The presentation describes the expansion for routine immunization from district level to community level in Africa. Reaching remote communities is important to bring immunization to all children.

1. Transitioning from
Reach Every District (RED) to
Reach Every Community (REC)
Dr. Zenaw Adam
Universal Immunization through Improving
Family Health Services (UI-FHS) – Ethiopia/
JSI Research &Training Institute Inc.
EPI Manager’s Meeting for East and Southern Africa
March 9-13 2015,Victoria Falls- Zimbabwe
Ethiopia

2. WHY from District (RED) to Community
(REC)?
• Almost all districts have been reached
with RI
• There are still unreached pockets of
areas and children who are un/under-
vaccinated
• The need for new & flexible
approaches focusing on equitable
services in underserved areas
Reaching
target
populations
Linking
services with
communities
Supportive
supervision
Monitoring
for action
Planning and
management
of resources

3. Concepts in moving from RED to REC
• Customize the approach to suit the context
• Address the “HOW” (facility level analysis,prioritization..etc.)
• Build capacity & partnership between health teams,local
governments and communities
• Build capacity of local health teams to analyze & use own data to
improve situation

4. How to operationalize these concepts?
Main examples to be discussed
Ethiopia:
Using Quality Improvement
(QI) methodology to mobilize
volunteers to identify all
children needing vaccination
Uganda:
Mapping target populations and
health facility catchment areas
for effective immunization
microplanning

5. Ethiopia: RED to REC supported by health
system structure
• Community level structure
– administration with defined area & population
• Community part of local administration
– Membership in kebele cabinet, command post,steering committee
• Health service structure to community level
– Primary Health Care Unit (PHCU) – HCs and HPs
• New Community structures: HDAs & 1-5 network

6. RED-QI: revitalize & operationalize RED by
adding quality improvement (QI) tools
• RED focuses on “WHAT” – to improve performance
• QI focuses on “HOW” - the process of problem analysis,
prioritization and seek local solutions
– Break large problems to smaller,more “do-able” pieces
– Identify small scale changes, promising practices and data to share
with peers on a regular basis
– Process improvements: find positive deviance examples, local
solutions,contextualize and test others’ successes

7. Putting the pieces together:
RED-QI to REC-QI
REC-QI
SupportiveSupervision
• QITs at management and service levels;
community membership
• Bottom-up microplanning : key in district
and facility planning
• Data analysis using RED categorization
tool,and its use at district,HC and HP
levels
• Supportive supervision (PBSS/ISS)
• Quarterly and monthly review meetings
(QRMs)

8. RED-QI: using Plan-Do-Study-Act (PDSA)
cycles
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Model for Improvement
PlanAct
DoStudy
• Identify problems and detailed analysis
(fishbone analysis)
• Prioritize the problems
• Select a problem and list change ideas for
solutions
• Implement one change idea for a short
period & study results
• Then Adopt,Adapt (orAbandon) the
change ideas

9. RED-QI Continued
Quality Improvement Teams (QIT) in Ethiopia
• QITs at management and service levels.
• District Health Office (management only)
• Health Center (management and service)
• Health Post at community level (service only)
• QIT at community level is particularly crucial
• Women with their network(s) are key members

10. RED/C-QI in action: examples
PDSA Experience in Hintalo Wajerate
district
A cluster of facilities (PHCU):1 HC, 6 HPs, ≈10 OR
– 25,000 population
• 4,600 women aged 15-44
• 560 children <1 yr
– Providers:6 HEWs,24 community volunteers
– Support by women’s group (WDA),each leading sub-groups of
‘one-to-five’ networks

11. PDSA Experience in HW district
CHANGE IDEA: visit each HH to register newborns,
unimmunized and defaulter children.
AIM: Increase coverage from 85% to 95% in 3 months
• Plan: QIT meetings:health workers and community
• Do: EnlistedWDAs to go house to house to list <1 children
• Study:
• 25 defaulters found and vaccinated
• 68 newborns and never-immunized found; follow up with 45 of
unimmunized starting vaccination
• Productive community effort improved coverage
• Act: Adopt the change idea and apply for other programs

12. Uganda: Mapping target populations
for facility catchment areas
• Macro mapping: a continuous process to identify and assign
communities (parish level) to facilities to enable effective health
service delivery
• Micro mapping: a continuous process to identify and assign
communities (village level) within a health facility catchment area to
RI service delivery points,both static and outreach

13. Macro-mapping process: How is it done?
1. District assembles key inputs
2. Prepare first draft of facility catchment area macro map
3. Build consensus on macro map

14. Criteria for assigning communities to HF
1. Proximity of community to HF
2. Access to HF – geographic,economic
3. Capacity of HF to serve communities - RI
• Transport
• Health workers
• Adequacy of vaccines & supplies
4. HF already providing services

15. Micro-mapping process
1. Assemble key inputs (includes
macro map and list of static and
outreach RI service delivery points)
2. Prepare first draft of facility micro
map:
3. Harmonize and build consensus on
micro map

16. Results and Applications of Mapping Process
Enhances planning and monitoring:
– Provides accurate basis for RED microplanning
– Enables identification of communities previously unreached with
RI
– Improves efficiency of resource allocations
– Strengthens community links to RI services
– Improves convenience of RI services to caretakers and fosters
better communication
– Provides target populations for other services

17. Results and Applications – District Example

18. RED/C-QI in Action: Examples
Zimbabwe: (Manicaland)
• Most populated province with low penta3 coverage of 52%
(2010 DHS)
• MCHIP PHO collaborated to implement RED components
– RED micro planning in all districts
– VHWs mobilize eligible infants and trace defaulters
– Conducted regular supportive supervision
– HFs updated monitoring chart monthly
– HFs defined target population-counting of kids usingVHWs
• Provincial penta 3 coverage >80% in 2013 (c.survey)

19. Operationalizing the REC Approach - Kenya
19
Continuous
monitoring process
includes essential
elements:
• Review meetings
• Peer-learning
• Self-assessment

20. Impact of REC in focus districts - Kenya
-1000
0
1000
2000
3000
4000
5000
6000
Bungoma
south
Vihiga Bungoma
North
Siaya Bondo Rachuonyo Kisumu
East
No.Ofchildren
District
Number of under-vaccinated children (with Penta 3), 2009-2012
2009
2010
2011
2012

21. Conclusions
• Circumstances in Ethiopia and other countries are conducive
and timely for the transition of RED to REC.
• Applying QI to REC provides an effective tool to operationalize
and revitalize the strategy
• REC-QI approach combines ‘WHAT’ & ‘HOW’ to strengthen
the RI system and fosters local solutions and ownership of the
program

22. Conclusions (continued)
• Brings together all EPI stakeholders,including non- traditional ones
– advocacy, resource mobilization
• RED-QI encourages innovation and is applicable to all other family
health services
• Peer learning on REC-QI and incorporation of innovations into
national policies,guidelines and tools is enhanced by working at
national and subnational levels