Immunisation health workforce capacity building in Southeast Asia: reflections from training programme implementation in Cambodia and Lao PDR

Abstract

The Immunization Agenda 2030 emphasises the need for a motivated, skilled and knowledgeable workforce equipped to plan, manage, implement and monitor immunisation programmes at all levels. The rapid introduction of COVID-19 vaccines during the pandemic highlighted the adaptability of the health workforce but also exposed gaps in professional development and learning.

This practice paper describes the implementation of an immunisation training programme in the Kingdom of Cambodia and the Lao People’s Democratic Republic. The programme was developed and delivered by the project team in partnership with local stakeholders and technical experts. A country-centric approach ensured that training programmes met each country’s needs, while input from technical experts ensured an evidence-based programme that aligned with international standards. There were 445 training participants from professional groups across various levels and sectors of the health system. Training curricula included a range of differentiated training modules which aimed to build knowledge and skills to drive increased vaccine demand, improve service delivery and optimise monitoring and evaluation of programmes.

The Gavi Learning and Performance Management framework supported a structured reflection of programme strengths, limitations and opportunities. Strengths were the country-centric and learner-centric approach and the high technical quality of the programme. The pandemic context necessitated agility and adaptation to meet changing country needs and priorities, however, this introduced some limitations. Future training programmes should undertake an enhanced assessment of training needs, workforce and digital capabilities and learning and performance management systems, alongside the development of country-driven immunisation workforce training roadmaps to ensure optimal impact and sustainability.

Summary box.

• Implementation of COVID-19 immunisation programmes placed immense pressures on the health workforce and exposed gaps in immunisation-related professional development and learning.

• This paper describes the implementation of tailored immunisation training programmes to build immunisation workforce capacity in two Southeast Asian countries (Kingdom of Cambodia and Lao People’s Democratic Republic).

• The Gavi Learning and Performance Management framework supported a structured reflection of the training programme; identified strengths were the country-centric and learner-centric approach, while limitations related to training impact and sustainability.

• This examination of the successes and challenges of immunisation training programme implementation in Southeast Asia can support the development and evaluation of future impactful and sustainable learning and performance management initiatives in the region.

Introduction

The COVID-19 pandemic highlighted the adaptability and innovation of the health workforce to rapidly introduce and implement COVID-19 vaccine programmes.¹ However, the extraordinary pace and scale of the programme placed immense pressures and challenges on health systems.² Health workers experienced increased workloads, large volumes of new information and frequent policy and practice changes.²,⁵ These factors contributed to mental health impacts, including burnout, anxiety and moral distress.³

In Southeast Asia, many countries faced significant challenges relating to affordability, supply and delivery of COVID-19 vaccines, however, vaccine acceptance was generally high compared with other regions, with many countries initially achieving good uptake.^{6 7} In early 2022, in the Kingdom of Cambodia (Cambodia), an estimated 90% of eligible individuals had received the primary vaccination series,⁸ and in the Lao People’s Democratic Republic (Lao PDR) around 70%.⁹ By mid-2022, the uptake of both primary and booster COVID-19 vaccination had plateaued¹⁰ and coverage was persistently low in certain subpopulations, such as rural and ethnic minority groups.^{8 9} In parallel, there were declines in routine childhood immunisation coverage and disruption to vaccine-preventable disease (VPD) surveillance attributed to service disruptions and diversion of resources during the pandemic response.^{11 12} A postpandemic resurgence of VPDs, such as measles, was observed in many parts of the world including Southeast Asia.^{11 13}

The Immunization Agenda 2030 (IA2030), endorsed by the World Health Assembly in 2020, emphasises the need to restore and strengthen immunisation programmes following the COVID-19 pandemic.¹⁴ An empowered immunisation workforce is central to achieving this which, in turn, relies on professional development¹⁵,¹⁷,^{5 18},¹⁹ Further, the quality of training for immunisation workers is also not readily linked to measurable improvements in population health outcomes.^{20 21}

This practice paper describes the implementation of a technical assistance project to enhance the capacity of the immunisation workforce in Cambodia and Lao PDR as part of a pandemic response. The project involved the design, development and delivery of tailored training programmes that leveraged country strengths and aligned with the WHO Standard Competencies Framework for the Immunisation Workforce (WHO Competencies).²¹ The Gavi Learning and Performance Management (Gavi LPM)¹⁷ framework was used for structured reflection on training programme implementation and to identify key learnings.

