August 2012
A STUDY OF
THE DRIVERS OF ROUTINE
IMMUNIZATION SYSTEM
PERFORMANCE IN ETHIOPIA
JSI Research & Training Institute, Inc
Arlington, VA
ARISE is managed by the JSI Research & Training Institute, Inc. (JSI) and funded by the Bill & Melinda Gates Foundation. JSI’s partners on ARISE are the
School of Public Health at Makerere University (Uganda), the Dartmouth Institute at Dartmouth College (United States) and George Washington
University School of Public Health (United States).
Cover photo from JSI/UIFHS Project.
TABLE OF CONTENTS
Acknowledgments ...........................................................................................................................................................v
Acronyms/Abbreviations ............................................................................................................................................ vi
Executive Summary ........................................................................................................................................................ 1
I. Introduction ................................................................................................................................................................ 11
II. Ethiopia Country Background ..........................................................................................................................13
Political Structure .................................................................................................................................................. 13
Economy .................................................................................................................................................................... 14
Social and Demographic Background ......................................................................................................... 14
Health System .........................................................................................................................................................15
Health Financing ..................................................................................................................................................... 17
Health Policy ............................................................................................................................................................18
Health Workforce .................................................................................................................................................19
III. Brief History of the Expanded Program on Immunization in Ethiopia .......................................22
The National EPI Policy and Objectives ......................................................................................................23
Immunization Service Delivery ......................................................................................................................23
Service Delivery at the Woreda and Sub-woreda Levels ...................................................................24
EPI Financing .............................................................................................................................................................25
Ethiopia’s Current Routine Immunization Situation ...............................................................................26
IV. Methodology ............................................................................................................................................................27
Selection of Study Woredas .............................................................................................................................28
Study Team ...............................................................................................................................................................29
Data Collection ......................................................................................................................................................30
Analysis .......................................................................................................................................................................32
V. Woreda Reports ......................................................................................................................................................34
Introduction to the Woredas ...........................................................................................................................34
Routine Immunization Coverage in Study Woredas .............................................................................34
Alage Woreda, Tigray Region ..........................................................................................................................35
Toke Kutaye Woreda, Oromia Region .......................................................................................................42
Sekota Zuria Woreda, Amhara Region .......................................................................................................49
Tikur Incini Woreda, Oromia Region ...........................................................................................................54
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
VI. Drivers of Routine Immunization Performance at the Woreda Level in Ethiopia ...............60
Framing RI Performance Improvement ........................................................................................................60
National and Subnational Context of RI Performance Improvement ...........................................60
Essential Immunization Inputs ..........................................................................................................................62
Woreda-level Drivers of Routine Immunization Performance Improvement ..........................65
Locally Recruited and Supported Health Extension Workers ...................................................65
Active Community Participation in Routine Immunization and Health ..................................67
Partnership Between Health and Government Administration .................................................68
Focus on Accountability and Performance Monitoring ...................................................................70
Supervision ..........................................................................................................................................................70
Review meetings ............................................................................................................................................... 71
Support from Development Partners ....................................................................................................72
VII. Implications ............................................................................................................................................................74
VIII. Investment to Improve Routine Immunization Performance .......................................................76
III
| AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
ACKNOWLEDGMENTS
We wish to thank the Ethiopian Federal Ministry of Health, representatives of international
organizations, and the many government officials (Regional, Zonal and woreda administration
and health officers), in addition to health center and health post staff in Alage, Sekota
Zuria, Tikur Incini and Toke Kutaya woredas/districts, who made time to provide thoughtful
responses to interview questions. Members of the communities in these woredas also met
and shared their knowledge and experiences. We extend special thanks to the Bill & Melinda
Gates Foundation for supporting the ARISE project, and our in-country research partner JaRco
Consulting (http://jarrco.info/) and its researchers (Getu Molla Tarekegn, Henok Negussie,
Edris Seid, Negusu Yifrashewa, Wubitu Hailu) for their important contribution to this research
as well as their willingness and flexibility to work long days. Lastly, we extend our gratitude
to Sangeeta Mookherji (George Washington University School of Public Health), and Freddie
Ssengooba, Lynn Atuyambe, and Ellie Rutebemberwa (Makerere University School of Public
Health) for technical guidance on adapting study methods to the Ethiopian context. The
research relied heavily on work peformed by Ryan Macabasco, Amanda Makulec, and Jessica
Posner of JSI Research & Training Institute, Inc.
RECOMMENDED CITATION
Recommended Citation: Justice, J, Sequeira, J.M., LaFond, A.K., Biellik R, Tarekegn, G.M., &
Negussie, H. (2012). Study of the Drivers of Routine Immunization System Performance in Ethiopia.
Arlington, VA: JSI Research & Training Institute, Inc./ARISE Project for the Bill & Melinda Gates
Foundation.
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
ACRONYMS/ABBREVIATIONS
V
ARISE
Africa Routine Immunization System Essentials
BCG
Bacillus Calmette-Guerin Vaccine
CHV
Community Health Volunteer
cMYP
comprehensive Multi Year Plan
DTP
Diphtheria-Tetanus-Pertussis Vaccine
DTP1
Diphtheria-Tetanus-Pertussis Vaccine, First Dose
DTP3
Diphtheria-Tetanus-Pertussis Vaccine, Third Dose
EDHS
Ethiopia Demography and Health Survey
EFY
Ethiopian Fiscal Year
EOS
Enhanced Outreach Strategy
EPI
Expanded Program on Immunization
ERIA
Enhanced Routine Immunization Activity
FMoH
Federal Ministry of Health
GAVI
Global Alliance for Vaccines and Immunization
GDP
Gross Domestic Product
HC
Health Center
HepB
Hepatitis B Vaccine
HEP
Health Extension Program
HEW
Health Extension Worker
Hib
Haemophilus Influenza Type B Vaccine
HRH
Human Resources for Health
HSDP
Health Sector Development Program
HSS
Health Systems Strengthening
ICC
Inter-agency Coordinating Committee
JSI
JSI Research & Training Institute, Inc.
MCH
Maternal and Child Health
MDG
Millennium Development Goals
MNCH
Maternal, Newborn, and Child Health
NGO
Nongovernmental Organization
OECD
Organization for Economic Co-operation and Development
OPV
Oral Polio Vaccine
| AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
ETHIOPIA COUNTRY BACKGROUND
Penta3
Pentavalent Vaccine, third dose
PHC
Primary Health Care
PIRI
Periodic Intensity of Routine Immunization
RED
Reaching Every District Strategy
RHB
Regional Health Bureau
RI
Routine Immunization
SWAp
Sector-wide Approach
TT
Tetanus Toxoid Vaccine
UNICEF
United Nations Children’s Fund
WHO
World Health Organization
WoHO
Woreda Health Office
ZHD
Zonal Health Department
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
FIGURES
Figure ES 1. Elements of the Pathway to Routine Immunization Performance ............................... 3
VII
Figure 1.
In-Depth Country Case Study Analytical Framework ....................................................12
Figure 2.
Timeline of Major Health System Events ...............................................................................16
Figure 3.
Ethiopia Health System Structure .............................................................................................16
Figure 4.
National Infant DTP1 and DTP3 Coverage (1981-2010) and Major Events and
Policies from 2000 .............................................................................................................................22
Figure 5.
Interviews Conducted by the ARISE Team ...........................................................................30
Figure 6.
Data Collection and Analysis Procedure ...............................................................................33
Figure 7.
Study Woreda and National Penta3 Coverage, 2006-2010 ..........................................35
Figure 8.
Location of Health Facilities in Alage Woreda, Tigray Region ...................................36
Figure 9.
Penta1 and Penta3 Vaccination Coverage, Alage Woreda, Tigray Region,
2006-2010 ..............................................................................................................................................37
Figure 10.
Number of Outreach Sites in Alage Woreda, Tigray Region, 2006-2010 .............38
Figure 11.
Wall Chart with 2011 Vaccination Targets, Alage Woreda Health Office ............39
Figure 12.
Chronology of Events in Alage Woreda, Tigray Region .................................................41
Figure 13.
Location of Health Facilities in Toke Kutaye Woreda, Oromia Region .................43
Figure 14.
Penta1 and Penta3 Vaccination Coverage, Toke Kutaye Woreda, Oromia
Region, 2006-2010 ............................................................................................................................ 44
Figure 15.
Number of Outreach sites in Toke Kutaye Woreda, Oromia Region,
2006-2010 ..............................................................................................................................................46
Figure 16.
Chronology of Events in Toke Kutaye Woreda, Oromia Region ..............................47
Figure 17.
Location of Health Facilities in Sekota Zuria Woreda, Amhara Region ................49
Figure 18.
Penta1 and Penta3 Vaccination Coverage, Sekota Zuria Woreda, Amhara
Region, 2007-2010 ..............................................................................................................................51
Figure 19.
Chronology of Events in Sekota Zuria Woreda, Amhara Region .............................53
Figure 20.
Location of Health Facilities in Tikur Incini Woreda, Oromia Region ...................54
Figure 21.
Penta1 and Penta3 Vaccination Coverage, Tikur Incini Woreda, Oromia
Region, 2006-2010 .............................................................................................................................56
Figure 22.
Chronology of Events in Tikur Incini Woreda, Oromia Region .................................58
Figure 23.
Number of Outreach Sites in Tikur Incini Woreda, Oromia Region,
2004-2010 ..............................................................................................................................................59
Figure 24.
Elements of the Pathway to Routine Immunization Performance .............................60
| AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
TABLES
Table ES 1. Characteristics of the Four Study Woredas and Their Routine Immunization
Systems ...................................................................................................................................................... 5
Table ES 2. How Context, Essential Immunization Infrastructure, and Performance Drivers
Work Together to Improve Coverage of Routine Immunization (ARISE Case
Studies of Four Ethiopian Woredas) ........................................................................................10
Table 1.
Multiple Means of Testing for Drivers in Qualitative Study .........................................27
Table 2.
Population Estimates and Pentavalent Coverage for Alage Woreda,
2006-2010 ..............................................................................................................................................37
Table 3.
Population Estimates and Pentavalent Coverage for Toke Kutaye Woreda,
2006-2010 ............................................................................................................................................. 44
Table 4.
Population Estimates and Pentavalent Coverage for Sekota Zuria Woreda,
2007-2010 ...............................................................................................................................................51
Table 5.
Population Estimates and Pentavalent Coverage for Tikur Incini Woreda,
2006-2010 ..............................................................................................................................................56
Table 6.
Characteristics of the Four Study Woredas and their Routine Immunization
Systems ................................................................................................................................................. 64
Table 7.
Context, Essential Immunization Infrastructure, and Performance Drivers
Work Together to Improve Coverage of Routine Immunization (ARISE Case
Studies of Four Ethiopian Woredas) ........................................................................................75
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
EXECUTIVE SUMMARY
BACKGROUND
The foundation of national immunization programs is routine immunization (RI)—the provision
of consistent, timely protection from common diseases to all children through vaccination.
Without an effective system to deliver RI, coverage rates cannot be increased, gains from
special vaccination campaigns cannot be sustained, and new vaccines cannot be introduced.
The Africa Routine Immunization System Essentials (ARISE) project was created in late 2009
to consolidate experience and learn about what drives improvement in RI coverage in Africa.
ARISE aims to learn from African experience with RI, particularly from countries whose RI
systems are performing well and explain why some RI systems achieve improvements in
immunization performance and others do not. The project will translate these findings into
actions to improve African RI systems whose performance continues to falter.
