The recent PMNCH Partners’ Forum in New Delhi highlighted the power of partnerships to achieve SDG and UHC goals. And while all attendees learned from each other’s experiences, everyone acknowledged that country health leadership is critical for achieving any type of global health goal.
Indeed, leading international health institutions have prioritized leadership within their own strategies. Gavi’s 2016–2020 strategy highlights actions that foster sustainable delivery of immunization programs. These include strengthening government EPI teams to improve their structures, capabilities, processes, and practices. WHO’s Global Vaccine Action plan’s first objective identifies the need for country ownership and prioritizes domestic resource mobilization and technical advisory leadership.
Despite the demonstrated benefits of peer learning in the global south, rarely had the approach been applied in Africa. In October 2018, JSI led an initiative to foster technical leadership through inter-country peer-to-peer exchange in sub-Saharan Africa. The initiative convened national and subnational EPI and primary health care managers and experienced country-based technical advisors from Ethiopia, Nigeria, and Uganda. While each of these countries has made progress in strengthening routine immunization (RI) systems and improving coverage and equity, immunization coverage in 2017, as estimated by a third dose of pentavalent vaccine, was 73 percent in Ethiopia; 85 percent in Uganda; and 42 percent in Nigeria, well below the global target of 90 percent. Each country has persistent challenges in reaching every child and reducing the numbers of unimmunized. Bringing these countries together to exchange learning, successes, and lessons triggered a major shift in how they implement technical leadership. The tri-country exchange went beyond localized peer learning to cross-country peer-to-peer learning and achieved the following objectives:
- Learn best practices from the implementation of a novel approach—Reaching Every District (RED) using Quality Improvement—that strengthens local capacity to overcome immunization system challenges to reach underserved populations.
- Share experiences of community engagement approaches, data monitoring, and verification systems from the Nigeria memorandum of understanding (MOU) model.
- Identify common RI systems challenges and explore practical solutions to improve performance.
- Discuss ways to position sub-national level to influence national policies and guidelines, as with the SS4RI project in Uganda.
The JSI-managed Nigeria Maternal and Child Survival Program Routine Immunization (MCSP-RI), Uganda SS4RI, and Ethiopia UI-FHS projects organized an exchange visit to Ethiopia from October 7 to 13, 2018. The teams visited UI-FHS implementation sites and travelled to the Southern Nations and Nationalities Peoples Region to meet their counterparts at the regional health bureau. They also travelled to Wolaita zone and met staff from the zonal health office, the Sodo Zuria and Humbo woreda health offices, and several health facilities. Throughout, participants learned how each other’s projects contribute to health and immunization systems strengthening efforts.
While the three countries have common approaches to RED strategy implementation, they are tailored to each country’s context. The Ethiopian UI-FHS and Ugandan SS4RI projects have been implementing the RED approach since 2011 and have adapted quality improvement tools and strategies to that have led to better outcomes in a number of regions and districts. All countries work with ministries of health to improve RI service delivery and with established community structures to support EPI service delivery through social mobilization, defaulter tracking, and enumeration of children. Nigeria implements the RED approach within a unique MOU model led by Bauchi and Sokoto state governments, Bill & Melinda Gates Foundation, Dangote Foundation, and USAID. JSI’s technical support through MCSP since 2015 in Bauchi and 2016 in Sokoto has contributed to improved service quality, immunization coverage, and stronger immunization systems.
At the end of the visit, the teams from Nigeria, Uganda, and Ethiopian had observed:
- Documentation and use of data in decision making (filed, displayed, and interpreted monitoring charts).
- Application of quality improvement methods such as plan-do-study-act (PDSA) cycles for solving problems.
- Human resources management in assigning responsibilities to each cluster area with continuous monitoring.
- Mobilization of financial resources through community health schemes in addition to the regular annual budget.
- Formal community engagement and capacity building through Ethiopia’s Health Extension Program.
- Immunization logistics and cold chain management and use of community resources to distribute vaccines.
- Strong coordination and accountability at all levels.
- Supportive supervision between woreda health office and health facilities.
- Community engagement through quality improvement team (QITs) and groups such as 1-5 women’s network.
- Fund disbursement from woreda/district to health centers to health posts.
The visiting country teams also identified actions and take-home messages:
- Display detailed data in health facilities.
- Monitor DPT1-measles dropout rate.
- Use religious leaders to reach all children under 1-year-of-age by asking for RI card before baptism and advocating for completion of immunization schedule during religious services.
- Advocate for engagement of women’s groups such as LC councils and self-help groups, at health facility level.
- Adapt data auditing efforts using Nigeria’s directly observed data entry at the immunization session model.
- Assign a district health team member to each sub-county to oversee immunization and other health services operations.
- Build accountability across all levels of health care.
- Build capacity through supportive supervision.
- Strengthen health center supervision and support of health posts.
- Use one reporting platform across all levels.
- Increase use of local women groups/networks for community mobilization.
- Use non-monetary incentives for all types/levels of volunteer work.
- Use QIT teams/PDSA cycle to manage health facility problems.
- Post data on the walls at all health facilities.
Overarching take-home messages agreed upon by the end of the visit include:
- Give leadership and governance stakeholders information and tools to mobilize local resources and facilitate local-level problem-solving.
- Achieving and sustaining strong immunization systems requires not only strong management capacity but also good leadership, governance, and accountability based on reality and the best practices to ensure that every eligible person gets the vaccination s/he needs regardless of where s/he lives.
- Maximize leadership potential, shape technical direction, and build high-performing teams and systems at country, regional, and global levels.
- Upskill immunization program managers and involve stakeholders to ensure robust performance management and improvement, effective political engagement, and sustainable financing.
While the country exchange was just a week long, it triggered a long-term learning relationship between the three countries. The teams continue to communicate and plan to update each other on their progress every quarter. The peer-to-peer communication provides real-time focus on issues and accelerates adaptation and application of effective solutions. This model can be replicated to help countries achieve UHC and the SDGs.