first-dose coverage is irrelevant if a third of children starting the schedule never complete it. The 33% dropout rate (standard EPI formula: (DTP1−DTP3)÷DTP1) and the 27 percentage-point coverage gap describe the same problem from two angles — both are warning signals. Option C (stock-out) is urgent. Make sure you haven't checked Option D.
Implementation Science Concepts Unlocked
Fidelity, Reach, and Missed Opportunities
Fidelity asks whether the intervention is delivered as designed. Session cancellations and stock-outs are fidelity failures. Reach asks whether the target population actually received the intervention. The 33% dropout rate (calculated as (DTP1−DTP3)÷DTP1 × 100, the standard EPI formula) means one in three children who started the schedule did not complete it.
Both failures generate Missed Opportunities for Vaccination. Ibrahim's case illustrates a missed opportunity for vaccination caused by a system failure rather than a community access failure — eligible, in contact, but not vaccinated due to a stock-out. The cause was a fidelity failure in the supply chain, not a community access barrier.
This distinction drives strategy selection. MOVs caused by fidelity failures (stock-outs, session cancellations, provider gaps) require system-design responses. MOVs caused by reach failures (no defaulter tracing, missed follow-up) require community-facing responses. Monitoring systems that track MOV rate alongside coverage and dropout give you the evidence to tell them apart.
Implementation Science Concept
Context Varies Across Time
The Kpako attendance drop in the second half of every month illustrates a core principle: context is not static. What worked in week one may fail by week three — not because the intervention changed, but because the context shifted around it.
Implementation science distinguishes two layers of context:
Structural context — relatively stable features (geography, poverty, migration routes) that require one-time adaptation when entering a community
Dynamic context — features that cycle or shift over time: economic rhythms (payday patterns), seasonal calendars (agricultural, pastoral, school), political transitions, and community events
The CFIR Implementation Process domain includes a dedicated "reflect and evaluate" phase precisely because context drift is predictable and recurring. Monitoring systems must track not only what the programme is doing but whether the context it was designed for still holds. In Kwara North, the month-cycle attendance pattern in Kpako likely reflects a payday or market-day dynamic. Monitoring should track not only programme performance but also changes in the context in which implementation occurs.
⚠ Adverse Event — Week 11
A local religious leader in Kpako has publicly claimed that the vaccination programme is a government scheme to collect personal data. Within 72 hours, attendance at Kpako mobilisation sessions drops from 14 households per week to zero. Two of your three community mobilisers report they no longer feel safe working in the settlement.
Simultaneously, a national NGO has contacted your district office offering to fund an independent community engagement initiative in Kpako — but only if you suspend your current mobilisation activities for 30 days while they conduct their own baseline assessment.
A compound crisis: active misinformation, staff safety concerns, and an external offer that would delay your programme. What is your immediate priority response?
✓ Correct — trust requires a trust-based response.
A government rebuttal deepens distrust in a community already hostile to government presence. Suspension signals that resistance succeeded. Redirecting resources abandons the highest-need community. The right response runs through the same mechanism that built initial access — trusted intermediaries — while negotiating co-design without accepting a suspension condition. In trust-deficit communities, misinformation is an implementation problem, not a communications problem.
This hands control to an external actor.
Accepting the NGO suspension condition pauses your programme for 30 days and signals that resistance was effective — which may encourage further avoidance. Explore partnership without surrendering operational control.
Official channels amplify the threat in this context.
A government rebuttal confirms to undocumented families that the government is paying attention to them — precisely what they wish to avoid. The channel is part of the problem.
This abandons the highest-need community.
Redirecting resources away from the most excluded community because it is harder to serve is the mechanism by which inequity compounds. Sustained trust-building through intermediaries is the only viable path forward.
Corrective Action — Rafin Zuwo Stock-Out
Your district supply officer argues that the VHW should be resupplied only after completing a formal root cause analysis — to prevent the same stock-out recurring. Your field supervisor counters that every day of delay risks those 31 children falling further from the system. Which response is more defensible from an implementation science standpoint?
Correct - parallel action, not sequential.
The supply officer concern is valid but timing is wrong. Act now to prevent immediate harm, investigate simultaneously to prevent recurrence. A reorder trigger at 20% stock takes minutes to establish without a formal analysis cycle. Monitoring creates value only when it drives timely corrective action.
