- The REC (Reaching Every District) approach implemented in Kenya effectively reduced the number of unvaccinated children in targeted districts by empowering districts to plan and monitor their own immunization services. This community-engaged approach promoted partnerships between districts, health workers, and communities. - Using phone contacts to trace immunization defaulters in four western Kenya districts proved feasible. It significantly reduced dropout rates and revealed that most defaulters were not truly lost but had received vaccines elsewhere. Competing tasks were a main reason for defaulting. - Proper planning and funding mechanisms like the HSSF could support scaling up cost-effective approaches like using phone contacts that engage communities and increase access to immunization.

1. Immunization work in Kenya
Impact of decentralization on immunization
services in Kenya
Mokaya Evans

2. Introduction
 The Constitution of Kenya 2010 provides for a two -tier
system of government (National and County respectively)
 The reasons for devolving power set out in Chapter 11 are
 To promote people’s participation in governance;
 To promote equitable development and the sharing of resources
throughout the country;
 To take services closer to the people;
 To enhance the system of checks and balances; and
 To foster unity by recognising diversity.
 Each county have an elected assembly, elected governor
and deputy governor

3. Exclusive Functions for National and County
Departments of Health (CoK, Schedule 4)
National
1. Health Policy
2. National referral health
facilities
3. Capacity building and
technical assistance to
counties
County health services
1. County health facilities and
pharmacies;
2. Ambulance services;
3. Promotion of primary health care;
4. Licensing &control of
undertakings that sell food to the
public
5. Veterinary services (excluding
regulation of the profession);
6. Cemeteries, funeral parlours and
crematoria;and
7. Refuse removal,refuse dumps and
solid waste disposal

4. Pros & Cons of County health services
Pros
• Infrastructure
improvements and additions
• Procurement of ambulances
• Procurement of diagnostic
equipment
• Some counties - replaced
exiting staff
Cons
• Unpredictable resources for
salaries and service delivery -
!!lump sum financing
(outreaches, supportive
supervision,gas)
• Mass exodus of health work
force - real and perceived
threats
• Inadequate M& E tools - lack
of prioritization
• Inadequate vaccine syringes,
safety boxes etc

5. Improving Coverage in Under-reached
Populations: Using The REC Approach in
Selected Sub-Counties In Kenya

6. Kenya immunization coverage performance
trend, 1992-2013X
0
20
40
60
80
100
120
1992 1993 1994 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Measles BCG DPT3 Fully Im
RED
Post Election
PCV

7. Reaching Every District (REC) Approach
Objectives of REC approach
• Empower districts to plan,
implement and monitor their
own immunization services
• Promote partnerships between
districts, health workers and
communities to improve the
population’s access to and
utilization of services
• Promote continuous use of
programme data to monitor
progress and solve problems
Components of REC approach

8. Operationalizing the REC Approach
Continuous monitoring
process includes:
• Review meetings
• Peer-learning
• Self-assessment

9. Impact of the REC Approach Implementation in
Focus Districts
-1000
0
1000
2000
3000
4000
5000
6000
Bungoma
south
Vihiga Bungoma
North
Siaya Bondo Rachuonyo Kisumu East
No.Ofchildren
District
Number of unvaccinatedchildren(with Penta3), 2009-2012
2009
2010
2011
2012

10. Impact of the REC Approach Implementation –
Adaptation in Additional District
0
10
20
30
40
50
60
70
80
Penta 3
coverage
OPV
coverage
Measles
ImmunizationCoverage Trend;
IgembeNorth District- 2012and
2013
2012
2013
0
10
20
30
40
50
60
70
Measles Penta 3 Penta 1
%coverage
Vaccine
ImmunizationCoverage Trend;
East Pokot - 2013and 2014 ( Jan
- April)
2013
2014

11. Data Quality Self Assessment
2011 2013
-
2.00
4.00
6.00
8.00
10.00
Recording
Archiving
Reporting
Demographi
c
Information
Core
Outputs
Evidence of
Using Data
Bondo District Quality Chart - May 2010
-
2.00
4.00
6.00
8.00
10.00
Recording
Archiving
Reporting
Demographi
c
Information
Core
Outputs
Evidence of
Using Data
Bondo District Quality Chart – June 2013

12. Lessons Learnt From REC Approach
• To improve equity in vaccination, need to deliberately
target populations not normally reached
• Continued advocacy and support for the approach at
district level is important for sustainability (REC is not a
project)
• UVIS to advocate for use of HSSF to fund immunization
operational costs
• Advocate with county health services to pay CHV stipends
• Community engagement : use of CHVs, village elders to
create demand and track defaulters
• Need to maintain vaccine supplies and logistics
(including for outreach) for the approach to succeed

13. Summary
• The REC approach is
practical and effective in
reducing the numbers of
unvaccinated children in
Kenya.
• REC has been adapted to
other health interventions
in MCHIP
- Increase uptake of ANC,
PMTCT and deliveries in
Facilities.