Background and setting

Cambodia

In Cambodia, primary care services including immunisation are provided by health centres or health posts in remote areas.^{22 23} Community health workers, including Village Health Support Groups, play a crucial role in connecting communities with health centres and secondary and tertiary health services supplied by a network of public provincial and referral hospitals.²³

The COVID-19 pandemic response in Cambodia was decentralised with local committees in each province overseeing vaccinations and other public health measures within their respective jurisdictions. The province of Tboung Khmum (TBK) was selected as an implementation site due to relatively low coverage of the primary course of the COVID-19 vaccine compared with other provinces. The TBK Provincial Health Department identified a need for training of immunisation staff to address the perceived challenges of vaccine misinformation, vaccine hesitancy and complacency and concern around adverse events following immunisation (AEFI).

Lao People’s Democratic Republic

In Lao PDR, public health services are delivered at central, provincial and district hospitals and health centres.²⁴ Community health workers, specifically ‘Village Health’ volunteers and committees, and traditional birth attendants, play a key role in health promotion and health service delivery at the community level.²⁴ The introduction of the National Health Insurance Scheme in 2016 included the provision of vaccination services at no cost, however, reaching remote groups and those with low health literacy remains challenging.^{24 25} These issues were exacerbated during the pandemic, as were concerns regarding the quality of immunisation data.^{26 27} To respond to data needs, Lao used a digital COVID-19 Vaccination Registry which later provided the impetus for a national electronic immunisation register (EIR). In early 2022, the Lao EIR was piloted in Vientiane as a module within the existing Digital Health Information System (DHIS2) platform.

Immunisation training programme implementation

Project team

Strong engagement and collaboration with in-country partners were central to this project. Our approach focused on local priorities with decisions led by in-country partners to ensure that the training aligned with national standards and sociocultural expectations, to support the needs of the local health system and COVID-19 responses. Cambodia’s partners included the Khmer HIV/AIDS Non-Government Organisation Alliance and the TBK Provincial Health Department. In Lao PDR, in-country partners included the Department of Hygiene and Health Promotion and the Department of Planning and Cooperation, the Maternal and Child Health Centre (MCHC), the National Centre for Laboratory and Epidemiology and the WHO Country Office.

Finally, we also formed a collaboration of international scholars with diverse expertise in immunisation systems. International partners came from the Australian National University, Australian Regional Immunisation Alliance,²⁸ National University of Singapore and the University of Sydney. These personnel ensured the technical quality of the training, incorporation of pedagogical best practices such as the application of evidence-based adult learning principles and alignment with international standards including the WHO Competencies and the IA2030.^{16 21}

Development of training modules

From April to October 2022, we undertook semistructured online and in-person consultations with key stakeholders to understand the context and priority learning needs of the immunisation workforce. The original purpose of the training programme was to support the uptake of the COVID-19 vaccine; however, consultations highlighted a need for broader immunisation programme support. These findings were presented to local health officials who were supported to refine and determine the training programme focus.

Separate country teams were established to develop the training programme. These teams reviewed local policy and guidelines, international standards and relevant peer-reviewed literature related to the topics for training. They also conducted additional stakeholder consultations to ensure that a comprehensive assessment of contemporary policy and practice was reflected in the training programme and to prevent duplication of other capacity-building initiatives.

The final programme consisted of seven discrete training modules which aimed to build knowledge and skills to drive vaccine demand, improve service delivery and optimise programme monitoring and evaluation. The scope and design of the modules were determined based on needs identified through stakeholder consultation in each country; modules 1–4 were offered in Cambodia and modules 5–7 in Lao PDR. Target participant groups were identified in collaboration with the departments of health in the respective countries. The target participants, key resources and learning objectives for each module are mapped to the WHO Competencies framework in table 1.

Table 1. Outline of immunisation health workforce training in Cambodia and Lao PDR mapped to the WHO Competency domains.

