Transformative investment: Strategies to Reach

Invest in tailored strategies that identify under vaccinated and unvaccinated persons and regularly provide them with the vaccines they need.

Justification for choosing this transformative investment and its relevance to Ethiopia

I have chosen this transformative investment that can to address the current challenge that the national immunization programme is facing.

Ethiopia is the second most population country in sub-Saharan Countries Ethiopia is the 2nd most populous country in Africa, with a projected 2018 population of 100 million, annual birth cohort is around 3.1 million.

Immunization in Ethiopia is one of exempted service and in the last two decades, construction of health facilities has been extensively extended to improve access of health services to the people. Despite these facts, immunization and other health service coverage is not yet reached the global and national target and significant number of children are still missing vaccinations. The trend of national immunization coverage for penta 1, penta 3 and measles has been stagnated since 2015. The low performance has resulted accumulation of susceptible cohorts for Measles and recurrent measles outbreaks were reported in many parts of the country. Measles pre- elimination target of 3 cases per million annually is also yet to be met as coverage is suboptimal.Furthermore, challenges with data quality are illustrated through the discrepancies in official coverage estimates reported through the administrative system as compared to survey data. The administrative and WHO-UNICEF (WUENIC) estimates reports for Penta 3 converged up to 2014 but has continued to diverge. The difference for penta 3 between WUENIC estimates and administrative reports was increased from 10% percent points in 2014 to 23% points while for measles increased from 14% Points in 2013 to 27% points in 2017.

According to WHO-UNICEF estimate, in 2016, Ethiopia is the 5th country in the world that contributes to the largest number of unvaccinated children with DTP3 estimated to be around 719,900 infants per year (WHO/UNICEF estimates July 2017). In 2017 this number has been increased to 853,470 and putting Ethiopia one of the of the 9 countries in Eastern and Sothern Africa that contributes the highest number of unvaccinated children. Successive EDHS (2000-2016) result also indicated that there is no change in proportion of children not vaccinated at all during the last one and half decades at around 16-20%, a clear evidence that remaining populations are systematically unreached. The Three big regions (Amhara, Oromia and SNNP) that have the majority of country population (82%) have low performance and contributed for more than 85 percent of unimmunized children in Ethiopia. As urbanization is increasing in Ethiopia, though Addis Ababa, Diredawa are reported high coverage , persistent measles outbreaks reported from urban slum. This indicates the importance of looking beyond reported administrative figures.

Coverage and Equity assessments have shown that (WUNIEC 2017)

• Penta 3 coverage – 73% , below Global and National target ( >80 )
• Measles First dose (MCV1) - 65% (below the Global and National target( >95%)
• Total unimmunized children 853,384 ( 700,000 in 2016)
• Signifiant régional disparités

Missed children concentrated in:

• Urban areas
• Rural areas
• Hard-to-reach areas
• 85% in big regions contributing 82% of country population (Amhara, Oromia and SNNPR)

To address need to invest in tailored strategies based on the evidence to tackle the underlying issues, identify under vaccinated and unvaccinated children to reach and vaccinate them with the vaccines they need using health system strengthening approach instead of Just only for immunization

Key STRATEGIES:

1. Identify and examine reasons for unvaccinated and under vaccinated
2. Investigate and address cultural, societal and behavioral barriers or confidence gaps in immunization
3. Explore health worker–client interactions, perceptions and practices
4. Improve the friendliness, convenience, efficiency and quality of services at health facilities
5. Use VPD surveillance and campaign monitoring opportunities to identify unvaccinated and under vaccinated children
6. Engage communities and create demand and design services to reach all equitably
7. Build capacity of vaccinators and manager
8. Ensure vaccine quality and availability
9. Secure political commitment and partnerships
10. Monitor programme performance

Priority strategies:

1. Identify and examine reasons for unvaccinated and under vaccinated

Immunization coverage is an important indicator of the health system’s ability to reach all segments of population including underserved communities and a key marker for Universal Health Coverage. Measurable gains have been made in the EPI programme since its launch in 1980 and the Government is successful in protecting a large proportion of its nearly 3 million annual birth cohort against 11 vaccine-preventable diseases. Though Ethiopia has been polio-free for nearly four years however, the current detection of the circulation of vaccine-derived polio virus in Somalia and Kenya created a great concern Ethiopia particularly Somali region mainly due to low population immunity, cross boarder population and geographical proximity to affected countries hence the Government of Ethiopia declared cVDP2 as public health emergency.