14. New vaccines introduction
• PCV10 & Rotavirus
vaccines
• Provided momentum for
KAPPd discussions at
national level and roll out
at selected district level
- Prevent, promote & treat
diarrhoea and pneumonia
President launching PCV 10
1st lady launching Rota vaccine

15. Pneumococcal vaccine introduction
• After a 20 year lull in new vaccine
introduction, Kenya introduced Hib
and HepB vaccines in routine
immunization in 2001.
• In 2011, Kenya introduced
pneumococcal vaccine (10-valent
PCV) to address a leading cause of
child mortality.
• Country-led process: High level
advocacy & participation; multi-
agency partnership; effective social
mobilization that created demand
for the vaccine.
President of Kenya and Minister of
Health

16. Polio Eradication Support
• Kenya at risk of importation ofWPV - last case in
2013
• MCHIP/MCSP support:
• Technical discussions in TWG to plan and implement
polio SIAs
• Support and supervision of Polio SIAs with focus on
strengthening routine immunization
• Participation in horn ofAfrica TAG meetings
• Supporting UVIS prepare for IPV intro. In July 2015
• Training operational level H/W onVPD surveillance

17. EPI Prototype curriculum
implementation status in Kenya

18. Training Needs Assesment
Assessment of pre-service training conducted
2005
• No harmony between pre-service and in-service
training.
• Time allocated to EPI theory was inadequate
and the practical sessions were not adequately
supervised
• EPI content was incomplete or outdated
• Reference materials and demonstration
equipment were lacking.
• Lecturers and tutors not abreast with new
developments in vaccination

19. EPITraining in KMTC
• In 2006, the prototype curriculum was widely
distributed to all African countries and health
training schools were required to initiated
revision of their institutional curricula to
incorporate EPI
• In 2008: Nursing Council of Kenya adopted
EPI Prototype curriculum (custodians of the
Nurse training syllabus,regulate nurse training
and practice)
• Dissemination of the curriculum was
hampered by lack of funding

20. Prototype Curriculum Evaluation
In 2011-2012, evaluations were carried out in
9 countries, to find out whether they are
teaching the updated EPI curriculum.From
the 61 schools visited, 16 were medical
schools, 45 were nursing schools.

21. Protoype Curriculum Evaluation
“Big Five” challenges identified include:-
• Inadequately trained pre-service teachers
• Lack of updated reference materials and tools
• Lack of detailed lesson plans with objectives,
content,teaching methods,etc.
• Lack of supervision by schools at field
placement sites
• Lack of updated Curriculum with current
advancements in EPI.

22. EPI Prototype Curriculum Review
In 2013 review of the prototype curriculum
was done with the supported of
WHO/AFRO in collaboration with the
Ministry of Health of Ivory Coast, GAVI
Alliance,UNICEF, MCHIP/USAID,AMP and
NESI/UA
Kenya was represented by KMTC (Nairobi) in
this forum with support from MCHIP

23. KENYA ACTION PLAN
• MOH in collaboration with partners to update
lectures/tutors through MLMTrainings - end of
March 2015 a total of 82 lecturers (GOK, FBO,
Private) nurse lectures will have undergone the
MLMTraining
• Finalise the EPI manuals - printed and shared
• Equip the skill labs - proposals to KMTC,
meanwhile link institutions with health facilities
• MOH/Partners to periodically facilitate
selected topics in nursing schools/medical
schools - on going

24. Nursingtutorsparticipatein a Cold chain
demo during an MLMtraining

25. Timeliness of vaccination in selected
districts in western Kenya

26. Objective & Rationale
Rationale
In readiness for Rota vaccine introduction;
- Age restriction, later lifted
- Importance of early vaccination;children
vulnerable > 3 months
• To determine timeliness of infant
immunization with pentavalent vaccine in
selected districts