Emergency resupply plus a reorder trigger addresses both the immediate problem and the systemic weakness that caused it. Real-time monitoring demands real-time corrective action — not periodic reporting. Children turned away may delay or miss subsequent vaccination opportunities; the cost of inaction compounds.
Consider the urgency.
31 children were turned away. Waiting for regular cycles, requesting analysis before acting, or relocating the post all delay the response while those children fall further from the system. Monitoring creates value when it drives timely corrective action — documentation is part of the response, but it is not a substitute for it.
Implementation Science Concept
Monitoring Systems
Effective monitoring systems track both implementation (what was done) and outcome (what changed) in near-real time — and route findings to decision-makers fast enough to drive corrective action. A monitoring system that generates reports no one reads, or that feeds data into a cycle too slow to respond, provides no implementation value.
Implementation Science Concept — Systems Thinking
Trade-offs and Unintended Consequences
Before implementing a corrective action, ask: what problems might this solution create elsewhere?
Resource displacement — surging staff and supplies into Rafin Zuwo draws them from other wards. If Tudun Wada's sessions are cancelled to staff the Rafin Zuwo push, the problem has moved, not been solved.
Campaign vs routine tension — intensive pushes can undermine the routine system they are meant to support. Staff are pulled from fixed sessions; communities learn to wait for the "big push". IA2030 Strategic Priority 1 (Immunization Programmes for Primary Health Care and Universal Health Coverage) prioritises strengthening routine immunization precisely because campaign-dependence creates fragile, non-self-sustaining coverage.
Incentive distortion — performance incentives for coverage may inadvertently encourage over-reporting, or neglect of the hardest-to-reach children who reduce measured performance.
Anticipating second-order effects — and designing to mitigate them — is what distinguishes systems thinking from problem-solving. No variable changes in isolation.
📊
Monitoring Officer
You identified fidelity failures, interpreted routine data, and applied real-time corrective action.
Reflect — Before you move on
Which implementation failure in this mission would have been hardest to detect without routine monitoring data? What would have happened if it had gone unnoticed?
Expert perspective
Stock-outs in outreach settings typically arise from three compounding system failures: inaccurate session registers (wrong expected attendance), push-based logistics that distribute according to calendar rather than consumption, and no early-warning trigger at the last mile. IA2030 Strategic Priority 6 (Supply and Sustainability) identifies vaccine supply chain performance as a prerequisite for equitable coverage — not a logistical afterthought. The WHO AFRO cold chain and vaccine management framework recommends automated consumption-based reorder triggers at all last-mile sites, precisely because manual reporting cycles are too slow to prevent stock-outs that turn away families. When children are turned away, available evidence suggests that a substantial proportion may delay or miss subsequent vaccination opportunities.
Mission 4 · MEASURE
What actually changed — and why?
Six months have passed. Indicators are moving. But before drawing conclusions, find out what changed, who benefited, and what is still being missed.
From the field — Aminata Diallo, Community Mobiliser, Kpako Settlement
"I have visited this settlement every week for six months. I know many families by name now. Some welcome me into their homes. Some tell me about their children.
But when I invite them to attend a vaccination session, they often smile, agree, and then never come.
Something still feels uncertain to them. I think trust takes longer to build than programmes usually allow."
Process evaluation interview, Month 6
Equity Reconstruction Challenge
The program has run for six months. Here are the before-and-after results. Analyse carefully — the headline looks promising, but the equity story is more complex.
Ward
Coverage before
Coverage after
Change
MOV before
MOV after
Sabon Gida
64%
75%
+11%
8%
5%
Rafin Zuwo
66%
79%
+13%
31%
14%
Tudun Wada
60%
71%
+11%
12%
9%
Kpako
52%
59%
+7%
4%
3%
MOV rate = proportion of facility contacts where an eligible child was not vaccinated. Rafin Zuwo's MOV reduction (31%→14%) reflects the same-day vaccination and stock-out protocol introduced in Month 3.
68→74%
Overall Coverage
2,500→2,100
Zero-Dose Children
+7%
Kpako Gain Only
Overall coverage rose from 68% to 74%. But approximately 2,100 children remain zero-dose — including most of Kpako. What is the most accurate evaluation of these results?
✓ Correct — this is nuanced evaluation.