During the first stage of the project, in 2010, ARISE interviewed implementers and technical
and development partners and completed a systematic review of published and grey literature
on the drivers of RI system performance in Africa (Performance is defined for the purpose
of this study as DTP3/Penta3 coverage). A preliminary set of policies, procedures, and
investments driving RI system performance emerged. To investigate these and other possible
drivers of coverage improvement in depth, and to better understand how they work in
practice, ARISE conducted a study of the drivers of RI performance in four districts in Ethiopia.
The research was part of a larger study that extends to Cameroon and Ghana as well.
METHODS
The ARISE research in Ethiopia used a mixed-methods multiple-case-study design, enabling
investigators to identify and explore:
– which drivers are critical to improving woreda-level RI system performance, as measured
by coverage with the third dose of pentavalent vaccine (penta3)
– how these drivers influence performance
– the contextual factors impeding or promoting a driver’s effectiveness
– the relationships among the drivers
The units of analysis were individual districts (hereinafter, we will use a transcription of the
Amharic word for “district”: woreda). For the purpose of the project, a RI performance driver
is defined as a structure, resources or process that works on or through the immunization
system to make the system perform effectively or to improve its performance. The
methodology was iterative; the focus of inquiry expanded, narrowed and shifted as information
saturation and convergence was reached and as new relationships and factors emerged.
Case selection was primarily based on trends in coverage from 2007 to 2009, as well as on
geographic and other standard criteria. The study team selected three woredas where penta3
coverage had improved and, for comparison, one “steady” woreda that showed little change in
coverage during the same period. The study woredas are listed on the following page.
1 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
E XECUTIVE SUMMARY
Seven Ethiopian and international researchers with experience in case
study methodology, expertise in qualitative research and RI programs,
and knowledge of the local context implemented the study in
February 2011. The research team conducted 104 interviews, collecting
data in two stages at the national, regional/zonal, woreda, facility,
and community levels, with greater emphasis on the latter three.
Researchers also reviewed national and district documentation and
administrative records, and conducted a woreda-level RI situation
analysis to understand how the system was supplied, organized, and
managed and how it delivered services.
Ethiopia study
woredas
Woredas with improved
coverage:
• Alage, Tigray Region
• Toke Kutaye,
Oromia Region
• Sekota Zuria,
Amhara Region
Data analysis leading to the identiication and exploration of
performance drivers took place in stages. As the researchers
progressed from woreda to woreda, they developed and then
Woreda with steady
tested theories of driver-to-performance pathways through review
coverage:
of interview notes, team discussions, pathway diagrams, and cross
• Tikur Incini,
referencing interview data with data collected from the RI situation
Oromia Region
analysis and from observation at service delivery sites. The study team
compared the experience of each woreda where coverage improved to
ind common or contrasting patterns related to resource management,
partnering, and data use. The researchers then analyzed data from the
woreda where coverage had not improved—the “steady” woreda—
to determine whether patterns observed at the other woredas were present or absent. Draft
indings were presented at a stakeholder workshop in July 2011, where representatives of the
four woredas reviewed results. After the workshop, the researchers conducted another round of
interviews in the woredas to verify indings and ill data gaps.
NATIONAL CONTEXT
The Ethiopian health sector has undergone significant reforms over the past two decades,
beginning with a new health policy introduced in 1993—the first such change in over 50 years.
The government decentralized authority in the health system to the regional level in 1996, and
further decentralized authority to the woreda level in 2002 (El-Saharty et al, 2009). In 2012,
the government continues to promote decentralization of leadership in the health system and
meaningful participation of the population in local development programs. Publicly funded
health services are administered through a Regional Health Bureau (RHB) at the regional
level, a Zonal Health Department (ZHD) at the zonal level (with the exception of some
regions, such as Tigray), and Woreda Health Offices (WoHO) (El-Saharty et al., 2009). While
governance and responsibility for service delivery is decentralized to the regions and woredas,
all levels of the health sector continue to rely on some centralized policy, planning, and budget
decisions and on the national supply chain for vaccines and other health commodities.
In 2003, the Federal Ministry of Health launched a new health care plan, called Accelerated
Expansion of Primary Health Care Coverage, as part of a comprehensive Health Extension
Program (HEP). The HEP represented an innovative, community-driven approach to health
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
service delivery, and it was designed with the goal of providing universal primary health care
coverage. The program plans to ensure that there are five HCs in each woreda, with one HC
to serve a total of 25,000 population. As part of this effort, the government introduced a new
cadre of community-based health worker: the health extension worker (HEW). By the end
of 2009, a total of 33,819 HEWs had been trained and deployed. The HEWs are government
employees and are paid from the government budget. They receive one year of training at the
Technical and Vocational Training and Education Centers.
In Ethiopia, as in many resource-poor countries, massive external financial and technical
support was invested during the 1980s in pursuit of a global goal of achieving universal
childhood immunization by 1990. As a result, vaccination coverage increased rapidly, to 50%
for DTP3 by 1990 from less than 5% in 1980. After 1990, external donors withdrew much of
their funding, and coverage dropped precipitously. After several years, coverage once again
rose quickly to 1990 levels and beyond, then stagnated for several years before beginning
a slow and steady rising trajectory during the past seven to eight years. As of 2010, DTP3
coverage had reached 87%, according to WHO/UNICEF estimates.
FINDINGS
In the three woredas where coverage improved, penta3 coverage rose to 87% or above in
2009 from percentages in the low to middle 70s in 2006. In the steady woreda, the coverage
remained in the mid-60s during that period, only increasing in 2010 to 73%. The identification
and analysis of the drivers of coverage improvement explain the difference between the
woredas where coverage improved and the woreda where improvement was limited.
Figure ES 1. Elements of
the Pathway to Routine
Immunization Performance
Framing RI performance improvement
The anticipated outcome of a national or woredalevel routine immunization system—improved penta3
coverage, in the case of this study—is a product of the
context in which routine immunization services are
delivered, the availability of essential program inputs,
and key performance improvement drivers. Figure ES
1 presents the performance improvement pathway.
While these pathways, in practice, are rarely perfectly
linear, this simple diagram shows broad steps on the way
to improved coverage. To qualify as a driver, a policy,
resource, action, or process had to be present in some
form in the woredas that had experienced recent gains
in immunization coverage and to be absent or weak in
the steady coverage woreda. In addition, key informants
must have identified the importance of the driver, and
the driver had to have a logical link to improved coverage
by either improving the supply or use of immunization
services during the period under study. The drivers
3 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
E XECUTIVE SUMMARY
identified in this study are not meant to represent a comprehensive list of what is required
for a successful RI program. Instead, they are drivers of the positive change that occurred
in the case study woredas in recent years. Inputs or processes that did not drive recent
improvement are not included, even though such factors may be key drivers in other districts
or different countries.
National and subnational context of RI performance improvement
The context of RI can influence the effectiveness of the service and may be as important
as any strategy chosen to improve performance. In Ethiopia, some aspects of the context
of woreda-level RI created conditions that supported the introduction and effective
implementation of performance drivers. They include: 1) high level political commitment to
improving RI services and immunization coverage, expressed in terms of policies, funding
streams for immunization and primary health care, and the adoption of specific strategies
in response to reports of large numbers of unvaccinated Ethiopian children. An important
example of political commitment is the Health Extension Program (HEP) whose introduction
and rapid expansion marked a period of intense investment in basic health services that set the
stage for the success of RI in the study woredas. The HEP’s main intent has been to improve
access to health services in rural areas which yielded remarkable progress in geographical
as well as social access to health care (mainly preventive, though curative care is also part of
the service package). These decisions created positive conditions for immunization coverage
improvement between 2006 and 2010 in the ARISE study woredas. 2) A second aspect of
the supportive context for improved coverage is the strong emphasis placed on measuring
and openly reporting on progress in health care, including immunization, which is part of
the government’s emphasis on public sector accountability as well as reflected in global and
national health policy goals.
Essential immunization inputs
Through the woreda RI situation analysis, the ARISE research team assessed the basic capacity
of each woreda in routine immunization from 2006 through 2010 in terms of the availability
of essential inputs for delivering a basic immunization service. The study found that all four
study woredas had a reliable supply of vaccines, few cold chain disruptions, and sufficient and
trained human resources. Where shortages or challenges emerged, woreda health staff was
able to address the problem by, for example, borrowing a vehicle to collect vaccines or by
moving vaccines to adequate cold storage. All four woredas experienced a marked increase
in the community-level health workforce under HEP. From 2006 through 2010, in two of the
three woredas where coverage improved, the number of HEWs increased tenfold. Alongside
this boom in the health workforce, each woreda gained health posts (ranging from three to
28) and experienced large increases in the number of outreach vaccination sites. The increases
in the number of health posts and outreach vaccination sites were less dramatic in the steady
woreda than in the other three. However, in most cases, the availability of essential inputs for
RI did not differ greatly among the four woredas. Table ES1 compares several characteristics,
including basic EPI capacity, of the woredas.
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Table ES 1. Characteristics of the Four Study Woredas and Their Routine
Immunization Systems
WOREDA
ALAGE
TOKE
KUTAYE
SEKOTA
ZURIA
TIKUR
INCINI
Region
Tigray
Oromia
Amhara
Oromia
116,263
(2009)
122,582
(2010)
142,728
(2010)
107,536
(2010)
Rural
Rural/semiurban
Rural
Rural
Penta3 coverage rates in 2006 and 2009
75%; 87%
78%; 95%
73%**; 93%
61%; 66%
Dropout rates between penta1 and penta3
in 2006 and 2009
6%*; -1%
7%; 4%
15%**; 3%
9%; 6%
Number of health posts in 2006 and 2010
11; 14
10; 31
5; 33
3; 7
1: 8,304
1: 3,954
1: 4,325
1:15,360
Number of outreach sites for vaccination in
2006 and 2010
21; 72
38; 62
Unknown;
132
22; 55
Ratio of outreach sites to population, 2010
1:1,614
1: 1,977
1: 1,081
1:1,955
60%
70%
85%
80%
Number of 4-wheeled and 2-wheeled
working vehicles, 2010
6
2
3
1
Number of health extension workers
(HEWs) in 2006 and 2010
22; 35
6; 62
5; 64
7; 39
Ratio of HEW to population, 2010
1:3,321
1: 1,977
1: 2,230
1: 2,757
5
9
12
8
Population size
Characteristics of settlement
Ratio of health post to population, 2010
Estimated share of vaccines delivered by
outreach, 2010
Number of working refrigerators at health
care facilities, 2010
*
2008 data; **2007 data
WHO/UNICEF coverage estimates for 1980-2010, as of July 2011. Please note that WHO/UNICEF coverage estimates were updated in July 2012.
However, all national level coverage estimates used in this report are based on data reported by UNICEF/WHO in 2010 and 2011.
5 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
E XECUTIVE SUMMARY
Woreda-level drivers of RI performance improvement
Respondents at the national and woreda levels cited the availability of essential immunization
inputs as an important contributor to improved coverage in Ethiopia. However, the presence
or absence of resources and infrastructure only partly explains the differences in outcomes
between the steady woreda and the woredas whose coverage increased an average of
16 percentage points in three to four years. By comparing and synthesizing the woredas’
experiences, the research team identified five common practices or innovative steps that
drove positive change in immunization coverage. These drivers of the performance of RI
systems were:
– locally-recruited and supported HEWs
– active community participation in RI and health
– partnership between the woreda health team and the local government (woreda and
kebele) administrations
– focus on accountability and performance monitoring
– suppor t from development partners
Locally-recruited and supported health extension workers
Health extension workers were central to improvements in RI coverage. In the study woredas
where coverage increased, respondents identified the HEWs more frequently than any
other factor as the primary force of change. These workers contribute directly to improved
immunization coverage, because they deliver immunization services and health messages
in the community on a regular basis. The dramatic growth in the size and reach of the
community-focused health workforce not only increased geographic access to immunization
services; it also established HEWs as focal points in their communities for health generally
and immunization specifically. Through their work organizing vaccination sessions and raising
awareness, HEWs in the three woredas where coverage improved, built trust and rapport,
which encouraged the use of immunization and other primary health services. The workers
also established partnerships with community leaders and volunteers, employing mechanisms
such as registration of newborns and immunization defaulter tracing to increase the likelihood
of mothers initiating immunization and completing it on schedule. The lack of parallel
improvement in the steady woreda, despite HEW involvement, can be traced to three factors.