27. Penta 1 at 6 and 15 weeks
n = 14,000
0 20 40 60 80 100
Bondo
Bungoma Kimilili
Bungoma North
Bungoma South
Kisumu East
Kisumu North
Rachuonyo North
Rachuonyo South
pent1 at 6wks penta 1 at 15 wks

28. Penta 2 and Penta 3 at 32 weeks
10 20 30 40 50 60 70 80 90 100
Bondo
Bungoma Kimilili
Bungoma North
Bungoma South
Kisumu East
Kisumu North
Rachuonyo North
Rachuonyo South
penta 2 at 32 wks Penta 3 at 32 wks

29. Conclusions and Recommendations
• Even with the age restriction; it will be
possible for Kenya to achieve a high coverage
with rotavirus vaccine.
• Low proportion of children who begin the
schedule (6wks) on time suggests a need to
educate the caretakers on the need for
starting the schedule on time.

30. Use of Phone Contacts to Increase The Return Rates
For Immunization Services

31. Background Information
why the 4 sub counties
• High drop out rate (> 10%)between Penta 1
and penta 3 was a problem in Rachuonyo N,
Rachuonyo S, Kisumu East and Kisumu North sub
counties (MOH - DHIS, 2011, 2012)
• Ownership of phones > 65% (Wesolowski et
al, 2012)
• Uncoordinated use of phone contacts to trace
defaulters for different interventions
implemented
31

32. Objectives of Study
• To test the feasibility of using cellular telephone contacts
to trace immunization defaulters in four districts in
Western Kenya.
• To document lessons learned and challenges in using
cellular telephone contacts to trace immunization
defaulters.
• To document barriers to continued utilization of
immunization services in the four districts in Western
Kenya.
• Estimate the cost of implementing this strategy at district
level to inform future scale up efforts.
32

33. Results (“Ownership” of Phone Number)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Mother Father Close relative Neighbour Don’thave
Series1 48% 27% 10% 7% 9%
%
Ownershipof phones numbersamong caregivers
33

34. Results (Pre - Post intervention Drop-out Rates)
0.0 5.0 10.0 15.0 20.0 25.0
Kisumu D.H
Rachuonyo D.H.
Kosele Disp
Nyangande H/C
Nyahera SDH
Rabuor H/C
Homahill Disp
Kendu SDH
Ober H/C
Othoro SDH
Kauma Disp
Miriu H/C
%
Facilities
Penta 1 - Penta 3 drop out rates
pre drop out rate Post drop out rate
34

35. Results (Reasons given for Defaulting)
0
50
100
150
200
250
300
350
400
450
500
Competing
tasks
Vaccinated
elsewhere
Sick child
and vaccine
side effects
Not
knowing or
Forgot the
return date
No reason Cultural/reli
gious beliefs
No. of respondents 469 191 152 59 28 15
No.ofrespondents
35

36. Results (Apparent Defaulter Rates vs Actual
Defaulter Rates)
0 5 10 15 20 25
Kisumu D.H
Rachuonyo D.H.
Kosele Disp
Nyangande H/C
Nyahera SDH
Rabuor H/C
Homahill Disp
Kendu SDH
Ober H/C
Othoro SDH
Kauma Disp
Miriu H/C
% drop out
Facilities
Baseline
Apparent
Defaulter rate
True
Defaulter rate
36

37. Cost of Tracking Defaulters (Time and Money)
Time
• On average - 3 minutes to establish status of
vaccination
Money cost
• High volume - Ksh 270 ($3)/visit
• Low volume - Ksh 45 ($0.6)/Visit
• High volume - Ksh 810 ($9)/ year
• Low volume - Ksh 135 ($1.8)/year
37

38. Conclusions & Recommendations
• Use of phone contacts is a feasible options for tracking
defaulters
• “Ownership” of phones is above 80%
• Caregivers were willing to give their contacts
• Calls were well received by the caregivers
• Health workers appreciated the use of phone
contacts to track defaulters: health workers used
their phones
• The cost is manageable
• With proper planning HSSF could be used to fund this
approach
38

39. Conclusions & Recommendations
• Competing tasks is a leading cause of defaulting of vaccination
services:
• need to scale up social mobilization activities
• Forgetting the return date was not a major reason for
defaulting: SMS based platforms
• Observation that when the recipient of the call were males, the
children were more likely to be returned to the facility faster:
• need for male involvement in MCH activities
• Apparent defaulters: need for a forum for health workers to
share and exchange details of defaulting children
39

40. Thank you