Modules and key resources	Target participants	Learning objectives	WHO Competency domains
Cambodia
Boosting vaccination uptake and coverage30 33	Policymakers and programme managers	Identify and discuss common drivers of under-vaccination. Identify barriers and facilitators of vaccine acceptance. Discuss interventions that could form a strategic plan to increase vaccine uptake.	Human resources and performance management Management and leadership Advocacy and communications Policy, planning and finance
Interpersonal and public health communication1034,40	Community health workers	Understand the principles and practices of good communication to effectively engage with communities in outreach activities.	Human resources and performance management Vaccine-preventable diseases and programme Advocacy and communications
Interpersonal and public health communication1034,40	Healthcare providers	Understand the principles and practices of good communication to effectively engage with patients and the public in a clinical context.	Human resources and performance management Vaccine-preventable diseases and programme Advocacy and communications
Adverse Events Following Immunisation (AEFI)39,42	Healthcare providers	Understand the principles of AEFI, including definitions and categories, and vaccine safety and surveillance practices. Develop skills and knowledge to support the prevention, detection, management and reporting of AEFI.	Human resources and performance management Vaccine-preventable diseases and programme Safety of vaccines and immunisation Monitoring, evaluation and data use Vaccination service delivery
Lao PDR
Immunisation registry data to support immunisation programmes, response and research1643,48	Public health officials, policymakers, data officers	Describe the role of immunisation registries and discuss individual and population benefits of EIR. Describe the principles of data quality and identify associated roles and responsibilities. Identify and discuss strategies to promote the capture of high-quality immunisation data. Develop foundational knowledge required to interpret and report on key vaccination measures.	Human resources and performance management Management and leadership Disease surveillance, investigation and response Monitoring, evaluation and data use
Principles of immunisation registries for vaccination teams1643,48	Healthcare providers	Describe the role of immunisation registries and discuss individual and population benefits of EIR. Describe the principles of data quality and identify associated roles and responsibilities. Identify and discuss strategies to promote the capture of high-quality immunisation data.	Human resources and performance management Disease surveillance, investigation and response Monitoring, evaluation and data use Vaccination service delivery
Vaccine-preventable diseases surveillance49	Surveillance officers	Strengthen knowledge and skills of surveillance practices at the national and provincial levels, including case investigation and contact tracing.	Human resources and performance management Disease surveillance, investigation and response Monitoring, evaluation and data use

EIRelectronic immunisation registerLao PDRLao People’s Democratic Republic

Evidence-based adult learning principles were adopted in the design of the training courses. Specifically, training materials and activities aimed to meet learner needs and motivations by combining content-focused theory with experiential approaches including scenario-based and group problem-solving activities, role play, practical demonstrations and co-creation of interventions.²⁰ We used images, stories and quotes from country public health officials, healthcare providers and community members by curating case studies and images from publicly available but local sources such as the UNICEF Country stories²⁹ and local media. The modules also incorporated features to cater to different learning styles, encourage participation and reflect diversity in gender, language and professional groups. Representation of Cambodian and Lao women in health leadership positions was deliberately emphasised.

Materials were first developed in English and then translated into local languages. All materials were reviewed by in-country, local-language speaking technical experts to ensure accuracy, local linguistic preference and sociocultural appropriateness.

Cambodia training modules

Module 1, ‘Vaccination uptake and coverage’, was developed for policymakers and programme managers in response to the low uptake of booster doses of COVID-19 vaccines. The module introduced participants to the ‘Behavioral and social drivers of vaccination’ framework³⁰ and included group activities that required participants to identify barriers affecting uptake in their local setting and then develop strategies to address these barriers.

Modules 2 and 3, ‘Interpersonal and public health communication’, were developed for community health workers and healthcare providers respectively. The modules were similar in content but were differentiated to meet the needs of each group, who have distinct roles and activities. The modules aimed to equip participants with knowledge and skills to support effective communication about vaccination with community members, patients and the public as relevant to their role. Participants were asked to apply their learning by co-creating messages to promote the uptake of COVID-19 boosters in their community.

Module 4 on ‘Adverse Events Following Immunisation’ was developed for healthcare providers, building on learning completed in Module 3. This module aimed to equip participants with the skills and knowledge to monitor, manage and report AEFI.

Lao People’s Democratic Republic training modules

Module 5, ‘Immunisation registry data to support immunisation programs, response, and research’, was developed for public health officials, policymakers and data officers who use vaccination data to support planning and resource allocation. This module provided an overview of immunisation registries and data quality followed by group activities where participants applied learnings to design interventions to improve immunisation data quality in their workplace.

Module 6, ‘Principles of immunisation registries for vaccination teams’, included similar content to module 5, however, was tailored to immunisation providers. A practical demonstration of the Lao EIR led by the UNICEF health information officer was included in this module.

Module 7, ‘Vaccine preventable disease surveillance’, formed part of a larger training programme for surveillance officers across 18 provinces led by the WHO Lao Office Vaccine-Preventable Disease and Immunisation and Health Emergency Team. This cascade training provided a refresher on core principles of VPD surveillance and outbreak response at the national and subnational level, followed by application of learning through case studies and scenarios.