First, in the steady woreda, many planned health posts and health centers had not yet been
constructed by 2010 and HEWs had no base to live and work. Second, some HEWs were not
recruited locally, and were therefore reported to be less effective. Third, the relationships
between the HEWs and the local administration were not as strong as those found in the
other woredas.
Active community participation in routine immunization and health
In the woredas where coverage improved, the HEWs and the community, including local
government (woreda and kebele administrations), local networks of volunteers, teachers, and
religious leaders formed a solid team that committed time and human and material resources
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
to raising awareness of health needs and interventions, organizing outreach vaccination, and
setting high expectations in the community for meeting health service targets. In the woreda
where coverage remained steady, the overall number of volunteers was low throughout the
study period, many volunteer roles were unclear, volunteers complained that incentives given
during campaigns and by NGOs were not available for routine services, and few volunteers
were involved in tracing defaulters.
Partnership between health and local government administration
Coordination and collaboration between local government and health offices and workers
distinguished the three woredas where coverage improved from the woreda where coverage
was steady. Administrative and health offices worked closely together in annual planning, on
supervision, and in supporting the HEWs to raise the profile of health and health workers
in the community. Respondents viewed the interpersonal relationships between the woreda
administration and the woreda health office as crucial for the improved performance of the
health system in general and, by extension, for immunization.
A focus on accountability and performance
At the woreda and community level, program performance review takes the form of quarterly
meetings of woreda health and administrative staff and regular supervision. At the community
level, HEWs, kebele representatives, and community members meet to review progress and
trace defaulters, guided by reports of children who are behind in their vaccinations or who
have not been vaccinated at all. Ranking health facilities and woredas based on coverage and
other indicators is also common. In addition to ensuring accountability, these practices are
used to recognize achievement, promote learning, and focus stakeholders on a common goal.
What makes these simple management tasks effective are their regularity and the managers’
commitment to following up on reports with specific actions to rectify poor performance. The
health workers also reported a direct benefit from this peer learning approach and from the
public recognition of achievement, which they said motivated them and gave them credibility in
their communities.
Support from development partners
Development partners acted more as enablers than direct drivers of improvement in RI system
performance. Major international agencies guided policy and technical issues, and supported
construction, training, assessments, and the development of guidelines. From the woreda
perspective, however, respondents were more likely to identify the contribution of NGOs to
improvements in immunization coverage than to attribute the improvements to major funders or
advisors. In the three woredas where coverage improved, NGOs provided equipment, training,
fuel, vehicles, and technical assistance. They also helped to build capacity by providing training on
all 16 HEP interventions to woreda health administrators, health care providers, and HEWs. In
contrast, there was no equivalent support from NGOs in the woreda with steady coverage, and
health managers considered this an obstacle to improving RI system performance.
7 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
E XECUTIVE SUMMARY
IMPLICATIONS
To improve and sustain RI coverage, woredas need a supportive political and policy context, as
well as essential immunization infrastructure. The national Health Extension Program provided
the impetus and the resources to bring about a dramatic improvement in geographic access to
immunization (and other health interventions). Longstanding national commitment to RI and
the support of development partners ensures the availability of vaccines and equipment. In the
three woredas where coverage improved, the relatively consistent availability of these essential
inputs provided the foundation on which the five routine immunization performance drivers
were able to move penta3 coverage from around 75 percent to as high as 94 percent.
The ARISE exploration of district level RI reveals, however, that it is the way in which each
improving woreda implemented RI that triggered coverage improvements. Comparing the
woredas, there was not much difference in terms of health infrastructure. Rather, woreda
experience differed in relation to the choices that woreda health teams made in managing
their resources and the shared commitment of the health system, the local government, and
the community to improving immunization coverage. Such positive relationships and enhanced
coordination motivated a range of community members (for example, volunteers, religious
leaders, and school personnel) as well as health workers to promote RI. In the steady coverage
woreda, many of these performance drivers – performance review, HEWs’ work in defaulter
tracing, and raising community awareness – were either very recently instituted, present but
not functioning as effectively as they were in the improving woredas, or missing altogether.
Investing in improved RI performance
The results of the study of drivers of improvements in RI system performance in four woredas in
Ethiopia may have a number of practical policy implications for other sub-Saharan African districts.
First, Ethiopia’s success with taking vaccination into the hearts of communities through Health
Extension Workers suggests that a community-focused, community-based health workforce
may catalyze immunization service uptake and completion of vaccination schedules. Closer
physical proximity to services and the trust built from regular interaction with HEWs worked
together to increase the availability of RI and the commitment of community members to take
their children for vaccination.
Second, without continued attention and investment to sustain the supply of essential EPI
elements, no RI program can deliver potent vaccines effectively and build the credibility for RI
within a community that is required to sustain acceptance and use of vaccination. As countries
gradually introduce new vaccines into the routine system, maintaining these basic service
inputs is critically important.
Third, from 2006 onwards, no major changes—positive or negative—in service supply were
reported. Respondents instead traced coverage improvement to decisions and actions related
to management and the motivation of staff, to the coalitions formed between health and
community actors, to the regular use of data, and to learning to focus workers on reaching
targets. Many of these performance drivers were not speciic to immunization programs
8
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
but could be generalized to the basic practices and functions of a health system as a whole.
Effective woreda-level RI services beneit from health systems that 1) channel resources and
services as close to the community as possible; 2) use data to hold health and community
workers accountable for the system’s performance and; 3) use program review techniques to
motivate workers to stay focused on performance goals. All of these drivers are potentially as
important to other basic health services as they are to immunization.
Fourth, in the woredas where coverage improved, no single driver could account for coverage
improvement. Rather, drivers tended to work in concert to inluence RI system performance.
Managers and policy makers are therefore cautioned about looking for one key driver of
coverage improvement. In complex systems with limited resources, the use of multiple
strategies for achieving better immunization service delivery and increased use of vaccination
is needed.
Finally, the responsibility for determining which performance drivers are effective in a particular
woreda, and managing resources to apply and adapt performance drivers rests mainly with
woreda (or district) level health teams. These teams were effective advocates for strategies
that worked, and channeled resources toward effective actions such as use of data for regular
performance review and motivation of HEWs.
Local health managers in Africa must work strategically to improve health service capacity and
effectiveness and increase the use of health services such as they did with respect to
immunization in Ethiopia. To do so they require resources, skills, and the authority to use
different strategies and adapt them as needed to the local context to optimize resources and
improve the chances of program success.
9 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
E XECUTIVE SUMMARY
Table ES 2. How Context, Essential Immunization Infrastructure, and
Performance Drivers Work Together to Improve Coverage of Routine
Immunization (ARISE Case Studies of Four Ethiopian Woredas)
FOUNDATION AND
DRIVERS
MECHANISMS
PATHWAYS TO RI SYSTEM PERFORMANCE
IMPROVEMENT
• Policies and funding that:
CONTEXT:
Political commitment
to RI
Supportive policies
FOUNDATION:
Essential immunization
infrastructure in health
facilities
DRIVER:
Locally-recruited and
supported health
extension workers
(HEWs)
DRIVER:
Active community
participation in RI and
health
DRIVER:
Partnership between
health and government
administration
DRIVER:
Focus on accountability
and performance
DRIVER /ENABLER:
Development partner
support for health and
immunization
– focus on increasing access to care
– focus on community-based health
– focus on performance measurement
and improvement
• Regular supply of vaccines and basic inputs
for immunization
• Services move closer to the community
• Maintain vaccine supply chain
• Increase community-focused health
workforce
• Motivate staff and promote accountability
• National political commitment through HEP
& well-functioning immunization program
• Cold chain equipment and basic transport
at every health facility offering ixed services
• Increase in the size of community-focused
health workforce
• Maintain the vaccine supply chain
• Maintain an adequate number of vaccination
providers
• Increase opportunities for ixed-site and
outreach vaccination
• HEW characteristics: female, from the
community, living in the community
• HEW partners with kebele administration
• HEW teams with extensive volunteer
network
• Community-based vaccination, defaulter
tracing, awareness raising
• Establish personal links between health
workers and community
• Provide regular vaccination clinics, defaulter
tracing, and health education
• Increase community and health partnership
• Support the credibility of vaccination and
HEWs
• Regular interaction of community health
volunteers with RI program
• Strong partnership of HEW and kebele
administration
• Involvement of communities in decisions
about service delivery
• Increase capacity to mobilize community
support, trace defaulters, and educate
communities about health
• Increase resources for health service
delivery
• Joint planning and implementation of RI
• Regular supervision by woreda, HC, and kebele
• HEW sits on kebele cabinet
• Joint review of RI performance
• Motivate health workers and community
• Increase community involvement
• Improve access to resources for
immunization
• Clear performance targets
• Monthly or quarterly meetings with health
teams to review performance
• Praise for and correction of performance
• Peer exchange of service delivery solutions
• Supervision using data and peer learning
• Motivate staff
• Use data to inform decision making
• Increase skills to improve community-level
service delivery
• Emphasize problem solving
• Capacity building
• Resources to support immunization services
• Technical tools and guidance
• Improve service quality
• Improve service consistency
• Motivate health workers
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
I. INTRODUCTION
The foundation of successful national immunization programs is routine immunization
(RI)—the provision to all children of consistent, timely protection from common childhood
diseases through vaccination. Effective RI systems increase coverage rates, sustain the gains
from vaccination campaigns, and provide a foundation for introducing new vaccines. The
Africa Routine Immunization System Essentials (ARISE)1 project was created in late 2009 to
consolidate experience and learning about what drives improvement in RI coverage in Africa.
Sub-Saharan countries have achieved solid advances in immunization programming in the past
10 years; the proportion of infants vaccinated with a third dose of the diphtheria-tetanuspertussis (DTP) vaccine grew to 77% in 2010 from 55% in 2000 (World Health Organization,
2011). However, coverage rates for a third dose of DTP (DTP3) and for a third dose of
pentavalent vaccine (penta3), which combines the DTP vaccine with vaccines for hepatitis B
(HepB) and Haemophilus influenza type b (Hib), still vary greatly among and within countries,
and pockets of low vaccination coverage are common. Some of Africa’s most populous
countries—Nigeria, South Africa, Democratic Republic of the Congo, and Uganda—have
coverage rates well below the target of 80%, as do many districts throughout the continent. 2
ARISE aims to learn from African experience with RI, particularly from countries whose RI
systems are performing well. It seeks to identify why coverage improves in some RI systems
and not in others, and to translate these findings into actions to improve coverage in systems
whose performance continues to falter.
The project’s overall objectives are to:
– Create an evidence base to better understand the drivers of RI system performance.
– Deepen and broaden African and global stakeholder engagement in improving RI.
– Position the learning from the project to inform the way forward to improve RI systems in
Africa, identify potential investment options, and clarify stakeholder roles.