Headline coverage gains can mask equity failures. Kpako — the hardest-to-reach community — gained the least, suggesting the programme is working well for more accessible populations but has not yet achieved the same momentum in trust-barrier communities. The equity gap remains large. Measurement is designed to reveal exactly this, and the appropriate response is redesign — not abandonment.
Look at who benefited.
Disaggregate before you evaluate. The communities that were already easiest to reach gained most. The hardest-to-reach gained least. These results suggest that important equity gaps remain despite overall improvement. Evaluation should go beyond the average.
Evaluation Framework Unlocked
RE-AIM — Evaluating Real-World Implementation
The RE-AIM framework (Glasgow et al., 1999) provides five dimensions for evaluating real-world implementation:
Reach — who received the intervention? Kpako: 12→19% (limited; trust barrier persists). Rafin Zuwo: 61→79% (strong reach following outreach post). Aggregate figures conceal who was missed.
Effectiveness — what was the impact for those reached? The 9-point overall gain was not equally distributed — effectiveness was high in accessible wards and low in Kpako.
Adoption — was it used as planned? Transport breakdowns in Tudun Wada and stock-outs in Rafin Zuwo are adoption failures.
Implementation — was it delivered with fidelity? The 33% dropout rate and Kpako's attendance drop signal implementation gaps in follow-up and retention.
Maintenance — can gains continue? This is what Mission 5 addresses. Without it, all gains erode.
No single metric substitutes for the full profile. High Effectiveness with low Reach is not success. High Reach with poor Implementation produces waste.
Source: Glasgow RE, Vogt TM, Boles SM (1999). American Journal of Public Health 89(9):1322–1327. Gaglio B et al. (2013). American Journal of Public Health 103(6):e38–46.
Implementation Outcomes vs Programmatic Outcomes
Programme outcomes tell us what happened. Implementation outcomes help explain why. Most immunization monitoring systems track only the first category.
Proctor et al. (2011): Eight implementation outcomes
Acceptability— does the programme feel appropriate and satisfactory to communities and health workers? Kpako's low engagement signals low acceptability.
Adoption— are intended sites and health workers actually using the new approach? Session cancellations in Tudun Wada are an adoption failure.
Appropriateness— does the intervention fit the setting, population, and problem? A strategy that doesn't match the barrier type has low appropriateness.
Feasibility— can it be delivered in the existing context? The Rafin Zuwo stock-out reflects a feasibility failure in supply chain design.
Fidelity— is it being delivered as designed? The 33% dropout rate is a fidelity failure in the follow-up component.
Penetration— what proportion of the intended population is actually being reached? Kpako's 19% DTP1 shows poor penetration despite active mobilisers.
Sustainability— can the programme continue without ongoing external support? This is what Mission 5 addresses.
Cost— what is the resource investment required to achieve and sustain the outcomes? The cost-effectiveness analysis above.
Why this matters for immunization monitoring
Immunization monitoring frameworks have historically tracked only programmatic outcomes (coverage, dropout rate, wastage) — which measure what happened to the target population. Implementation outcomes measure what happened to the programme itself: whether it was delivered as designed, whether it was acceptable to those delivering and receiving it, and whether it can persist over time.
IA2030's monitoring and evaluation framework explicitly calls for tracking both levels. A programme that achieves 80% coverage (programmatic success) through approaches that have low acceptability, poor fidelity, and zero community ownership will not sustain those gains — and will be unable to reach the final 20% that represent the most excluded populations. Implementation outcomes are the early warning system for programmatic outcome failure.
Quick check: The Kpako strategy has low penetration (19% DTP1) despite active community mobilisers. What is the most important implementation outcome to investigate first?
✓ Correct — acceptability and appropriateness first.
When penetration is low despite active delivery effort, the most likely explanations are low acceptability (the programme does not feel right to this community) or low appropriateness (the strategy does not match the actual barrier). Kpako's undocumented migrant community has deep structural reasons to avoid government services — a mobilisation strategy designed for a willing but geographically distant population will have low appropriateness in this context. Investigating these two implementation outcomes guides the redesign.
Think about what the mobilisers report tells you.
When effort is high but penetration is low, the issue is rarely effort (adoption) or future funding (sustainability). When effort is high but penetration is low, the issue is frequently that something about how the programme is designed or delivered does not fit the community. Acceptability and appropriateness are the diagnostic implementation outcomes for this pattern.
Source: Proctor E et al. (2011). Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health 38(2):65–76.
