In Africa, approximately 8.3 million infants each year do not receive the most basic vaccines. According to the World Health Organization (WHO), one major reason for low immunization coverage in many developing countries is the lack of adequate numbers of skilled health workers.

As a founding partner in the GAVI Alliance, a historic public/private partnership committed to saving children's lives and protecting people's health by increasing access to immunization in lowest income countries, Merck responded to this public health challenge by launching a multiyear philanthropic initiative to help strengthen the capacity of Expanded Program on Immunization (EPI) health workers in sub-Saharan Africa.

Formally endorsed by the GAVI Alliance in 2003, the Merck Vaccine Network — Africa (MVN-A) supports collaborative partnerships in the development and implementation of sustainable EPI management training programs in Kenya, Uganda, Mali and Zambia. MVN-A also supports the achievement of the UN Millennium Development Goals, including reducing by two-thirds the mortality rate among children under five by 2015.

With philanthropic funding from The Merck Company Foundation, and following a competitive grant application process in 2003, two collaborative partnerships established MVN-A training programs in Kenya and Mali. Following a second competitive grant application process in 2007, The Merck Company Foundation provided funding support to establish two additional MVN-A training programs in Uganda and Zambia.

The four MVN-A training programs provide mid- to high-level immunization program managers in Kenya, Mali, Uganda and Zambia with customized, hands-on training in vaccine management and immunization services. Each MVN-A program is managed and administered by two primary institutions that have forged a broader collaborative partnership of key national stakeholders, including Ministries of Health and Education, nongovernmental organizations, medical and nursing schools, and multilateral organizations such as WHO and UNICEF:

• MVN-A Kenya: Indiana University School of Medicine (Indianapolis, Indiana, USA) and Moi University School of Medicine (Eldoret, Kenya)
• MVN-A Mali: Center for Vaccine Development at the University of Maryland School of Medicine (Baltimore, Maryland, USA) and Centre pour le Développement des Vaccins, Mali (Bamako, Mali)
• MVN-A Uganda: Task Force for Global Health (Decatur, Georgia, USA) and Makerere University School of Public Health (Kampala, Uganda)
• MVN-A Zambia: Brighton and Sussex University Hospitals NHS Trust (Brighton, England, UK) and University Teaching Hospital of the University of Zambia School of Medicine (Lusaka, Zambia)

Each MVN-A program has developed and continues to adapt customized training curricula and methodologies to improve the capacity of EPI health workers and address evolving national immunization management needs. Baseline training needs assessments in all four countries helped to identify specific gaps in the knowledge, skills and practice of EPI health workers, as well as inadequacies in reference materials, cold chain equipment and logistical resources. In each country, the MVN-A collaborative partners utilized these findings to develop and customize a highly focused EPI training curriculum that would effectively address the most significant gaps, promote best practices and improve knowledge retention among health workers. This extensive process involved adapting and refining a subset of existing mid-level manager EPI training modules published by the World Health Organization Regional Office for Africa and other GAVI Alliance partners.

We know that a significant cause of low immunization coverage in Africa is the lack of trained healthcare workers. The Merck Vaccine Network — Africa is helping the Republic of Mali and its people address this critical issue by building a skilled cadre of immunization managers. This partnership is a testament to how the public and private sectors can come together to help strengthen healthcare capacity and ensure the health of our nation's children.

Professor Abdel Kader Traoré,

Ministry of Health, Republic of Mali

MVN-A training courses currently span a wide range of relevant topics, including management training on storing and handling vaccines safely, forecasting community needs to ensure an adequate vaccine supply, planning and conducting disease surveillance activities and providing supportive supervision to health workers at peripheral levels. The MVN-A collaborative partners in each country also developed highly customized ancillary training materials to suit specific national needs, such as a cold chain repair practicum designed specifically for district health workers in Kenya. After conducting a series of customized "training of trainers" sessions, MVN-A collaborators identified a pool of highly effective facilitators to administer national-, provincial- and district-level EPI management training across each country. Interactive adult training techniques were also implemented and adjusted for various EPI delivery levels, from the national level down to the health subdistrict level in the four countries. Some MVN-A programs also chose to implement rigorous supportive supervision to effectively reach EPI health workers at the peripheral health center level.

MVN-A training facilitators include senior Ministry of Health EPI program administrators, medical and nursing school professors, medical training college instructors, WHO EPI personnel from the country and/or regional level, cold chain equipment technicians and also former MVN-A graduates who have since demonstrated experience training health workers at the operational level.

Health worker training initiatives in sub-Saharan Africa face numerous operational challenges, including maintaining, adapting and continuously improving training activities to address high staff turnover; internal health worker migration from low-population density rural to high-population density urban areas; and unforeseen events, such as natural disasters and political unrest that can lead to disease outbreaks. For this reason, each MVN-A training program is fully integrated into the existing national healthcare infrastructure, which ensures complete alignment with the immunization priorities identified by the Ministry of Health and also with strategic policies and initiatives endorsed by regional and international stakeholders such as WHO, UNICEF and the GAVI Alliance.