In the first stage of the project, conducted in 2010, ARISE team members interviewed
implementers of RI, as well as RI technical and development partners and completed a
systematic review of the literature on the drivers of RI system performance in Africa. (RI
performance is defined in this context as DTP3/penta3 coverage.) 3 The team reviewed both
commercially published literature and “grey” literature produced by various other sources,
including governments, nongovernmental organizations (NGOs), academic institutions, and
industry. From these efforts, the team identified a preliminary set of policies, procedures,
and investments that drive RI system performance (JSI Research & Training Institute, 2011b).
1 ARISE is managed by the JSI Research & Training Institute, Inc. (JSI) and funded by the Bill & Melinda Gates Foundation. JSI’s
partners on the ARISE project are the School of Public Health at Makerere University in Uganda and, in the United States, the
Dartmouth Institute at Dartmouth College and the School of Public Health at George Washington University.
2 Landscape Analysis Synopsis: An Initial Investigation of the Drivers of Routine Immunization System Performance in Africa (May
2011). Arlington, VA: John Snow, Inc./ ARISE Project for the Bill & Melinda Gates Foundation. Available at http://arise.jsi.com/
landscape-analysis-2
3
DTP3 and penta3 are accepted indicators of routine immunization system performance.
11 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
INTRODUCTION
To further investigate these and other possible drivers of coverage improvement, and to
understand better how they work in practice, ARISE conducted a study of RI performance in
four districts (woredas) in Ethiopia. The research was part of a larger study that extends to
Cameroon and Ghana as well. This report presents the results of the Ethiopia case study. 4
The analytical framework used to guide the ARISE study of the drivers of RI performance is
presented in Figure 1. Drivers can inluence any stage of the program cycle: inputs, essential
immunization components, implementation processes, and outcomes. Sections Two and Three
of this report present an introduction to the social, economic, and political context and the
national health care system in Ethiopia, with particular attention paid to the Expanded Program
on Immunization (EPI). Section Four describes the ARISE case study design and its application
in Ethiopia. Details are provided regarding data collection and the analytical approach. The
characteristics of each case study woreda are described in Section Five, including information
on livelihood, geography, health system, RI performance, and the essential components of a RI
system. Section Six integrates the indings from the four woredas and discusses the drivers of
RI performance and the pathways identiied for improving RI performance. Implications of the
indings for current and future RI policies in Ethiopia and elsewhere in sub-Saharan Africa are
presented in Sections Seven and Eight.
Figure 1. In-Depth Country Case Study Analytical Framework
4 The full Ethiopia case study report, research reports, briefs from Cameroon and Ghana, and the synthesized indings of the
three case studies are available at http://arise.jsi.com
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
II. ETHIOPIA COUNTRY BACKGROUND
Located in the interior of the Horn of Africa, Ethiopia is a low-income country that faces the
challenge of providing equitable health services across a highly disbursed population. The
country is home to approximately 83 million people who occupy 1.1 million square kilometers
of diverse topography. 5 Approximately 82% of the population lives in rural areas (World Bank,
2010b). Despite challenges related to drought and civil unrest, Ethiopia in recent years has
made and sustained declines in maternal and child mortality and gains in education, as well as
in its gross domestic product (GDP).
Ethiopia ranks 174th out of the 187 countries listed on the United Nations Development
Program’s Human Development Index for 2011. Its score of 0.363 is lower than the 0.463
average score for sub-Saharan Africa (UNDP, 2011). 6 Despite the country’s economic
improvement, urban and rural poverty persist. Nearly half (47%) of the total population lives
below the poverty line. Although reported enrollment in primary education is high, literacy
among adults (age 15 and older) is low (36%), particularly when compared with the average
for the region (62%). Amharic is the official language, but English is commonly spoken and is
taught across secondary schools. Many primary schools teach in a local language, rather than in
Amharic or English.
The country has a long and rich history, with a diverse population of 80 ethnic groups. The
Oromo (34.5%), Amhara (26.9%), and Tigre (6.1%) ethnic groups account for more than
two-thirds of the population. Additional ethnic groups include the Somali (6.2%), Sidama (4%),
Guarage (2.5%), Wolaita (2.3%), and Afar (1.7%), with the remaining 3% of the population
comprising numerous smaller ethnic groups. Dominant religious groups are Ethiopian Orthodox
Christian (43.5%), Muslim (33.9%), and Protestant (18.6%) (Government of Ethiopia, 2007).
POLITICAL STRUCTURE
Ethiopia is a federal republic, and its political leadership and governance has changed multiple
times since imperial rule ended in 1974. The first popular elections were held in May and
June of 1995, when the current government took office. Since being elected, Minister Meles
Zenawi’s government has promoted a policy of ethnic federalism, where significant powers are
delegated to regional ethnically based authorities (El-Saharty, 2009).
Ethiopia has a tiered government system consisting of a federal government with executive,
legislative, and judiciary branches and authority decentralized to regional authorities. The
federal government oversees the ethnically based regions, zones, woredas, and kebeles (the
lowest administrative level). Ethiopia is divided into nine ethnically based administrative states
and two City Administrations—Addis Ababa and Dire Dawa—and subdivided into 103 zones.
It is further subdivided into approximately 800 woredas and 15,000 kebeles.
5 Country population data from the World Bank was accessed at http://data.worldbank.org/country/ethiopia
6 Human development index trends, 1980-2011. Human Development Report (2011). New York, NY: United Nations Development Programme. Available at http://hdr.undp.org/en/media/HDR_2011_EN_Table2.pdf
13 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
ETHIOPIA COUNTRY BACKGROUND
The nation’s Constitution assigns extensive power to regions that can establish their own
government and democracy. Each region has its own council, where members are directly
elected to represent the woredas. The councils have legislative and executive powers to
direct internal affairs of the regions. As a result, there is extensive decentralization of service
delivery, with relatively autonomous regions largely responsible for implementation.
ECONOMY
According to the World Bank, Ethiopia’s annual GDP was estimated at $28.5 billion in 2009.
(All dollar amounts in this report are in U.S. dollars, unless noted otherwise.) From 2005
to 2010, the economy experienced 8%-12% annual GDP growth, a particularly notable
achievement in a period of global economic uncertainty (World Bank, 2010a). The World
Bank has estimated that the economy will experience continued growth through 2013, with a
6.5% average annual increase in GDP. Despite the nation’s economic growth, however, sharp
inflation and currency depreciation have created economic challenges.
In 2010, Ethiopia launched a ive-year Growth and Transformation Plan designed to support
continued economic growth in the future. The plan is supported by the continuation of
the Poverty Reduction Strategy Program, as an extension of the government’s Plan for
Accelerated and Sustained Development to End Poverty, which operated from 2005-2006
through 2009-2010. As part of these efforts, the government increased its share of total
spending targeted at decreasing poverty to over 64.1% by the end of 2007-2008, up from 42%
in 2002-2003. National investment in poverty reduction and human development programs
has supported gains across much of the health and education sectors (OECD, 2011a).
Agriculture accounts for 50.7% of Ethiopia’s GDP, followed by the service industry and
industrial activity (OECD, 2011a). The government is emphasizing industrialization through
increased exports and import substitution; industry and services demonstrate average annual
growth of 20% and 11%, respectively, while agriculture is expected to grow by only 8.1%
annually under the five years of the Growth and Transformation Plan, which extends through
2016 (OECD, 2011a). This transition away from the country’s agrarian roots and toward more
manufacturing may have interesting implications for the health of Ethiopia’s people.
SOCIAL AND DEMOGRAPHIC BACKGROUND
Ethiopia has numerous health challenges, particularly related to communicable diseases
caused by poor sanitation, malnutrition, and food insecurity. Infant and maternal mortality
rates remain high. The World Health Organization (WHO) estimates maternal mortality
at 470 deaths per 100,000 live births (WHO, 2010) and preliminary results from the most
recent Ethiopia Demographic and Health Survey (EDHS), published in 2011, estimates
neonatal mortality at 37 deaths per 1,000 live births. Preliminary results from the survey
indicate a promising rapid decline in mortality among children under five years of age, to 88
deaths per 1,000 live births in 2011 (ICF Macro and Ethiopia Central Statistical Agency, 2011)
from 133 deaths per 1,000 live births in 2006 (Central Statistical Agency [Ethiopia] and ORC
Macro, 2006).
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
Fertility is high in Ethiopia, with an average of nearly five children born per woman and annual
population growth estimated at 2.5% (ICF Macro and Ethiopia Central Statistical Agency,
2011). Fertility is markedly higher in the large rural population, at 5.5 children per woman,
compared with 2.6 children in urban areas. Nationwide, nearly one-quar ter of women have an
unmet need for family planning, indicating that large family size is not always by choice. While
unmet need remains high, contraceptive prevalence has nearly doubled in recent years, to 29%
in 2011 (ICF Macro and Ethiopia Central Statistical Agency, 2011) from 15% in 2006 (Central
Statistical Agency [Ethiopia] and ORC Macro, 2006). Ethiopia continues to have one of the
lowest rates of skilled birth attendance in sub-Saharan Africa, estimated at only 10% of all
births (ICF Macro and Ethiopia Central Statistical Agency, 2011).
The Organization for Economic Co-operation and Development (OECD) has noted
that Ethiopia’s government has made notable progress toward achieving the Millennium
Development Goals (MDGs) set by the United Nations. The percent of Ethiopians living in
poverty decreased to 32.3% in 2009-2010 from 38.7% in 2004-2005. The country is on track
to achieve gender parity in primary school enrollment by 2015, as well as to meet the MDGs
for maternal and child health.
HEALTH SYSTEM
For nearly two decades, national health and development plans in Ethiopia, including the Plan
for Accelerated and Sustained Development to End Poverty and Health Sector Development
Programs (HSDPs), have proposed improvements in health services and health outcomes. The
plans, which acknowledged the importance of improving health as part of a broader socioeconomic development strategy, have helped to reform the system so that it delivers more
consistent and equitable health services. Changes in the health sector, particularly efforts to
decentralize programs and to increase the health workforce by adding community-based health
workers, are beginning to produce better service outcomes. A timeline of recent political and
policy-related events that have affected the health system is found below in Figure 2. 7
The Ethiopian health sector has undergone significant reforms over the past two decades,
beginning with a new health policy introduced in 1993—the first such change in over 50 years. 8
Reforms have focused on fiscal and political decentralization of the health system, as well as
on expanding primary health care and supporting partnerships with and participation by the
private and nongovernmental sectors (Wamai, 2009). The government decentralized authority
in the health system to the regional level in 1996, and further decentralized authority to the
woreda level in 2002 (El-Saharty et al, 2009). According to Ethiopia’s comprehensive Multi
Year Plan (cMYP) for 2010-2014, the health system currently reaches 89.6% of the population,
with access defined as residence less than 10 kilometers from a health facility, based on a
framework specifying one Health Center (HC) per 25,000 catchment area population and one
health post per 5,000 population (Federal Ministry of Health of Ethiopia, 2009a).
7 Details on GAVI support to Ethiopia can be found at http://www.gavialliance.org/country/ethiopia
8 Federal Democratic Republic of Ethiopia (FDRE). Health Policy of the Transitional Government of Ethiopia. Addis Ababa: FDRE;
1993.
15 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
ETHIOPIA COUNTRY BACKGROUND
Figure 2. Timeline of Major Health System Events
In 2012, the government continues to promote
decentralization of leadership in the health system
and meaningful participation of the population in local
development programs. Publicly funded health services
are administered through a Regional Health Bureau
(RHB) at the regional level, a Zonal Health Department
(ZHD) at the zonal level (with the exception of some
regions, such as Tigray), and Woreda Health Offices
(WoHO) (El-Saharty et al., 2009). The lowest level of
the structure is the kebele level. The diagram on the
right (Figure 3) illustrates the basic governmental
health infrastructure.9
The varying levels of the health system have differing
degrees of authority over one another and with respect
to the Expanded Program on Immunization. Ethiopia does
not have a national EPI manager, but has representatives
that oversee EPI for agrarian and pastoralist areas. The
RHB houses an EPI focal point, and it is responsible for
overseeing the ZHD within its catchment area. ZHDs
oversee the WoHOs, which are responsible for provision
Figure 3. Ethiopia Health
System Structure
Source Bill & Melinda Gates Foundation. (2012). "Ethiopia Health
System," PowerPoint presentation.
