With the Ministry of Health Immunization Departments of Tanzania and Zanzibar and other partners and donors, JSI, through the MCSP project, participated in the national expanded program on immunization (EPI) review in July 2015. I was part of a team with the MOH/EPI of Zanzibar (Dr. Abdul Saleh) and CHAI/Tanzania (Mr. Paschal Bwile) that conducted field visits in Zanzibar. One facility that we visited was the Jambiani Health Center in Kusini District, where we interviewed and observed the vaccination and child health session conducted by Public Health Nurses Mwatima and Sharifa. The vaccination session was part of Mwatima and Sharifa’s regular weekly routine.
I have worked in many countries around the world and visited hundreds of health facilities. Jambiani was among the best that I have seen, and these nurses deserve the credit. It wasn’t donor funded or part of a special project or initiative. The session was well-organized; they had a comfortable waiting area for the clients and an innovative system to encourage male involvement whereby the men could go to the front of the queue if they brought the baby/child for vaccination and growth monitoring. They also encouraged parents to continue to visit the facility regularly after completing the first year of vaccination by offering some small school supplies for a child that also completed growth monitoring through 4 years. We witnessed this in action, as several men were at the session when we arrived. Their children (who were older than one year of age) were quickly consulted, weighed, and their attendance noted down by the two nurses. The nurses then continued on with the remaining mothers for vaccination and the other services.
Not only did the efficiency and initiative of these nurses impress me, but also the quality of their data recording and use. As you can see in these pictures, the immunization registers were neatly updated and the home based records (i.e. vaccination and growth monitoring card for each child) were available, up-to-date, and compared with the register. Although simple and standard practices in immunization, we often do not see these done with such proficiency and attention in facilities, in large part because health workers are not sufficiently supported in the use and analysis of these paper-based tools, or supervisors (or the health system) are not helping to ensure that these tools are available, updated, and their purposes for local decision-making and tracking understood. For these nurses, this was not a burden, but a part of their daily job. We also interviewed four mothers at the end of the session. They all noted how happy they were with the services and staff of the facility and that they knew the importance of vaccination and child health, including keeping and bringing their cards to the sessions.
Often external visitors or proponents of electronic solutions are too quick to judge paper-based systems as being antiquated or inefficient. However, I argue – based on what I have seen in many resource-poor settings – that the public health community has not sufficiently valued, supported and emphasized that these long-existing systems function and are understood by the users themselves. Electronic systems can definitely help (and good work is being done around this in Tanzania on a “Vaccine Information Management System”), but these electronic tools should be harmonized with what is already working and sustainable. These nurses (and the Zanzibar EPI) showed what can be done when a paper-based system functions and when the health staff have the tools and resources that they need. And this was also evidenced by the satisfied parents with their vaccinated infant and home based records in-hand.