Evaluation Rigor — Attribution and Plausibility
Coverage in Kwara North rose from 72% to 81% over six months. The natural conclusion is that your programme caused the improvement. But a rigorous evaluator asks a harder question: how do you know your intervention caused the change, rather than something else?
Rival explanations to rule out
Secular trends— coverage may have been rising anyway due to national campaigns, economic improvement, or general health system strengthening unrelated to your work
Concurrent interventions— did an NGO, a Gavi grant, or a measles campaign operate in the same period? Their effect may be mistaken for yours
Data artefacts— did the improvement come from better data recording rather than more children vaccinated? A denominator revision can create an illusory gain
Regression to the mean— wards selected because they were performing badly may improve naturally toward the average regardless of intervention
The plausibility argument
District programmes rarely have randomised controls — you cannot withhold vaccination from half the district to create a comparison group. Instead, rigorous evaluators build a plausibility argument: evidence that makes a causal contribution credible even without an experiment. The strongest plausibility evidence in Kwara North is dose-response and specificity — Rafin Zuwo, where the outreach post and same-day vaccination protocol were introduced, improved most (66→79%) and its MOV rate halved; Sabon Gida, where the primary strategy was DIR-supported defaulter tracing, showed solid gains. The improvement is concentrated precisely where each intervention was most intense, and the mechanism is specific to what changed. That pattern is hard to explain by secular trends, which would lift all wards equally. Good evaluation is not about proving causation. It is about presenting the most credible explanation supported by available evidence.
Equity Analysis — What Happens Next
Kpako gained only 7 percentage points despite active community mobilisers. Your next-quarter budget is constrained. How do you prioritise?
✓ Process evaluation first.
Doing more of a strategy that isn't working wastes scarce resources. The evaluation has revealed a gap — now you need to understand why. A rapid process evaluation (interviews with mobilisers and community members) will reveal the mismatch and inform a redesign. This is the learning loop that distinguishes implementation science from implementation habit.
Think about the learning loop.
Scaling up a failing strategy, abandoning the hardest-to-reach, or chasing easy gains all represent evaluation failures. The measure stage exists to identify what needs to change — not just confirm what worked. Diagnose before you redirect resources.
Dr. Grace Okafor — MNCH Coordinator
We improved postnatal follow-up in two facilities because of the AI-supported pilot.
Several newborns were identified earlier than usual and referred for vaccination.
Has the immunization team considered how that information could be used?
Maternal, Newborn and Child Health Unit — Cross-programme update, Month 6
Practice Exercise — Cost-Effectiveness Analysis
Using data from your six-month programme, calculate the cost per additional fully immunized child (FIC) for two wards. For the purposes of this exercise, FIC is defined as a child who received DTP3.
Ward
Budget spent
New FIC gained
Cost per FIC
Rafin Zuwo
₦480,000
162 children
₦?
Kpako
₦360,000
42 children
₦?
Which statement best describes what these cost-effectiveness figures tell you?
✓ Correct — cost-effectiveness informs, not dictates.
Rafin Zuwo cost ₦2,963 per additional fully immunized child; Kpako cost ₦8,571. Kpako is roughly 3× more expensive per child. But IA2030's equity mandate means efficiency and equity considerations may point to different priorities and often require explicit balancing. Reaching zero-dose children in the hardest-to-reach settings typically costs more — but IA2030 calls for equity to be weighed alongside efficiency in programme investment decisions.
Consider the equity dimension.
Cost-effectiveness ratios — Rafin Zuwo ₦2,963/child, Kpako ₦8,571/child — are real and matter for resource planning. But maximising cost-effectiveness in immunisation programmes without an equity lens leads to a predictable failure mode: resources concentrate on accessible populations (already higher coverage) while zero-dose communities (highest need, highest cost) are progressively defunded. IA2030 emphasises that equity should be weighed alongside efficiency in all programme investment decisions.
Implementation Science Concept
Cost-Effectiveness in an Equity Context
Cost-effectiveness analysis (CEA) measures the resources required to achieve a unit of health outcome — commonly expressed as cost per fully immunized child (FIC) or cost per disability-adjusted life year (DALY) averted. In immunization programming, CEA is a necessary but insufficient basis for investment decisions: reaching zero-dose children in hard-to-reach settings will often have a higher cost-per-child than maintaining coverage in already-accessible populations. IA2030's equity imperative means programmes must demonstrate that investment reaches those with the highest unmet need — even at higher unit cost.
