Drivers of what works for strengthening routine immunization in Africa

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1 Drivers of what works for strengthening routine immunization in Africa Photo credit: ARISE/Ghana Jenny Sequeira Africa Routine Immunization System Essentials (ARISE) WFPHA, 26 April 2012 Addis Ababa, Ethiopia ARISE is funded by the Bill & Melinda Gates Foundation and implemented by JSI Research & Training Institute, Makerere University & The Dartmouth Institute

2 ARISE Project Background Managed by John Snow, Inc. (JSI) Subcontracts with Makerere University School of Public Health and George Washington University School of Public Health Supported by the Bill & Melinda Gates Foundation Timeframe: September 2009 July 2012 Guidance from External Panel of Experts

3 ARISE Project Objectives 1. Strengthen the evidence base to improve understanding of the drivers of routine immunization (RI) system performance. 2. Deepen and broaden African and global stakeholder engagement in improving RI. 3. Position the learning to help stakeholders improve RI systems in Africa, identify potential investment options, and clarify stakeholder roles.

4 Global immunization Global DTP3 coverage estimated at 85% in 2010 Source: WHO/UNICEF coverage estimates

5 Project Approach Enhancing evidence base on RI drivers Landscape analysis Country case studies Synthesis Consulting and engaging stakeholders Experience and evidence Issues to explore Current investment priorities Recommend steps for improving RI systems

6 What is a driver? A driver is a structure, resource, or process that works on or through RI system components to improve the RI system s effectiveness. Drivers may take multiple forms: specific interventions innovations or best practices changes in the overall health system

7 Country Case Study Methodology Selection of countries: Ethiopia, Ghana, Cameroon Increase in DTP3, DTP3 coverage sustained at a level higher than the regional average Geographic, linguistic, and GNI variation Four districts per country selected for study: All started at 65-70% DTP3 coverage 3 districts with positive change since district without recent positive change, for validation Qualitative interviews with respondents at central, regional, district, sub-district, health center, health post, and community levels, group discussion, and observation Program data review and situation analysis of EPI program Assets-based approach: what contributed to improvement?

8 Country Case Studies: Analytical Framework DRIVERS Intervene to determine how inputs manifest DRIVERS Intervene to translate inputs into essential RI components DRIVERS Intervene to boost implementation DRIVERS Intervene to translate implementation into effective RI system performance Drivers Inputs Finances Human resources Stakeholders Transport Imm System Essential Components Cold chain Vaccines Service delivery (facilities, outreach sites, strategy) Implementation Processes Vaccine quality Stock outs Access Service Quality Immunization System Performance DTP1 coverage DTP3 coverage Dropout Equity Immunization System Context

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10 Direct Drivers of RI Performance Regular Review of Program and Health Worker Performance Health System and Community Partnership Immunization Services Tailored to Community Needs Cadre of Community Centered Health Workers Improved Service Delivery Increased Acceptance and Use Improved Immunization Coverage

11 Cadre of Community-centered Health Workers Take vaccination into heart of the community Mechanism More workers, build trust, local support, vaccine supply. Transformational step Raised awareness, improved access, increased use Effect

12 Partnership between the Health System and the Community JOINT: Planning, AwarenessRaising, Performance Review, Resource Pooling Shared sense of purpose & accountability, credibility Mechanism Transformational step Ensured service availability, decreased dropout rates Effect

13 Regular Review of Program and Health Worker Performance Regular summary, presentation and interpretation of data, assess progress, compare performance Team-oriented review; problemsolving approach, collective accountability Mechanism Transformational step Maintains focus on delivery and demand improvement, motivation, momentum Effect

14 Tailor Immunization Services to Community Needs Standard program strategies are adapted to local context Health workers modify their behavior towards mothers and children District management teams have fiscal autonomy to help health workers tailor their services

15 Tailor Immunization Services to Community Needs Gather knowledge about preferences; choose appropriate sites for outreach, adapt services Personal links, used appropriate avenues, trust and credibility of health workers and service Increased physical and social access to care; increased acceptance, improved completion of vaccination schedule Mechanism Transformational step Effect

16 Enabling drivers Enabling drivers Political and Social Commitment to Routine Immunization Actions of Development Partners 2 essential health system components District management teams Basic routine immunization inputs Direct Drivers of RI Performance

17 Synergy Among the Four RI Direct Performance Drivers

18 Conclusion CONTEXT & Assetsbased thinking CONTEXT & Assetsbased thinking

19 Every child should be a VIP: Vaccinated, Immunized and Protected Ethiopia FMOH Fully Immunized Certificate in Amharic Photo credit: ARISE/Ethiopia