9 Reducing Unimmunized Children-Ethiopia Experience, Annual Regional Conference on Immunization, Harare, Zimbabwe, 15
December 2009.
16
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
of most services and for development of annual plans. (In cases where an area lacks a ZHD,
the RHB provides oversight of the WoHOs.) In addition, HCs are strategically placed to best
serve population centers, and they answer to the WoHO.
While governance and responsibility for service delivery is decentralized to the regions
and woredas, all levels of the health sector continue to rely on some centralized policy,
planning, and budget decisions and on the national supply chain for vaccines and other health
commodities. Woredas receive block grants from regional governments and are allowed to
set their own priorities, deliver services, and determine budget allocations responsive to local
needs (El-Saharty et al., 2009). Educational and supervision visits are undertaken by both the
Federal Ministry of Health (FMoH) and the regional and woreda leadership.
HEALTH FINANCING
Health services in Ethiopia are financed mainly by the government (both federal and regional)
and bilateral and multilateral donors (both grants and loans). NGOs and private organizations
also contribute financial and material support.
Government
As of 2009, expenditures on health care accounted for 11% of total government spending, and
government expenditures on health accounted for 47.6% of total health expenditures in the
country. Per capita health spending in the same year was estimated at $15, compared with the
$34 per capita recommended by WHO for providing effective health services in developing
countries. The government budget is set centrally and then allocated to regions, which in turn
allocate funds to sectors according to local priorities.
In 2010, the federal government introduced a pilot program to test the feasibility of
community-based health insurance schemes in order to provide a mechanism to protect
individuals and families against financial hardship as a result of medical expenses. Targeted
primarily at rural populations, the schemes will operate in conjunction with a social health
insurance system, which will be covered through payroll taxes from public and private
institutions, employer contributions, and government subsidies.
Donors
In 2009, Ethiopia received more than $2 billion in assistance through bilateral aid through
OECD’s Development Assistance Committee countries. An additional $549 million came from
the World Bank (World Bank, 2011). Of the total donor assistance in 2009, $516.35 million
was allocated as development assistance for health, which amounts to approximately $5.91 in
donor health financing per capita. For comparison, the whole of sub-Saharan Africa received
approximately $7.6 billion in development assistance for health the same year. 10
10 Institute for Health Metrics and Evaluation (2011). Financing Global Health 2011: Countdown to the Millennium Development
Goals. University of Washington.
17 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
ETHIOPIA COUNTRY BACKGROUND
The United States government is one of the country’s most substantial donors; in fiscal
year 2012, over $314 million was requested for human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) programs, $45 million for maternal and child health
programs, and millions more for other health priorities. European Union countries contributed
$202.5 million in donor support in 2009.
Private-sector
Private-sector contributions to the health system are limited. The World Bank estimated that
out-of-pocket expenditures accounted for 42% of total health expenses in 2009. 11
HEALTH POLICY
Since the 1970s, Ethiopia has endorsed a Primary Health Care (PHC) strategy, and the
government continues to emphasize the importance of nationwide access to an integrated
package of PHC services. The current health policy, introduced in 1993, policy was
implemented under the government’s series of four five-year Health Sector Development
Programs, and the health sector currently operates under HSDP IV, which was designed to
cover the period from 2010-2011 to 2014-2015. The first HSDP, introduced in 1997, featured a
four-tier health service system, which included a primary health care unit (a health center and
five health posts), a hospital, a regional hospital, and a specialized referral hospital. HSDP III
provided an institutional framework for achieving Ethiopia’s MDGs (Federal Ministry of Health
of Ethiopia, 2005).
HSDPs overlapped during the period from 1991 to 2002 when the country was operating
under the sector-wide approach (SWAp) to health development. Originally pioneered by the
organizations like WHO and the World Bank in the 1980s, SWAps guided donors and lenders
to contribute collectively to fund a country’s entire health system (Cassels & Janovsky, 1998),
and they became the mainstays of health sector development strategy in many countries.
During implementation in Ethiopia, the SWAp was regarded as a way to achieve sustainability
over time and to support capacity building around government management of health,
education, and road programs (Brown et al., 2001).
In 2003, the Federal Ministry of Health launched a new health care plan, called Accelerated
Expansion of Primary Health Care Coverage, as part of a comprehensive Health Extension
Program (HEP). The HEP represented an innovative, community-driven approach to health
service delivery, and it was designed with the goal of providing universal primary health care
coverage by 2009. Recognizing the huge gap between need and health care services available,
the FMoH focused on providing quality promotive, preventive, and selected curative health
care services in an accessible and equitable manner to reach all segments of the population,
with special attention to mothers and children (Bilal, 2011). The policy placed particular
emphasis on establishing an effective and responsive health delivery system for those who live
11 World Bank (2010). World Bank Data Library: Out-of-pocket health expenditure (percent of private expenditure on health).
Accessed March 2012 at http://data.worldbank.org/indicator/SH.XPD.OOPC.TO.ZS
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in rural areas, as highlighted in a recent Lancet article that described the Minister of Health’s
commitment to community-based health care (Donnelly, 2011). As part of this effort, the
government introduced a new cadre of community-based health worker: the health extension
worker (HEW).
In 2010 under this initiative, the program expanded beyond its initial rural targets to six
urban areas where new HEWs installed. At the time of the study, training and deployment of
urban HEWs had begun in Tigray region; Amhara region; Oromia region; Southern Nations,
Nationalities and Peoples region; Harari region and the City Administrations of Dire Dawa,
and Addis Ababa.
HEALTH WORKFORCE
In 2007, the World Bank reported that Ethiopia had an acute shortage of skilled health
workers, with only 2.4 nurses or midwives and 0.2 physicians per 10,000 population (World
Bank, 2007). According to the FMoH’s 2007 assessment of human resources for health
(HRH), low health workforce density, poor distribution of workers, weak HRH management,
and absence of an effective HRH regulatory framework were the primary human resource
challenges in the health sector. In response to these findings, the federal government has
piloted and implemented several initiatives focused on training, education, and retention of
health workers; released a 12-year HRH Strategic Plan (2009-2020); and developed a legal
framework and Human Resources Information System.
Health Extension Workers
The comprehensive Health Extension Program, with its emphasis on expanding the number
of health workers available to provide services, succeeded in increasing health care coverage
dramatically (Wakabi, 2008). Coverage of publicly funded health care rose to 87% in 2007
from 61% in 2003, when the HEWs were introduced. If private health care is included, health
care coverage reached 98% of the population in 2007.
By the end of 2009, a total of 33,819 HEWs had been trained and deployed under HSDP III.
Even though this level of deployment exceeded the program’s goal, however, only 26% of
households were covered by a HEW, leaving more than 11 million households still in need of
services (Federal Democratic Republic of Ethiopia Ministry of Health, 2010). Nevertheless, the
size of this cadre of community-based health workers is growing quickly; in the kebeles served
by the Last Ten Kilometers Project alone, an additional 7,000 HEWs and 45,000 community
health volunteers (CHV) were scheduled to be trained in 2010 (Bill & Melinda Gates
Foundation, 2010). A group that the Ethiopian government calls the Health Development
Army, a network of volunteers started in Tigray in 2010, was rolled out nationally in 2011 after
the completion of the ARISE study.
The HEP is structured such that two HEWs are selected from each kebele and assigned to the
local health post. Community volunteers of varying numbers work under each pair of HEWs
(Karim, 2011). The program plans to ensure that there are five HCs in each woreda, with one
HC to serve a total of 25,000 population living in the woreda. Each HC supervises five health
19 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
ETHIOPIA COUNTRY BACKGROUND
posts. Except in some pastoral regions, the HEWs are female (primarily young women) and
are required to have a minimum of a tenth grade education. Other criteria for becoming a
HEW include residing in the local kebele and having personal good health and fitness. The
HEWs are government employees and are paid from the government budget. They receive
one year of training at the Technical and Vocational Training and Education Centers.
The requirements of HEWs are demanding. They are expected to implement all 16
components of the HEP package, which is divided into four main areas: hygiene and
environmental sanitation, disease prevention and control, family health services, and health
education and communication as part of outreach. Immunization is one of the preventive
health interventions in the package. HEWs also have other responsibilities, such as supporting
growth monitoring as part of community-based nutrition programs; informing members of the
community about the HEP package through health education and other methods of creating
community awareness; and working with community leaders, including kebele members, school
directors and teachers, and local religious groups, to raise community awareness. One of the
two HEWs in a given kebele—usually the senior HEW—serves as a member on the local
kebele cabinet. At its core, the intent of the HEP and the work of the HEWs is to transfer
ownership of and responsibility for individual health to households, through transferring
knowledge and skills (Bilal & Herbst et al., 2011).
HEWs are tasked with spending 75% of their time visiting families in their homes and
performing outreach activities in the community, training 360 “model families”12 each year.
They spend their remaining time providing services at the health posts, including providing
immunizations and injectable contraceptives. In addition, collection of community-based
data for decision making has been added to the core HEW strategy in 14 districts, where
community health providers map the households in their neighborhoods for targeted
maternal, newborn, and child health (MNCH) services. This addition has fostered community
participation in planning, monitoring, and evaluating interventions (Karim, 2011). The HEWs
also work in close collaboration with community-based reproductive health agents to provide
reproductive health and family planning services at the household level.
In 2010, the Bill & Melinda Gates Foundation conducted a systematic review of assessments
and evaluations of the HEP, in response to a request from the Government of Ethiopia. Key
findings on the effectiveness of HEWs included:
– HEWs played a role in improving coverage of a number of preventive health services, such
as bednets, family planning, hygiene, and antenatal care, but challenges remain related to
access to safe delivery and newborn care services due to weak HEW capabilities and lack of
demand for these services.
– Community volunteers were important in bolstering community trust of HEWs.
– There was inadequate supportive supervision of HEWs and inadequate training in
management of labor and delivery.
12 The model family initiative rewards families that have adopted all 16 services delivered under the HEP and holds them up as
examples for others.
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– Stockouts of key MNCH drugs and supplies at the health post levels limited HEWs’ ability
to provide services.
– HEWs had limited skills for making data-driven decisions at the local level.
– Promising information is becoming available on how revenue is being used for quality
improvement, and reform components have been implemented.
The HEP program was taken rapidly to scale and now faces the challenge of linking its
achievements in training and deploying personnel to a medium-term strategy to focus HEP
activities that will enable the program to translate outputs into impact (Bill & Melinda Gates
Foundation, 2010).
21 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
B RIEF HISTORY OF THE E XPANDED PROGRAM ON IMMUNIZATION IN ETHIOPIA
III. BRIEF HISTORY OF THE EXPANDED PROGRAM ON IMMUNIZATION
IN ETHIOPIA
The World Health Organization established the global Expanded Program on Immunization in
1974 to control vaccine-preventable diseases. In 1980, Ethiopia launched its national EPI, with
a goal of achieving 100% vaccination coverage of children under two years of age by 1990. In
1986, Ethiopia set a more conservative goal of 75% coverage of infants under one year of age.