Delivery of the training modules

In Cambodia, training was delivered in April and May 2023 at the Provincial Health Department and in the Krouch Chhmar, Memot and Ou Reang Ov operational districts of TBK. In Lao PDR, training was delivered in June 2023 in Vientiane Capital. Training was co-delivered by the project team and local health staff from the TBK Provincial Health Department in Cambodia and in Lao PDR, MCHC and the WHO Lao office. Specific participants from the target groups were selected by each country’s department of health based on the module scope and objectives. A total of 445 individuals participated in training: 263 in Cambodia and 182 in Lao PDR (table 2).

Table 2. Target participant groups and gender representation.

Country	Target participant group	Total participants(% of country)	Female participants(% of participant group)
Cambodia	Policymakers and programme managers	28 (10.6)	3 (10.7)
	Community health workers	143 (54.4)	70 (49.0)
	Healthcare providers	92 (35.0)	27 (29.3)
	Total participants	263	100 (38.0)
Lao PDR	Public health officials, policymakers, data officers	32 (17.6)	13 (40.6)
	Healthcare providers	30 (16.5)	21 (70.0)
	Surveillance officers	120 (65.9)	61 (50.8)
	Total participants	182	95 (52.2)

In Cambodia, the policy makerspolicymakers and programprogramme managers group included representatives from the National Immunisation ProgramProgramme, Expanded ProgramProgramme of Immunisation, Rapid Response Team, operational districts, and health programprogramme leaders. The Cambodian community health worker group comprised of distinct subgroups including Village Health Support Groups, the Union of Youth Federation of Cambodia, the Red Cross, and outreach workers. For the healthcare providers group, this included health centre chiefs and vice-chiefs, health centre nurses, and other specialist healthcare providers.

In Lao PDR, the public health officials, policy makerspolicymakers and data officers group included representatives from the Mother and Child Health CenterCentre, Vientiane Capital Health Department, Department of Planning and Finance, and international development agencies (United Nations Children’s Fund and the World Health OrganizationWHO). For Lao healthcare providers, this included individuals and teams involved in immunisation service delivery at central hospitals, the Vientiane Capital Health Department, the Military Medical Department and Prevention, and the Hygiene and Medicine Institute of the Lao Army. For the surveillance officer group, representatives were from 18 Lao provinces and included representatives from the Mother and Child Health CenterCentre, the National CenterCentre for Laboratory and Epidemiology, Communicable Disease Control, the World Health OrganizationWHO, and provincial hospitals.

Lao PDRLao People’s Democratic Republic

Training was predominantly delivered face-to-face, however, in Lao PDR sessions were also delivered remotely via live video conferencing. Experienced educators delivered the training in local languages or in English with live translation and multilingual facilitators. Printed training materials in the preferred language were provided to participants for use during the session and as a take-home learning resource.

During the training, project teams participated in daily de-briefs to identify challenges, limitations and opportunities for improvement. Where possible, modifications were made to the content or delivery methods in real-time. For example, in Cambodia, parts of the curricula were considered too academic for some participant groups, particularly community health workers, and were simplified accordingly by the local trainers. In Lao PDR, the schedule was modified to allow for more time in group problem-solving activities when facilitators recognised that this mode of learning enhanced participation.

Training evaluation and reflections

Participant feedback

A formal training evaluation was not conducted, however, four of the participant groups were invited to complete an online survey following training delivery which comprised of 5-point Likert scale questions and free-text (figure 1, online supplemental table 1). The survey was not administered for the Cambodian policymakers and programme managers nor the Lao PDR surveillance officer group. The former were senior health officials, from whom we solicited direct feedback which was considered more contextually appropriate. The VPD surveillance officer training was delivered as part of a larger programme led by the WHO Lao office, and assessments relevant to this programme were led by in-country stakeholders.

Figure 1. Post-training programme evaluation results. Lao PDR, Lao People’s Democratic Republic.

Of the four participant groups where the survey was conducted, 200 responses were received across both countries. Most respondents (≥85%) reported that the training programme met their expectations, was relevant to their role and increased their knowledge. Participants across the programme requested future learning opportunities, including periodic refresher training and expansion of training to other sites.

Participant and stakeholder feedback acknowledged alignment with local learning needs and immunisation programme priorities. A senior health official from TBK Provincial Health Department, Cambodia expressed the following:

(it)…reinforced awareness and knowledge of counselling and education to health professionals and health providers at the provincial health department level and at health centres level

In Lao PDR, a senior health official reflected on the EIR training modules:

I personally see it as an important and necessary part in immunization and this training made the participants aware and understand more about EIR as well.

