Transitioning from reach every district to reach every community

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

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

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

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

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

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

Putting the pieces together:

RED-QI to REC-QI

REC-QI

Su

pp

ortiv

e S

up

erv

ision

• 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)

RED-QI: using Plan-Do-Study-Act (PDSA)

cycles

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill 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 (or Abandon) the

change ideas

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

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

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: Enlisted WDAs 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

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

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

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

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

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

Results and Applications – District Example

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 using VHWs

• Provincial penta 3 coverage >80% in 2013 (c. survey)

Operationalizing the REC Approach - Kenya

19

Continuous

monitoring process

includes essential

elements:

• Review meetings

• Peer-learning

• Self-assessment

Impact of REC in focus districts - Kenya

-1000

0

1000

2000

3000

4000

5000

6000

Bungomasouth

Vihiga BungomaNorth

Siaya Bondo Rachuonyo KisumuEast

No

. Of c

hil

dre

n

District

Number of under-vaccinated children (with Penta 3), 2009-2012

2009

2010

2011

2012

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

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