Figure 4 depicts the historical trends in coverage for the first dose of diphtheria-tetanuspertussis vaccine (DTP1) and for DTP3, the third dose of the vaccine, from 1981 through
2010 in Ethiopia, according to estimates by WHO and the United Nation’s Children’s Fund
(UNICEF)13 It also depicts trends in immunization drop-out rates, as illustrated by the gap
between the two lines.
Figure 4. National Infant DTP1 and DTP3 Coverage (1981-2010) and Major
Events and Policies from 2000
Source: WHO/UNICEF coverage estimates for 1980-2010, as of July 2011.
13 For more information on how WHO/UNICEF estimates are derived, see http://www.who.int/immunization_monitoring/routine/
immunization_coverage/en/index4.html. Please note that WHO/UNICEF coverage estimates were updated in July 2012. However, all national level coverage estimates used in this report are based on data reported by UNICEF/WHO in 2010 and 2011.
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In Ethiopia, as in many resource-poor countries, massive external financial and technical
support was invested during the 1980s in pursuit of a global goal of achieving universal
childhood immunization by 1990. As a result, vaccination coverage increased rapidly, to 50%
for DTP3 by 1990 from less than 5% in 1980. After 1990, external donors withdrew much of
their funding, and coverage dropped precipitously. Other countries with weak health systems
experienced similar challenges. After several years, coverage once again rose quickly to 1990
levels and beyond, then stagnated for several years before beginning a slow and steady rising
trajectory during the past seven to eight years. As of 2010, DTP3 coverage had reached 87%,
according to WHO/UNICEF estimates.
THE NATIONAL EPI POLICY AND OBJECTIVES
Ethiopia updated its policy governing the national EPI in 2007. Hepatitis B and Haemophilus
influenza type b vaccines were successfully added to the standard EPI schedule in 2007, when
the country introduced pentavalent vaccine with support from the Global Alliance for Vaccines
and Immunization (GAVI). In October 2011, also with GAVI’s support, Ethiopia became the
15th GAVI-eligible country to introduce pneumococcal vaccine—thereby meeting one of the
goals of its cMYP 2010-2014. By adding this vaccine to the EPI schedule, the country hopes to
reduce child deaths from pneumonia which is the most common cause of death for children
under age five in Ethiopia and globally.
The 2012 program currently focuses on reaching children younger than one year of age with
these vaccines: Bacillus of Calmette and Guérin (BCG; target 95%), measles (target 86%),
pentavalent vaccine (penta 1 target of 97%; penta 3 target of 91%), pneumococcal vaccine
(target 91%), and oral polio vaccine (OPV; target of 91% for OPV3). The program also seeks to
cover 87 percent of women of reproductive age (15 to 49 years old) with the tetanus toxoid
vaccine (Federal Ministry of Health, 2009a). The immunization schedule for the basic EPI
vaccines for children and tetanus immunization for women of reproductive age strictly follow
the WHO recommendations for developing countries. Ethiopia plans to introduce rotavirus
vaccine by 2012, according to the 2010-2014 cMYP.
Ethiopia has a national Inter-agency Coordinating Committee (ICC) created to improve sharing
of technical, material, and financial resources. The national ICC advises the FMoH, provides
technical assistance and supports planning, logistics, and monitoring and evaluation. Due to
the decentralized structure of the Ethiopian health system, some regions have also established
their own regional ICCs, with Somali region being first to take this step.
IMMUNIZATION SERVICE DELIVERY
Under Ethiopia’s bicameral parliament, the Committee on Social Affairs in the House of
People’s Representatives has responsibility for overseeing immunization and immunization
financing, along with various other health-related activities. Vaccines are placed under
government regulation through the Food, Medicine and Health Care Administration and
Control Proclamation No. 661/2009 (Federal Democratic Republic of Ethiopia Ministry of
Health, 2010).
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B RIEF HISTORY OF THE E XPANDED PROGRAM ON IMMUNIZATION IN ETHIOPIA
Ethiopia has adopted a national immunization policy that recommends the use of static
sites (defined as health facilities with a refrigerator), outreach sites, and mobile teams as
appropriate strategies for delivering immunization services. According to a 2006 EPI coverage
survey, approximately 40% of the immunization services in Ethiopia are delivered at outreach
sites and the remainder at static sites (Kidane et al., 2006).
For the purposes of planning service delivery, the regions of the country have been divided
into agrarian and pastoralist blocs, with a specific WHO EPI Officer and UNICEF EPI Officer
seconded to the FMoH and assigned to each bloc. The emphasis on vaccination service
delivery through outreach is greater in the pastoralist bloc than in the agrarian bloc, as
pastoralist communities are more dispersed and nomadic. Global goals and strategies related
to specific disease control initiatives, including polio eradication, measles mortality reduction,
and maternal and neonatal tetanus elimination, have been integrated into the national
immunization policy (Federal Ministry of Health of Ethiopia, 2009a). In Ethiopia, both routine
EPI activities and supplemental immunization activities also include efforts to provide Vitamin
A supplementation to community members.
Ethiopia in 2002 adopted WHO policies covering the reuse of open vials of vaccines (multi
dose open vial policy or MDVP), as well as policies that call for the exclusive use of autodestruct syringes for delivering all immunization injections. In 2001, the government put in
place national guidelines on safe injection practices and safe disposal of injection equipment
for EPI services. The guidelines recommend, among other actions, the use of safety boxes for
collection of used equipment and incinerators for their destruction (Federal Ministry of Health
of Ethiopia, 2009b).
SERVICE DELIVERY AT THE WOREDA AND SUB-WOREDA LEVELS
The Federal Ministry of Health, the Regional Health Bureaus, and the Woreda Health Offices
share in the decision-making processes in the development and implementation of the health
system. As a result, the FMoH and the RHBs focus on policy matters and technical support,
while the WoHOs manage and coordinate the day-to-day operation of PHC services, including
immunization service delivery.
Each of the 11 RHBs has an EPI focal point (Sabin Vaccine Institute, 2011). As a result of the
2008-2009 reorganization of the FMoH, immunization services are now decentralized, along
with numerous other health services. Immunization planning is included in the woreda planning
process. With support from GAVI, the country introduced a system to ensure that cold chain
equipment is available for vaccine storage for a cluster of two to three health posts in each
woreda; in this way, no health post is more than five kilometers from a refrigerator. When
health posts are particularly remote, they are provided with their own cold chain equipment.
Children often receive vaccinations from HEWs. By providing immunizations at the community
level in rural areas, the country is addressing persistent obstacles in reaching remote
populations with immunization services; some of the obstacles include low access to services,
limited awareness of caregivers, and high drop-out rates (Kidane & Tekie, 2004).
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EPI FINANCING
Routine immunization activities are funded primarily by development partners and the
government, with donors providing most of the financial resources. The partners largely
channel their funds through UNICEF, WHO, and GAVI. GAVI finances the bulk of costs
for new vaccines, and UNICEF finances the bulk of costs for some traditional vaccines. The
government’s role is illustrated by its support in 2009. In that year, the government covered
the cost of vaccines for BCG and TT, as well as 50% of the cost of OPV and injection materials
for traditional vaccines (Federal Ministry of Health of Ethiopia, 2009a).
According to WHO/UNICEF, the government spent approximately $1.4 million to immunize
3.2 million infants in 2009, accounting for 12% of the total EPI budget. However, data from the
cMYP for 2010-2014 indicate government funds accounted for only 3% of the total EPI budget.
The remainder was financed by private and donor sources (Sabin Vaccine Institute, 2011).
Government funds have not been consistently tracked while being disbursed to the
decentralized administrative units. In 2008-2009, the FMoH did not generate real-time reports
for quarterly disbursements to the RHBs. Many woredas had difficulty reporting financial
data to the FMoH due to shortages of skilled personnel, and regions did not fully use their
budgets (Federal Ministry of Health of Ethiopia, 2009b). As a result of the decentralization of
immunization and other health services, many donors allocate funds at the regional or woreda
level (Sabin Vaccine Institute, 2011).
The gap between DTP1 and DTP3 coverage—the drop-out rate, illustrated by the difference
between the two lines in Figure 4—began to narrow starting around 2002. This effect was
likely related to the availability of Immunization Services Support (ISS) funding from GAVI and
the introduction of the Reaching Every District (RED) strategy. Although DTP3 is not the only
vaccine of interest in immunization programs, it is customarily used as a marker of the strength
and development of the routine system to deliver successive vaccine doses of perceived good
quality to a population that is prepared to receive them.
Since 2002, Ethiopia has received nearly $279 million in funding from GAVI for five focus areas:
Immunization services support (ISS), injection safety support (INS), new vaccine introduction
support (NVS), health system strengthening (HSS) support, and civil society organization
support. Of the funds disbursed by GAVI, 64% were allocated to procure vaccine, while
the remainder supported building local capacities, strengthening systems, and implementing
innovative financing and incentive systems. Specifically, GAVI’s HSS support funding ($76.5
million for a three-year period, 2007-2009) was allocated to strengthen human resources for
delivery of basic health services; to improve supply, distribution, and maintenance systems;
and to enhance the organization and management of health services delivery (John Snow,
Inc., 2009). Funding for a number of other components, such as technical support, cold chain
equipment, transport equipment, social mobilization, and some operational costs, has been
made available by WHO, UNICEF, and other development partners.
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B RIEF HISTORY OF THE E XPANDED PROGRAM ON IMMUNIZATION IN ETHIOPIA
With respect to general health financing and budget provisions, the government has taken
steps to reallocate resources from urban hospital-based curative services toward more
preventive and promotive care, targeting the rural population. The overall focus has been on
communicable diseases, common nutritional disorders, environmental health and hygiene (i.e.,
latrines), and safe and adequate water supply.
ETHIOPIA’S CURRENT ROUTINE IMMUNIZATION SITUATION
Implementation of the Reaching Every District and Sustainable Outreach Services approaches
to immunization have supported improvements in coverage since 2003. Currently, nearly
all public health facilities, as well as select private hospitals in the Addis Ababa urban area,
provide immunization services. Services are provided free of charge at public and NGO
facilities; private institutions, which function primarily in urban areas, levy charges for
vaccination services.
Systemic barriers to universal coverage remain, even as the country makes progress
toward more equitable geographical distribution of care with construction and staffing of
15,000 additional peripheral health facilities. To address these challenges, the government
implemented bridging approaches, such as the Enhanced Outreach Strategy (EOS) and
Enhanced Routine Immunization Activity (ERIA), to support improvements in coverage in
remote woredas (Fielder & Chuko, 2008). The cMYP for 2010-2014 indicates additional
challenges for increasing RI coverage, including: limited harmonization among health and
nutrition outreach initiatives; a need to cultivate an increased sense of responsibility for and
social mobilization around protecting the health of the community and its children; desire for
additional training among peripheral health workers; limited use of immunization cards as a
mobilizing strategy among community members to ensure children stay on schedule; and the
need to ensure that unit costs and service delivery mechanisms are the most cost-effective in
a time of limited financial resources (Federal Ministry of Health of Ethiopia, 2009a).
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IV. METHODOLOGY
The design of the ARISE Ethiopia study of drivers of routine immunization performance was
structured as mixed-method case studies. The units of analysis are individual woredas. Case
study methodology has a number of advantages for this type of investigation (Yin, 2009). It
permits a holistic, detailed description and analysis of what the drivers are and how they are
working to improve RI system performance in a specific setting. Case studies are particularly
appropriate for an empirical inquiry that investigates a contemporary phenomenon in depth
and within its real-world context, especially when the boundaries between the phenomenon
and its context are not clear, as is the case with drivers of RI system performance.