📈
Equity Evaluator
You applied disaggregated evaluation, identified equity gaps, and selected the appropriate response to mixed program results.
Reflect — Before you move on
The Kwara North data showed that overall coverage improved while the equity gap in Kpako actually widened in relative terms. In your work context, who reads the disaggregated data — and what typically happens when it shows that headline progress is masking equity failure?
Expert perspective
One of the most persistent structural failures in immunization M&E is that equity data is collected but not acted upon. IA2030's monitoring framework includes an explicit equity indicator — the proportion of districts achieving ≥80% DTP3 coverage — because aggregate national figures routinely conceal subnational inequity. The WHO guidance on equity-focused immunization programming distinguishes between "equity in coverage" (do all groups have the same rates?) and "equity in improvement" (are gains reaching those furthest behind first?). A programme that improves average coverage without improving the position of the worst-off quintile is, by IA2030 standards, failing its primary equity mandate, even if it meets numerical targets.
Mission 5 · ADVOCATE
What should happen next?
Evidence has been gathered. Gains have been made. Now convince decision-makers to sustain what worked, address what didn't, and secure resources for scale.
From the field — District Health Secretary, Kwara North
"When the budget meeting begins, everyone has a reason their programme deserves funding. Roads. Schools. Agriculture. Water. Vaccination is different. Its greatest success is often invisible. When children do not become sick, there is nothing dramatic to point to. No crisis. No headline. That is why evidence matters. If we cannot explain the value of immunization clearly, someone else will explain why it can wait."
District Planning Meeting, Month 9
The decision-maker — Alhaji Musa Tanko, LGA Chairman
"Alhaji Tanko grew up in Sabon Gida ward — the highest-coverage ward in your district. His mother was a traditional birth attendant. He won his last election with 61% of the vote, strongest in the wards where your outreach programme runs. He is not against immunization. He does not know it is working. Nobody has told him in language he recognises."
District profile note — for advocacy preparation
Encounter — The Sustainability Crisis
Tomorrow's budget meeting may determine whether the outreach programme continues. The LGA Chairman is considering redirecting your budget to road construction. You have 24 hours to build the case. This is one opportunity. Make it count.
📍 Stakeholder Intelligence Brief
LGA Chairman: Prioritises infrastructure and economic development. Responds to employment, productivity, and economic ROI arguments. Won recent elections in wards where coverage is highest.
State Ministry Director: Technically supportive but under pressure to show national targets are met. Needs concrete numbers and aligned reporting — not narratives.
Emir of Kwara North: Broadly trusted across Kwara North's settled communities and has influence with some community leaders in Kpako. Has not yet been engaged by the immunization program. Note: communities with undocumented status may have their own internal authority structures that require direct engagement alongside formal traditional leaders.
Stakeholder Negotiation Room
Click the three stakeholders you would engage first, in order of priority. Consider who controls the decision, who has reach, and who hasn't yet been activated.
—Engage the LGA Chairman with economic framing — connect immunization to workforce productivity and child survival
—Brief the State Ministry Director with coverage numbers and equity analysis aligned to national targets
—Engage the Emir — request a public endorsement and access to community networks including Kpako
—Organise a community mothers' group meeting to build grassroots demand pressure
✓ Strong prioritisation.
The LGA Chairman (budget authority + economic framing), the State Ministry (technical alignment + national reporting), and the Emir (community trust + Kpako access) are the three highest-leverage stakeholders. Mothers' groups are valuable but secondary — budget protection must come first.
Reconsider the priorities.
Effective advocacy starts where the decision is being made. The LGA Chairman controls the budget. The Emir holds trust that government cannot manufacture. The Ministry provides technical legitimacy. These three should be your first three moves.
Collaborative approaches in implementation science treat communities and stakeholders as co-designers — not merely targets of communication or service delivery. Two distinct levels operate simultaneously:
Community collaboration means structured engagement with households, leaders, mothers' groups, and traditional institutions in co-designing session timing, location, messaging, and service norms. IA2030 SP2 (Commitment and Demand) identifies community ownership as a prerequisite for sustained demand — not a pre-implementation phase, but an ongoing relationship. Programmes that co-design with communities consistently show higher uptake, lower dropout, and more durable behaviour change.