Ethiopia is one of the country receiving refugee population who are reside both in camps and host communities In 2018 Ethiopia was faced with an unprecedented caseload of more than 2.6 million internally displaced persons (IDPs) affected by conflict and drought, mainly along the Oromia regional border with Somali and the Southern Nations, Nationalities and Peoples’ Region (SNNPR) and Benshabgul Gumuz with children constituting more than half of the displaced population. Children in displaced population (>3 mil) continue to suffer from VPD and other childhood illnesses resulted from humanitarian crises (drought, conflict.) and the health system is not resilient to absorb the shock and provide basic health/immunization services on timely manner.

Improving the provision of equitable immunization service delivery is a top priority agenda for Ethiopia health sector Transformation Plan (2016-2020). The Health extension program is key vehicle of immunization service delivery in Ethiopia. More than 70% of immunization service is provided at health post level. Strengthening the health extension and health development army is key driver for increasing coverage and equity in immunization and other health services. Currently, the Reaching every district strategic approach is recast to reaching every child strategic approach to deal with inequities within districts. costed micro plans and vaccination session plans, developing evidence based tailored and context specific demand generation intervention , monitoring high risk community vaccination status, coverage, bottleneck reduction and improving quality of services and management capacity of EPI managers and services providers key areas of intervention to address the gaps.

Monitoring immunization status of children and rigorous validation of reported data at all levels to ensure that performance gaps are clearly identified and addressed in an open and timely fashion will be key areas of intervention in this strategy reach and vaccinated children unvaccinated or partially vaccinated so that children are from vaccine preventable diseases and Ethiopia can achieve global and national target for Measles elimination.

2. Improve the friendliness, convenience, efficiency and quality of services at health facilities

The frequency and the quality of EPI service delivery strategies affect notably the immunization coverage as well as the cost effectiveness of the program. In Ethiopia immunization services are provided through static and outreach strategies. Mobile strategy, although applied in few parts of Somali and Afar region where there are close to 49 mobile teams that cover very hard to reach areas providing immunization services together with other essential health packages.

According to policy instruction from the FMOH, immunization services should be available every day but majority of health facilities tended to provide immunization services monthly basis. In 2018, there are 17,086 health posts and 3962 health centers. But, there is no data on what proportion of these health facilities are providing vaccination service through different approaches. Despite considerable progress has been made in the past, gaps persist in immunization service delivery which has resulted disparities in coverage, high number of unimmunized children and high dropout rate.

The 2018 SARA showed that, 12% of facilities offered immunization services in daily basis at the facility and Child immunization as an outreach service was not commonly offered and only 3% of facilities providing this type of service. The EPI services ideally should not be interrupted, because each interruption may lead to defaulters and mothers/caretakers may lose the trust with the health service providers and the system. In addition, immunization programme is affected by the poor interaction between service providers and care takers. the interpersonal communication (IPC) between health workers and care takers in Ethiopia is suboptimal. Even when correct information was provided, the manner in which it was delivered was not conducive to parents’ returning to complete immunization for their children. A national study of the behavioral determinants for immunization service utilization in Ethiopia in 2012 revealed that, weak health worker interpersonal communication during immunization sessions. Majority 82% of the respondents correctly perceived that vaccine prevent diseases, but communities often lack knowledge about the time, place, and importance of completing routine immunization. the major reasons cited for reasons for never vaccinated were unaware for need: 30.6% urban; 35.5% rural , Time is unknown, 13% urban; 19.4% rural and Place is unknown, 10.9% urban; 16.7% rural . 47.8% How many times the child should get vaccination to finish immunization schedule (5 times), 31% drop out did not intend to use immunization. In this study, other barriers include, far distances to the immunization site, fear of vaccine side effects and reactions, inconvenient timing of sessions, and caregiver competing priorities. For Poorest of the poor families and for those living in urban slums, preventive health care like immunization in particular are a relatively low priority compared to their income generating activities and obligations. Children and women coming for immunization services should also receive other preventive health interventions at the same time to avoid missed opportunities in respect of other interventions.

Therefore, this strategy will highly contribute the national effort to improve equity and coverage in immunization and other high impact other child survival interventions.

3.Use VPD surveillance and campaign monitoring opportunities to identify unvaccinated and under vaccinated children

In Ethiopia Measles and Neonatal tetanus included in case-based surveillance where data vaccination status of a child for AFP and Measles and Maternal tetanus immunization collected. The best practices documented from Global Polio Eradication initiatives and measles control and elimination and Maternal and neonatal tetanus surveillance to monitor routine immunization programme by identifying unvaccinated children. For instance unvaccinated children with “zero dose” from surveillance data, No.of missed children from Independent monitoring and LQAs used for monitoring of Supplemental immunization activities by location will help to map unvaccinated children and provide vaccination. Use of supplemental vaccination activities such as campaigns to actively look for and refer inadequately immunized children to regular vaccination sessions.