The approach for primary data collection was mainly qualitative. The methodology was
designed to be iterative. The focus of inquiry expanded, narrowed, and shifted as information
saturation and convergence was reached and as new relationships and factors emerged. The
qualitative approach does not rule out the use of quantitative indicators. One of the study’s
important analytical tools was to triangulate information gained from the review of health
records and reports, coverage data, and observations of data use at health facilities. In
addition, the team conducted semi-structured interviews that yielded quantitative measures of
RI performance, including changes in performance over time, within a woreda or specific
health facility. In this way, the team gained details about such measures as vaccination
coverage, numbers of vaccine doses administered, numbers of vaccinators, and numbers of
cold chain and other logistical equipment available.
Table 1. Multiple Means of Testing for Drivers in Qualitative Study
QUALITY
DEFINITION
Replicability
Methods are clearly documented and can be replicated in other settings
Reliability
Driver mentioned frequently and considered important in diverse settings
Internal validity
Opinions about drivers and their cause and effect are consistent in improving woredas and
absent or weak in steady woreda
Triangulation
Driver emerged through different data methods and sources
Chronology
Driver emerged prior to changes in performance or outcomes
External validity
Stakeholders and subject experts consider the driver’s impact to be plausible
Mixed-method case studies conform to a set of rigorous data collection and analysis
techniques to enhance validity and generalizability of the findings, as described in Table 1.
In quantitative studies, validity and generalizability are achieved principally through use of
an unbiased sample selection and a sufficiently large number of cases. In qualitative studies,
validity and generalizability are achieved through the use of specific data collection and analysis
processes that reduce interviewer bias and subjective interpretations. Examples of these
27 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
METHODOLOGY
processes include good interviewing techniques and note taking. Robust qualitative analytical
processes include such methods as verifying the information through more than one source or
method, postulating the chronology of events to be causal, ensuring the logical plausibility of
relationships, and using some type of study control.
For the purposes of the ARISE project, a RI performance driver is defined as a structure,
resource, or process that works on or through the immunization system to make the system
perform effectively or to improve its performance (JSI Research & Training Institute, 2011a).
SELECTION OF STUDY WOREDAS
The study team focused on four woredas. The ARISE protocol, which was adapted to
Ethiopia in collaboration with the FMoH, called for the woredas to be selected from the most
populous regions of the country. The team selected three woredas showing increased DTP3/
penta3 coverage from 2007 to 2009 and, for comparison, one “steady” woreda that had
little change in coverage during the same period. (In selecting the woredas, the study team
also relied on the advice of EPI experts in Addis Ababa on the reliability of national estimates
of immunization coverage.) The steady woreda was chosen from the same region as one of
the three “improving” woredas to control for regional contextual factors. The study time
frame was chosen based on the availability of coverage data and the need to focus on recent
patterns of change to reduce recall bias.
Based on data from the 2007 census, the study team selected woredas from Amhara, Oromia,
and Tigray regions. (Southern Nations, Nationalities and Peoples region met the criteria but
was excluded due to difficulties securing coverage data in time for case selection. Somali
region was excluded because of security constraints and road closures.) Additional criteria for
selection included such practical considerations as access and the ability to obtain clearances
for the study from regional Institutional Review Boards.
In Ethiopia, most vaccination coverage data are aggregated at the zonal level, then
computerized and reported by zone to the national level. The exception is Tigray region,
which computerizes and reports coverage to the national level by woreda rather than zone.
Thus, for Tigray, the team was able to review coverage data and apply the woreda selection
criteria using data available at the national level. To select the study woredas in the two other
regions, the team first applied the selection criteria to zonal-level coverage data. Once zones
were selected, the team requested woreda-level coverage data from each zone directly and
then attempted to apply the following criteria to select study woredas:
– DTP3/penta3 coverage in 2007 between 65% and 70%.
– DTP3/penta3 coverage in 2009 greater than 85%.
– Not recently subdivided or newly created.
– Not in a major urban area.
– Minimum population of 100,000.
In all cases, the team had to adapt the selection process because of challenges faced with the
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availability and consistency of coverage data. In Oromia, for example, the team was unable to obtain
a full set of woreda-level data. Thus, to make the inal selection of study woredas, it was necessary
to adapt the woreda selection process in each region, as explained in the following sections.
Tigray region was the only one for which woreda-level coverage data were readily available
at both the national and regional levels. Yet data from the regional level showed an unusual
degree of variability, which appeared to be related to denominator estimates used to calculate
population targets and coverage. For example, Tigray used different target population
estimates from those employed by the FMoH both prior to and following the 2007 census. The
region conducted its own population census to estimate the target population for vaccination.
Furthermore, the FMoH had advised regional staff to use different denominator estimates for
calculating coverage for antigens recommended at birth (BCG, OPV0) than for antigens given
later in life (pentavalent and measles—3.8% and 3.5% of the total population, respectively) in
order to comply with donor reporting requirements. The study team’s efforts to recalculate
denominators using growth rates derived from the 2007 census were unsuccessful because
census data were unavailable at the time.
To select the study woreda, researchers sorted woredas in descending order of official 2009
vaccination coverage used by Tigray region (based on 2007 census denominators). They
then selected woredas with a consistent year-by-year upward trend of 15%-25% based on
numerator data from 2007 to 2009. Woredas with 2009 coverage greater than 100% or
less than 85%, and those subject to security concerns or located in extremely remote areas
(requiring more than one day by car to reach the site), were excluded. From the three eligible
woredas that remained, the team selected Alage woreda, because it allowed maximum access
to the largest number of health facilities during the fieldwork period.
In Amhara region, only one eligible zone emerged from the application of the selection criteria:
Wag Himra. Applying the same approach to woreda selection as used in Tigray revealed only
one eligible woreda: Sekota Zuria. In Oromia region, woreda-level data were available for only
three of 17 zones. Applying the same approach to woreda selection as above revealed only one
eligible woreda: Toke Kutaye, in West Showa zone. To select the fourth woreda, the steady
woreda, the team reviewed coverage in woredas that were in close proximity to Toke Kutaye
and whose coverage rates had been largely unchanged based on numerator data from 2007 to
2009. Only one eligible woreda emerged, Tikur Incini, and it was contiguous with Toke Kutaye.
All study woredas were located in agrarian areas. Feedback from the FMoH and partners at
the national level regarding the RI coverage scenarios and data quality concerns in each of the
four woredas affirmed that the woredas fell into the specified selection categories: woredas
with recently improved coverage from 2007 to 2009 and a comparison woreda with a steady
coverage for the same period.
STUDY TEAM
A case study approach requires that the team collectively has multiple skill sets, including case
study methodology expertise, qualitative research expertise, immunization expertise, and
29 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
METHODOLOGY
knowledge of local context. The team members in Ethiopia brought significant experience in
conducting qualitative health services research and in RI along with specific understanding of
health service delivery and RI systems in the country.
The international team members were:
– Judith Justice, PhD , team leader
– Jenny Sequeira, JSI/ARISE Ethiopia research manager
– Robin Biellik, PhD, Routine Immunization adviser
The local team was recruited by an Ethiopian firm, JaRco Consulting. Team members were:
– Getu Tarekegn, public health research consultant
– Henok Negussie, public health research consultant
– Edris Seid, public health researcher
– Wubitu Hailu, public health researcher
– Negusu Yifrashewa, researcher
DATA COLLECTION
The team collected data at national, regional, zonal, woreda, health center, health post, and
community levels (Figure 5). In the four study woredas, the team attempted to visit all health
centers and satellite health posts whenever possible. The team adapted open-ended and semistructured interview guides from the ARISE field manual to reflect the Ethiopian context, and
it pretested all data-collection instruments in a peri-urban woreda near Addis Ababa, making
further modifications based on the results. During field work, the team made minor changes in
the instruments to improve the flow of questioning and data recording.
Figure 5. Interviews Conducted by the ARISE Team
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The team used one main interview guide for interviews with central-level stakeholders,
woreda administrators, health managers and supervisors, health staff (doctors, nurses, cold
chain managers, health extension workers), community leaders (in the kebele administration
and other groups), and community members (local groups, volunteers) regarding drivers of RI
improvement. The interview guide included the use of follow-up probes. Suggested question
lines were also created for community health volunteers and mothers.
The team developed separate tools for conducting the RI situation analysis at the national and
woreda levels. In collecting data from documents and administrative records and in conducting
interviews, the team focused on:
1. the history of immunization system development;
2. the current immunization system at the national level and in study woredas;
3. the capacity of the immunization system in study woredas; and
4. immunization system performance data (mainly on coverage) at national, regional/zonal, and
woreda levels.
At the subnational level, the team used one semi-structured questionnaire for the woredalevel RI situation analysis. It focused on performance indicators and descriptions of RI service
delivery capacity and was used to interview the following: the woreda EPI/cold chain officer
or equivalent, the planning and/or maternal and child health (MCH) officer, and the disease
control or surveillance officer, if available. The team also collected information from the head
or deputy head of the woreda health unit. The goal of the situation analysis was not to provide
a comprehensive picture of RI technical capacity. Rather, it aimed at providing sufficient
information about how the RI system was organized and managed and how it delivered
services within the specific woreda (and with reference to the national context) so that the
team would be able to pursue meaningful inquiry about drivers of RI system performance.
The team collected data in February and March of 2011, conducting a total of 104 interviews
or group discussions. It conducted 14 interviews at the central level with representatives of the
FMoH, WHO, UNICEF, and NGOs, among other groups. The team used the results of these
interviews to understand the context of immunization service delivery at the woreda level and
to map central-level perceptions of key RI performance drivers. The remaining interviews (90)
were conducted at the subnational level. In most cases, team members spent three to four
days in the woredas. They followed a field-level data collection process subject to availability
of key informants.
In the fieldwork, one team focused on quantitative data collection for the RI situation analysis,
collected administrative documents, and took photographs of charts and graphs displayed
in health units. Where possible, the team also recorded data on vaccination doses given
at the health-facility level and reviewed service delivery records (e.g., immunization data in
the EPI registers, data graphing, and cold chain status). Another team of two interviewers
conducted key informant interviews with managers, health workers, community respondents,
and representatives of development partners (donors and NGOs), traveling to HCs, health
31 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
METHODOLOGY
posts, administrative offices, and community meeting places. One team member took the role
of principal interviewer and the second served as note taker. As soon after the interview as
possible, the note taker would enter the notes into a Microsoft Word document, which would
be reviewed and modified by the other team members before finalization. When respondents
gave permission, the team members recorded interviews as a memory aid. Consistent with the
ARISE protocol, team members did not construct verbatim transcripts.
At the national level, the team conducted all interviews in English. Interviews conducted at
the subnational level were conducted in English where possible, but were mostly conducted
in local languages, sometimes through an interpreter. The team had five Ethiopian researchers
who were fluent in Amharic, while one spoke Oromian and one spoke Tigranian.
At a workshop held in Addis Ababa in July 2011, the team presented study results to
stakeholders from national and woreda levels, elicited feedback, and verified findings. The
team also conducted additional individual interviews and group exercises at the workshop to
augment the initial data set. Two members of the team then returned to each study woreda
in August 2011 to conduct a second stage of data collection. This second visit included repeat
interviews with some respondents in the woredas and interviews with new respondents at
national and subnational levels.
ANALYSIS
The team conducted its data analysis in several stages in order to identify and test RI drivers.
It used Algae woreda in Tigray region as a full-scale pilot test for the methodology, which
allowed for further adaptation to the local context. During fieldwork in Alage, the team held
daily discussions to refine interview techniques, note-taking procedures, and formatting of
interview notes, as well as to refine the process of data analysis. During this period, the team
formulated and discussed initial theories related to key performance drivers. The process
continued in each subsequent woreda visited.