Multi-stakeholder collaboration means creating shared decision-making spaces where health workers, district managers, local government, CSOs, and community representatives jointly review data, interpret findings, and adapt programmes in real time. District immunization coordination committees and community scorecards are implementation strategies in their own right.
Stakeholder engagement means building tailored relationships with decision-makers and influencers — matching message to audience, as applied in the LGA Chairman advocacy pitch above.
Sustainability is the ability to maintain outcomes after initial support ends — requiring political will, embedded financing, system ownership, and community demand. The distinction between scale-up and scale-out is addressed in the Field Guide. A useful test: if external support ended tomorrow, what would continue and what would stop?
Advocacy Pitch Builder — LGA Chairman
You have 3 minutes with the LGA Chairman. Select the three elements that will make the most persuasive case for this specific audience.
Scale-Up vs Scale-Out — Why the Distinction Matters
Amina Bello — Health Information Officer
The DIR improved defaulter tracking in Sabon Gida. But adoption rates at Rafin Zuwo remain inconsistent, and Kpako PHC deployment hasn't started. Scaling the programme means deciding whether to scale the DIR alongside it — or whether those facilities will need different support first.
You have protected the budget for Kwara North. The next strategic question is: how does what works here spread to other districts? Implementation science distinguishes two fundamentally different pathways.
Scale-Up
Increasing the volume and reach of an intervention within the same system — more outreach sessions, more VHWs, more districts receiving the same model. Scale-up assumes the original context is similar enough to the expansion context that the same approach will work.
Scale-Out
Adapting and replicating an intervention into different contexts — communities with different barrier profiles, different health system structures, or different cultural dynamics. Scale-out requires deliberate re-contextualisation: a strategy designed for one barrier type cannot simply be transplanted to a community where a different barrier dominates.
Interventions may lose effectiveness when expanded into new settings if implementation quality or contextual fit is not maintained — a phenomenon known as the voltage drop. This happens when pilot conditions are not replicated, adaptations erode core components, implementation support is not scaled alongside the intervention, or the original strategy was never documented with enough detail for others to understand what it actually was.
The Kpako trust partnership has run for four months. Coverage has risen from 12% to 19% — modest but the first sustained gain. The state manager wants to expand immediately to all 12 districts. Your programme officer argues to wait until Kpako reaches 40% before scaling. The manager counters that other districts with similar undocumented populations are waiting. Who has the stronger implementation science argument?
✓ Correct — context fit before replication.
The Kpako model was designed for a specific barrier profile: undocumented migrants with high government distrust. Scale-up (more of the same, same context) may be appropriate for districts with similar profiles. Scale-out (adaptation to different contexts) is needed everywhere else — which requires a CFIR context assessment for each expansion district before strategy selection. Replicating a trust-barrier strategy in a district where the primary barrier is geographic distance wastes resources and produces no results. WHO's ExpandNet and the Scalability Assessment Tool both start with context mapping for exactly this reason.
Assessing contextual fit should be part of planning for replication.
Budget, staffing, and coverage thresholds are important — but the foundational question for any scaling decision is whether the new context shares the barrier profile the strategy was designed for. Scaling interventions without assessing context can lead to ineffective and costly programme expansion.
"Evidence does not speak for itself. Leaders help decision-makers understand why evidence matters."
The purpose of Mission 5
📢
Immunization Advocate
You mapped stakeholders, built a tailored advocacy pitch, and applied sustainability and scale-up principles to protect program gains.
Reflect — Before the Final Challenge
You built an advocacy pitch for the LGA Chairman. Thinking about your own programme context: who is the decision-maker most critical to sustainability right now — and what do they care most about that immunization currently fails to speak to?
Expert perspective
The most common advocacy failure in immunization financing is framing the argument in health terms to an audience that makes decisions in economic and political terms. IA2030 Strategic Priority 2 (Commitment and Demand) identifies three specific barriers to government commitment: shifting leadership priorities, low visibility of disease burden, and social and behavioural drivers. Effective advocacy addresses the specific barrier facing the specific decision-maker — not a generic "vaccines save lives" message. For finance officials, the most compelling evidence is typically cost-of-outbreak data: a measles outbreak in a district costs 20–40× more to respond to than to prevent through sustained routine immunization (Bishai D et al., 2011; Ozawa S et al., 2016). For elected officials, the electoral correlation between high-coverage wards and higher health outcomes is often more persuasive than epidemiological arguments.