Use of Polio, Measles, NNT case-based surveillance data and risk assessment tools as part of routine immunization prioritization will help to accelerate routine immunization activities in low performing areas

As of today, Ethiopia has used more than 25 rounds of Polio campaign since 2013 using house-to-house vaccination and conducting nationwide Measles campaign every 3-4 years through fixed and temporary fixed service delivery strategy. Though these strategies offer an opportunity to review the vaccination status of all children encountered and to refer them for any needed dose, it has not been maximally utilized in all regions to identify and reach unvaccinated children. Therefore, this strategy will help the country to careful plan campaign activities in such a way that contribute to identify unvaccinated children and have the potential to strengthen routine immunization system in Ethiopia.

In recent GAVI 5.0 Policy , improving equity and coverage is top priority and all countries were requested to include routine immunization strengthening activities for New and underutilized vaccine introduction and SIA applications where Ethiopia has included in 2020 Measles application which was approved 22 march 2019. This will provide an opportunity to implement this strategy.

Activity planning

Strategy 1

Activity

Details of activity

Key partners Stakeholders

Activity 1

Conduct KPI analysis using DHIS2 data, surveillance data of three regions at all levels to address the persistent barriers in vaccine and healthcare delivery systems in the country and Prioritize regions/zones to reach the largest number of unvaccinated ( In this project SNNPR sleeted where majority of unvaccinated children found for targeted support )

Identify hard to reach areas for Periodic Intensification of Routine Immunization (PIRI) in order to reduce under vaccinated and unvaccinated children.

Secure political commitment and partnerships through advocacy visit and meetings for allocation of resources to underserved community

FMOH

RHB

ZHO

WOHO

PHCU

Activity 2

Continue with periodic updating of Microplans with a focus to reach the unimmunized and under immunized in underserved areas/communities through implementation of RED/REC components;

Review existing service delivery strategy ensure its appropriateness to reach unvaccinated children

 

ZHO

WOHO

PHCU

Activity 3

Scale up and operationalize full components of the revised RED guide /PIRI strategy- Strategies to focus to reach un reached in underserviced areas including urban slums

RHB

ZHO

WOHO

PHCU

P

Activity 4

Strengthen integration of EPI service delivery with other programs and use different service platforms at all levels (Nutrition, PSNP..)

Ensure children in IDPs are receiving immunization and other child survival interventions on time and regularly

PHCU

Activity 5

Develop evidence based tailored and context specific demand generation intervention defaulters tracking activity through Involving the dedicated women development army.

.

RHB

ZHO

WOHO

PHCU

Activity 6

Monitor immunization status of children and rigorous validation of reported data including disease occurrence at all levels to ensure that performance gaps are clearly identified and addressed in an open and timely fashion.

RHB

ZHO

WOHO

PHCU

Activity 7

Documentation of Lessons learned and best practices from the existing equity sites to scale-up in other parts of the woredas/zones in targeted regions.

FMOH

RHB

ZHO

Strategy 2

Activity

Details of activity

Key partners Stakeholders

Activity 1

Identify and address key bottlenecks around immunization supply management

Ensure Vaccine request forms are used at all levels , requested and delivered on timeFMOH

RHB

ZHO

WOHO

PHCU

Activity 2

Assess existing service delivery strategies and expand sites if are inadequate for regular

provision of preventive health services to all targeted areas

 

Provide orientation to service providers on the importance of service integrations to avoid missed opportunities for vaccination.

 

Provide training to service providers on IPC for improved communication

 

WOHO

PHCU

HC

HP

Activity 3

Track implementation of immunization session plan and their frequency and types of services are carefully planned

Ensure required vaccines human resources and transports are adequate and planned a head of time for outreach services to avoid service interruption

RHB

ZHO

WOHO

PHCU

P

Activity 4

Provide supportive supervision to Health facilities to monitor the implementation, identify operational challenges and for timely action.

ZHO

WOHO

PHCU

Activity 5

Monitor the effectiveness of demand generation, service provision modalities defaulter tracing mechanism through data, field monitoring and by conducting Rapid Convenient monitoring (RCM) , document lessons learned to scale up this strategy in other parts of the region or zone

RHB

ZHO

WOHO

PHCU

Strategy 3

Activity

Details of activity

Key partners Stakeholders

Activity 1

Collect VPD surveillance data to identify unvaccinated children

Review AFP.Measles and NNT risk assessment report to map areas with high number of unimmunized children.

Activity

Activity 2

Use surveillance data to accelerate routine immunization through RED/REC approach - PIRI strategy

Activity 1

Activity 3

Use the opportunity of Polio and Measles SIA to intensify demand generation, identification of unimmunized children and provision of vaccination starting from planning up to monitoring

Activity 2

Activity 4

Use LQAs and IM data of campaigns to identify poorly covered areas to be reached through RI and PIRI strategy

Activity 3

Activity 5

Monitor over all activities , lessons learned and used for action.

Activity 4