Participants of the training programme reflected positively on the opportunity for interactive, peer-to-peer engagement while building new skills and knowledge:

I feel warm to be with colleagues, I have enjoyed the opportunity to refresh my knowledge and learn new things. This is my first face to face training since before the COVID-19 pandemic. Healthcare Provider

Learning about factors that can impact on the capture of high-quality immunization data; Having the opportunity for group discussions to share our ideas and knowledge. Data Officer

Some negative and neutral responses were provided by individuals from the community health workers group in Cambodia and from the public health officials, policymakers, data officers group in Lao PDR. In Cambodia, three community health workers (3.5%) provided a neutral or negative response to the statement ‘The training is relevant to my role’. In the same group, four provided a neutral or negative response to the statement ‘The training materials were appropriate’ (4.7%). In Lao PDR, four individuals from the public health officials, policymakers and data officers group provided a neutral response to the statement ‘The training is relevant to my role’ (15.4%).

Project team reflections

The project team encountered some challenges during the project. The original purpose was to support COVID-19 vaccination programmes, however, the rapidly changing COVID-19 situation alongside an increasing recognition of the serious disruptions to routine immunisation programmes prompted a shift to a broader ‘immunisation program’ focus. Additionally, virtual training was initially planned due to COVID-19-related travel restrictions, however, easing of restrictions and a local preference for face-to-face training resulted in the decision to deliver in-country programmes.

The in-country engagement with the government and considerable pivots in training design resulted in a longer formative period than originally anticipated and reduced the time available for the development and delivery of the training. Ultimately, however, these changes supported impact beyond the COVID-19 response, to strengthen immunisation programmes. The shift to face-to-face delivery also aligned with local preference and obviated recognised limitations in digital infrastructure which would have made virtual training delivery more challenging.

The promotion of gender equity was recognised as important and is reflected in training materials, however, implementing this in a practical sense was not straightforward. In line with the country-driven approach, participants were selected by the departments of health. Women, however, were under-represented in three of the six groups trained: in Cambodia, 10.7% of participants in the policymakers and programme managers group were female and 29.3% of the healthcare providers group; in Lao PDR, women made up 40.6% of participants in the public health officials, policymakers and data officers group. This under-representation of females reflects recognised gender gaps in health workforce participation and leadership.^{31 32} Future training should prioritise early discussions about gender and social norms with stakeholders to advance equity, diversity and inclusion and provide opportunities to address barriers for participants.

Reflections guided by the Gavi Learning and Performance Management framework

The Gavi LPM framework, published in 2023, aims to support countries to implement evidence-based approaches to address the learning needs and motivations of healthcare workers irrespective of gender, geography and profession.²⁰ It was underpinned by five guiding principles outlining that LPM should be impactful, country-driven, sustainable, learner-centric and digitally supported. The Gavi LMP Quality Assessment Criteria and Tool¹⁷ were used to guide a structured reflection of the training programme and support the identification of strengths, limitations and opportunities (online supplemental table 2). Key strengths were the country and learner-centric approach which prioritised country decision-making and catered to a diverse health workforce across the immunisation programme in each country. Additionally, high-quality, evidence-based content and learning approaches were viewed positively by participants and stakeholders.

Several limitations were highlighted through this reflection process; many of which were unavoidable in the context of the pandemic and rapidly changing needs. Integration of learning materials into routine programmes was a clear limitation and impacted sustainability. This is commonly expected during emergency responses, however, highlights an opportunity to consider how the sustainability of learning can be enhanced. Opportunities for digitally supported learning could have been further explored within the context of varying levels of digital literacy and infrastructure. Both these aspects of the LMP framework merit greater consideration so that emergency responses can build the capacity of the immunisation workforce for the longer term.

Through the reflection process, some feasible opportunities for improvement were identified. Enhanced assessment of training needs and workforce capabilities at the national, subnational and service delivery level is a key recommendation and should include exploration of LPM strategies, digital literacy and digital infrastructure. Formal evaluation of short and long-term training outcomes is also needed to support the development of training programmes that are impactful and learner-centric. Multifaceted LPM strategies which include policies and guidelines alongside training programmes are more likely to result in sustained improvements and this should also be considered.^{5 17 19} The development of national immunisation workforce training roadmaps could support country-driven, innovative and integrated LPM strategies to drive impactful and sustainable learning and capacity building.

Conclusions

The successful implementation of immunisation workforce training programmes in Cambodia and Lao PDR was attributed to a country and learner-centric approach which was evidence-based and aligned with country needs and international standards. Strong partnerships and collaboration with stakeholders and agencies were critical to successful implementation. A diverse range of professional groups from various levels and sectors of the health system participated in the training programme and, overall, found it to be valuable. The Gavi LPM framework supported the identification of learnings which can inform future immunisation workforce training programmes in the region.

Data availability statement

Data are available upon reasonable request.