District Review Board · Final Assessment
You have completed all five missions.
The district has changed. The challenges have multiplied. The decisions are yours. No single barrier dominates. Geographic access remains uneven. Several communities report low trust in government services. Supply chain disruptions occur regularly. Political support is uncertain. Your task is to manage an entire implementation system.
Gombe East District — New Assignment
65%
Coverage
4,000
Zero-Dose
Limited
Budget
Weak
Political Support
Challenge 1 of 9
You arrive in Gombe East with no prior data. Coverage is 65% and you know nothing else. What is your first action as the new District Immunization Officer?
✓ +10 XP. Correct — diagnose before you act.
Even under pressure, context assessment should precede intervention. Without understanding the distribution and causes of missed children, any action risks wasting a limited budget on the wrong communities or the wrong barriers.
Context first.
Understand the distribution and causes of missed children before designing or deploying any intervention. Action without assessment risks misallocating scarce resources.
Challenge 2 of 9
Your rapid assessment finds: three pastoral wards (seasonal migration), one urban slum (high refusal, undocumented residents), and two remote rural wards (no facility within 20 km). Budget allows for two major strategies. Which do you prioritise?
✓ +10 XP. Barrier-matched strategy selection.
Each population's barrier requires a specifically matched strategy. Pastoral communities need calendared mobile outreach. Undocumented communities need trust-based, documentation-free partnerships. These are the two most context-specific problems and the two highest-leverage investments.
Match strategy to barrier.
Generic approaches cannot address context-specific barriers. Each population identified in your assessment needs a matched strategy. Equal distribution or mass media ignores the barrier analysis.
Challenge 3 of 9
Eight weeks in, monthly data shows DTP1 at 74% but DTP3 at only 48%. Community mobilisers confirm sessions are running on schedule. What is your priority monitoring response?
✓ +10 XP. Fidelity is not the same as reach.
Sessions running on schedule (fidelity) does not guarantee children are completing the vaccination schedule (reach). A 26-point dropout gap is a serious signal that demands investigation — are caregivers being followed up? Are reminder systems working? Are barriers to return different from barriers to first contact?
Recall the fidelity vs reach distinction.
A program can have perfect session fidelity and terrible reach. Sessions running does not mean the right children are attending. The 26-point dropout gap is the critical signal here — investigate its cause before adding more sessions or reporting partial success.
Challenge 4 of 9
At six months: overall coverage has risen from 65% to 76%. Urban slum improved from 34% to 62%. Pastoral wards improved from 41% to 55%. Which evaluation conclusion is most accurate and complete?
Both populations improved but at different rates — which means they need different next-steps, not a single overall conclusion. The urban slum success can be reinforced. The pastoral strategy may need refinement. Headline gains are a starting point for evaluation, not its conclusion.
Disaggregation reveals the real story.
All populations improved — but differently. That distinction matters enormously for next-step decisions. A single overall judgment conceals which strategies are working for which communities and prevents intelligent resource allocation. Always disaggregate before concluding.
Challenge 5 of 9
Your program has reduced zero-dose children from 4,000 to 2,400. But your political champion has left office. His replacement is new and has no immunization background. What is your first advocacy move?
✓ +10 XP. Sustainability is active, not passive.
Political transitions are one of the most common sustainability risks in immunization programs. The response is proactive, direct, and audience-centred — not technical reports, not working through outgoing champions, and certainly not waiting. Frame your success in terms of the new official's priorities, then make it real through a direct encounter with the program's impact.
Sustainability requires active relationship-building.
Technical reports rarely persuade new officials who have no prior connection to the program. Waiting is a sustainability failure. The approach should be proactive, direct, and framed around the new champion's own goals — not your program's goals.
Challenge 6 of 9
After six months, your cost-per-fully-immunized-child (FIC) in the urban slum is ₦3,200 and in pastoral wards ₦9,400. A state economist recommends concentrating all resources where cost-per-FIC is lowest. What is your response?
✓ +10 XP. Equity-weighted cost analysis.
Hard-to-reach populations have higher cost-per-FIC because proximity to services is itself a proxy for socioeconomic advantage. IA2030 emphasises that efficiency and equity considerations may point to different priorities — prioritising only the least expensive populations to reach can unintentionally deepen existing inequities and leave zero-dose children unreached year after year.
