USE OF PLAN-DO-STUDY-ACT
(PDSA) CYCLES TO STRENGTHEN
ROUTINE IMMUNIZATION IN
ETHIOPIA
Operational Research Findings
Universal Immunization through Improving Family Health Services
(UI-FHS) project
Adriana Almiñana, MPH
February 20, 2018
Durban, South Africa

Background
• Quality improvement is a priority for the
Ethiopian Federal Ministry of Health
• Universal Immunization through
Improving Family Health Services (UI-
FHS) project:
• Improve routine immunization in 6
regions; 103 districts
• Operationalize national immunization
strategy “Reaching Every District”
(RED) by providing technical
assistance for immunization, and the
introduction of QI = “RED-QI”
Photo: Bill & Melinda Gates Foundation

Quality ImprovementTeams (QITs)
• UI-FHS trained staff at district health offices, health centers
(HCs) and select health posts (HPs) on RED-QI
• District responsible for cascading training
• Trained staff expected to activate QITs – focus on
solving immunization problems through PDSA
• Other support: reinforced during supportive supervision
visits, review meetings, etc.
Process
• District and HC: approx. 4-6 people, including the
immunization focal person, head of the facility, other
health staff
• Some HCs included community members
• HP: 1-2 health workers plus 3-6 lay community members
(usually an already existing group)People

Study Methods
• 3 districts: differing health system
and demographic contexts
• Case study; mainly qualitative:
What is the
experience of quality
improvement teams in
Ethiopia with using
PDSA cycles to
improve routine
immunization service
delivery?
24 Key informant interviews
with facility staff
12 Focus group discussions
with QITs
3 Interviews with UI-FHS staff
Document reviews of facility
documents on PDSA cycles

Findings
• Training:
• Direct training with follow-up most
effective
• Cascade training limited by available
resources
• Uptake and Use:
• More focus on “Plan” and “Do” phases
of the PDSA cycle; “Study” was
difficult
• Indicators related to “aim,” not
change idea; PDSA documentation
overall incomplete/limited
• Higher use of other QI tools (e.g.
fishbone diagram) compared to PDSA
We used fishbone more because it
helped us to keep on asking why
questions and find out causes.
– District Office, Damboya
The study part is a bit difficult
[laughter], it needs sacrifice.
– HealthWorker, HP, Damboya

Findings
• QITs:
• HP: community members engaged for
“Plan” and “Do” phases. QIT was a
mechanism to better community
engagement and linkage to health
facility
• HC: QITs more engaged throughout
entire cycle
• District: involved for parts of the
PDSA cycle (barriers of competing
priorities)
• Benefits:
• Increased partnership and
communication with the community
• Problem identification and testing
solutions was valued
The results out of these cycles
encouraged us to use it further.
– HealthWorker, Dubti
They [QIT] mobilize the
community during EPI, identify
and solve problems in the
community, and support [health
post] activities in the community.
– HealthWorker, HP,Tahtay
Koraro

Takeaways & Lessons Learned
• The use of QI added focus to the quality of immunization services and health
services in general; the idea of breaking down problems and focusing on
processes is taking root
• QI tools are useful at facility level for local problem solving
• Streamlined, simplified approaches that integrate into the existing health
system are critical
• PDSA cycles require training; can still see process improvements with only
part of the QIT formally trained
• Need to explore ways of documenting PDSAs that are consonant with the
skills and abilities of peripheral health workers
• Strong linkages with the community helped improve immunization services.
Peripheral health workers engaged QIT community members at specific points
in the PDSA cycle, gathering feedback from them or leveraging their
relationships with the larger community to enlist extra manpower for some
activities

Thank you!
www.jsi.com/UIFHS
bit.ly/UIFHSLinkages
Icons: Andrejs Kirma, Jemis Mali, and Xinh Studio from The Noun Project