Revisit the equity-efficiency relationship.
Pure cost-effectiveness optimisation in immunisation systematically disadvantages the hardest-to-reach. IA2030's three impact goals — Prevent Disease, Promote Equity, Build Strong Programmes — require equity to be weighted alongside efficiency, never subordinated to it.
Challenge 7 of 9
Your VHW reports vaccines arriving warm on the 4-hour outreach route — temperature excursions are suspected. DTP1 coverage is rising but potency may be compromised. What is the priority response?
✓ +10 XP. Immediate cold chain response.
Temperature excursions require real-time investigation and correction. IA2030 Strategic Priority 6 (Supply and Sustainability) identifies cold chain integrity as foundational to vaccine delivery. Doses administered outside the cold chain may be ineffective — children appear vaccinated in registers but remain unprotected, creating a hidden zero-dose problem. WHO guidance recommends immediate stock quarantine, route review, and re-vaccination of potentially affected children where excursion is confirmed.
Cold chain breaches cannot wait.
Every dose administered outside the cold chain risks being ineffective. Children appear vaccinated but are unprotected. Immediate corrective action is required — not quarterly reviews or state authorisation.
Challenge 8 of 9
You have reduced Gombe East zero-dose children from 4,000 to 2,400 — a 40% local reduction. IA2030 targets a 50% global reduction in zero-dose children by 2030. Which statement most accurately reflects IA2030's approach?
✓ +10 XP. IA2030 operates at every level.
IA2030 is driven by district-level implementation. Its monitoring framework requires tracking zero-dose reductions by population group, not just in aggregate. A 40% reduction concentrated in peri-urban populations while pastoral and migrant communities remain unreached does not satisfy IA2030's equity mandate. IA2030 explicitly calls for focusing on "communities where large numbers of zero-dose children are clustered" — disaggregated action is the mechanism, not an optional enhancement.
IA2030 emphasises disaggregated tracking.
IA2030 is driven by subnational implementation. Its equity monitoring framework requires that reductions be tracked by population group. Aggregate improvements masking persistent inequity in the hardest-to-reach communities do not satisfy IA2030's mandate to leave no one behind.
Challenge 9 of 9
Final scenario. Month 14 in Gombe East. Coverage: 81%. Zero-dose: 1,900. A measles outbreak is reported in a neighbouring district. Your VHW network is stretched, cold chain is under pressure, and your newly re-elected political champion has announced budget cuts to district health services. You have a meeting with the state immunization team in 48 hours. What does your agenda cover?
✓ +20 XP. Applying all five pillars under pressure.
The district faces multiple challenges simultaneously: outbreak risk, financing uncertainty, implementation constraints, and persistent zero-dose populations. No single intervention will solve the problem. Success depends on integrating identification, reach, monitoring, evaluation, and advocacy within a single implementation strategy. This agenda is correct because it integrates all five pillars simultaneously — identification of the highest-risk population, delivery capacity, real-time monitoring, equity-based evaluation, and evidence-led advocacy. The 1,900 remaining zero-dose children are both the most vulnerable to a measles outbreak and the core argument for sustained routine immunization investment. The economic case addresses the budget threat directly. Real-time monitoring during outbreak risk is non-negotiable.
All five pillars are needed simultaneously.
Partial responses — reporting one metric, suspending outreach, or addressing only the budget — each leave critical gaps. Real-world immunization leadership under pressure requires holding all five IRMMA pillars simultaneously: knowing who is missed, maintaining reach, monitoring the situation, measuring vulnerability, and advocating on evidence.
🏆
Immunization Implementation Science Champion
You have completed all five DISTRICT missions and the District Turnaround Simulation.
Somewhere in a district like Kwara North, there is a Hauwa who has never been told her children need vaccinating. A Musa who became a Village Health Worker because of what happened to his own daughter. An Aminata who continues knocking on doors despite repeated refusals. An Ibrahim whose mother walked kilometres for a service she expected would be available.
Implementation science does not improve health outcomes on its own. People do. Its value lies in helping programme teams understand problems more clearly, make better decisions, and deliver services more effectively. That is the capability you have developed throughout DISTRICT.
Congratulations. You are now ready to apply it in practice.
Before you go — three questions worth sitting with:
What implementation assumption changed most during this course?
Which lesson will most influence your decisions in practice?
What would you do differently in your own district tomorrow?