In all four woredas, the team held two-hour analysis sessions most evenings, where
researchers identified key points of each interview and identified and gradually categorized
performance drivers by theme. Interview recordings and interview notes were logged, and
duplicate files were sent to JSI headquarters. The team later reviewed records of the analysis
meetings in order to advance the analysis process. Between woreda field visits, the team held
analysis meetings where researchers scrutinized notes and began to categorize RI performance
drivers by theme. Once fieldwork was completed, the study team held additional analysis
discussions to further develop theories related to key drivers and subdrivers that influenced RI
performance.
In the next stage of analysis, the researchers conducted a systematic review of the full set of
interview notes using a standard template and integrated interview data with data from the
RI situation analysis. The researchers compared data from the three woredas where coverage
had improved in order to find common or contrasting driver experience, and they examined
data from the steady woreda where coverage had not improved to explore the presence or
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absence of the drivers and to identify obstacles to coverage improvement. At the same time,
the team identified data gaps and constructed a plan for the second phase of fieldwork.
At the stakeholder workshop where preliminary study results were shared with national and
study woreda actors working in EPI, woreda team members from each woreda case study
constructed a chronology of all events or actions at contextual, policy, and program levels to
explore the temporal relationship between context, drivers, and RI performance. Researchers
later integrated these chronologies and data from the second phase of fieldwork into the
data set, along with related information from relevant literature and documentation, and
then analyzed the data using concept mapping, driver coding and data triangulation to reach
conclusions. The researchers constructed a conceptual map of drivers showing the temporal
and logical pathways that created the drivers and how the drivers influenced improved RI
performance. Figure 6 outlines the data collection and analysis process.
Figure 6. Data Collection and Analysis Procedure
33 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
V. WOREDA REPORTS
INTRODUCTION TO THE WOREDAS
The analysis of the ARISE study woredas revealed a range of experience with RI programming.
This section of the report presents background on each woreda, including key contextual and
environmental characteristics, social and demographic data, and details of the RI programs.
By examining the experiences of the three woredas that have seen recent improvements
in immunization coverage, as well as the experience of the woreda that showed little or
no improvement, the analysis begins to draw out key forces and conditions that influenced
coverage improvement—or drivers of change and map the pathways to performance. Section
VI will compare and contrast woreda experience for a comprehensive look at woreda-level RI
performance drivers.
ROUTINE IMMUNIZATION COVERAGE IN STUDY WOREDAS
While initial selection of the woredas was based on data and feedback gathered from nationallevel databases, this section reports coverage data provided by woreda-level respondents (Figure
7). As noted above, the study team found some discrepancies between coverage data reported at
the woreda level and the national level. The discrepancies arose from the fact that some woredas
used their own census data to calculate immunization program denominators (the number of
children under one year of age) rather than the estimates derived from the latest national census.
In the study woredas, there were numerous missing data and numerical discrepancies in the
numerator and denominator data, including unusual trends in total population estimates and,
as a result, in the denominators used to calculate vaccination coverage. The study team was
told that Tigray region used new census data to adjust denominators from 2007 onward,
whereas the other two regions with improved RI performance appeared to follow FMoH
policy and adjusted denominators from 2009 onward. In addition, two of the three woredas
with improving penta3 coverage appeared to meet the selection criteria based on coverage
estimates reported from the national level, whereas local data from Alage woreda in Tigray
region suggested that in fact it had a mixed coverage trend from 2007 to 2009. EPI data quality
is acknowledged to be a continuing concern in Ethiopia, and under its cMYP for 2010-2014, the
country intends to strengthen activities to improve the reporting system in the future (Federal
Ministry of Health of Ethiopia, 2009a).
In the three woredas where coverage improved, penta3 coverage rose to 87% or above in
2009 from percentages in the low to middle 70s in 2006. In the steady woreda, coverage
remained in the mid-60s during that period, only increasing in 2010 to 73%. During fieldwork,
the study team was in some cases able to learn more about the trends in RI coverage over
a longer period than 2007 to 2009 and about some of the challenges health teams faced in
calculating coverage. Some woreda coverage trends are not comparable to national-level
figures because of the use of different denominator estimates, as noted. For example, the
dramatic change in 2007 coverage in all of the study woredas is likely due to the updating of
denominators with new census figures.
34
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The identification and analysis of the drivers of coverage improvement reported below and
in Section VI explain the difference between the woredas where coverage improved and the
woreda where improvement was limited.
Figure 7. Study Woreda and National Penta3 Coverage, 2006-2010
Source: National data from WHO/UNICEF coverage estimates for, as of July 2011 and Woreda data from
Ethiopia administrative report
ALAGE WOREDA, TIGRAY REGION
Background
The study team began woreda-level data collection in Alage woreda in Tigray region. Alage is
one of three study woredas where vaccination coverage improved from 2006–2010. Alage
has a total of 21 kebeles. The health facility located nearest to the regional capital, Mekele, is
approximately a two-hour drive south along the main road. Agriculture is the main economic
activity in Alage. The topography is hilly and road travel can be challenging. Health workers
estimate that up to 40% of villages are inaccessible at some point during the year. The total
population of Alage in 2010 was 116,263.
35 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
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Health service
The Woreda Health
Office suppor ts five
health centers and 14
health posts. Although
some facilities are close to
the main road leading in
and out of Mekele, several
HCs and most health posts
are in remote areas, some
of which are not accessible
by four-wheeled vehicles.
Figure 8 depicts a local map
showing the location of
most health facilities.
Figure 8. Location of Health Facilities in Alage
Woreda, Tigray Region
Woreda methodology
The study team conducted
fieldwork in Mekele and
Alage for four days. In Alage,
the team visited all five HCs
and six health posts. Team
members conducted 32 interviews with representatives of the Regional Health Bureau and
WoHO, woreda administration, HCs and health posts, and NGOs, as well as with members
of the community. The team met three times to debrief during the fieldwork and held a
half-day analysis workshop in Addis Ababa immediately following the field visit. The team
reviewed and verified its findings with woreda-level par ticipants at the stakeholder workshop
in July 2011.
Routine immunization performance
The target population for DTP1 is 4,418 children under one year of age. Penta3 coverage
increased to 89% in 2010 from 75% in 2006, with a peak of 92% in 2007 (see Figure 10 and
Table 2). This spike in coverage may be explained by the region’s use of new census data to
adjust denominators from 2007 onward. From 2008 to 2010, there was a decrease in the
propor tion of children who were “left out”—never reached by immunization services—as
measured by the gap between the target population and those immunized with penta1 (dark
green on the graph in Figure 9). Penta1 data for 2006 and 2007 were not available from the
woreda. The drop-out rate, which measures the percentage of children who received penta1
but did not receive the third dose of pentavalent vaccine (deep purple on the graph), has
remained consistently under 10% for the past three years.
36
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
Figure 9. Penta1 and Penta3 Vaccination Coverage, Alage Woreda, Tigray
Region, 2006-2010
*
Source of population data: National Census.
Table 2. Population Estimates and Pentavalent Coverage for Alage Woreda,
2006-2010
2006
2007
2008
2009
Total population*
130,658
106,184
104,868
116,263
Surviving infants **
4,258
3,461
3,411
4,069
NA
Penta1 coverage
(%) ***
Data
unavailable
Data
unavailable
88%
86%
93%
Penta3 coverage
(%) ***
75%
92%
83%
87%
89%
6%
-1%
4%
Penta1-3 drop-out
(%) ****
*
2010
Source of population data: National Census.
Surviving infants are the number of children who survived to their irst birthday (the target used for all nonbirth EPI doses such as penta1 and 3).
***
Penta1 and penta3 data from woreda administrative reports.
****
[doses penta1 – doses penta3] x100 ÷ doses penta1
**
37 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
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Routine immunization service sites
Vaccination services were offered at both fixed and outreach sites, including HCs (5), health
posts (14), and outreach sites (72). The number of health posts that deliver vaccine increased
to 14 in 2010 from 11 in 2006. The number of outreach sites doubled between 2007 and 2008
and nearly doubled again between 2008 and 2009 (Figure 10).
Human resources for
immunization
The woreda health team includes
a Doreda Health Head, a Deputy
Head/MCH Planning officer, an
EPI officer, a staff member serving
as a data manager/secretary, and
another staff member serving
as a surveillance officer. The EPI
officer is responsible for cold
chain management. Vaccines are
administered by nurses and HEWs.
There were no vacant vaccinator
posts reported in the woreda.
The Woreda Health Head who
coordinates and directs the team
was not medically trained and had
been in the post for two years.
Figure 10. Number of Outreach Sites in
Alage Woreda, Tigray Region, 2006-2010
72
42
21
21
Source: Alage Woreda Health Ofice
In Alage, a network of volunteers
supports the health service and particularly the immunization services. Many of these
volunteers help in community-based nutrition programs. In 2008, these volunteers were each
assigned 30 families to serve. Prior to 2008, there were other groups of volunteers working
with a variety of health programs. These groups included community-based reproductive
health agents, traditional birth attendants, and other groups trained to treat minor illnesses
and malaria. These tasks have now been absorbed into the responsibilities of the volunteers in
community-based nutrition programs. The volunteers perform activities for the EPI as well as
other programs, and they support the kebele’s work to encourage families to become model
families (families that adopt the full complement of HEP health practices. There were a total
of 750 volunteers in the five sub-woredas of Alage. At the time of the study, plans were under
way to roll out the Health Development Army, a new concept for volunteer coordination.
Cold chain and vaccine supply
All five HCs had a functioning cold chain. The study team observed good vaccine-handling
practices at the HCs. Each refrigerator was equipped with a temperature-monitoring chart
that was up to date and showed twice-daily temperature recordings within normal range.
38
72
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
No date-expired vaccine vials or vaccine vials with changed monitors (indicating that vaccine
should be discarded) were observed. All 14 health posts had refrigerators that could run on
either electricity or kerosene. However, most health posts lacked electricity and local staff
were not able to operate the refrigerators using kerosene. The Tigray Regional Health Bureau
has a small staff of five technicians responsible for the maintenance and repair of all health
facility equipment, including cold chain, and three trucks to transport equipment. The officer
in charge reported that he did not have sufficient resources to maintain the cold chain at
the woreda level, and he did not consider it feasible to train HEWs to manage and maintain
kerosene refrigerators.
The study team was not able to examine the woreda stock control register. However,
staff reported that there had been no vaccine stockouts in the past 12 months, which was
confirmed by other respondents. Normally, the woreda sends a vehicle to the Maichew town
satellite cold store (38 kilometers away) to collect vaccines. In 2010 when fuel for the woreda
vehicle was unavailable, the health team borrowed a vehicle from the agriculture service to
make the trip. Vaccines are typically sent to HCs by car or motorbike. In most instances, health
post staff had to collect vaccines from the health centers, walking several hours each way.
Transportation
The woreda health team had the use of one four-wheeled vehicle and five motorbikes. Delays
in releasing funds disrupted fuel supplies for the four-wheeled vehicle for all of 2010 and for
the motorbikes for one month the same year.
EPI policies, strategies, and operations
The woreda has an EPI plan that includes targets, but not specific strategies for reaching them.
These EPI targets were
Figure 11. Wall Chart with 2011 Vaccination Targets,
posted on the wall of the
Alage Woreda Health Office
Woreda Health Office
(Figure 11: Wall Chart
with 2011). Health workers
reported that the majority
of vaccines were delivered
through outreach services
(approximately 60%), and
the frequency and number
of outreach sites had
increased in recent years
(Figure 10). The number of
outreach sites was initially
set at one per kebele
(21) until 2008, when an
additional 21 outreach sites
were established.
39 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
This expansion provided one outreach site per kushet (the lowest administrative unit in
Tigray), doubling the availability of outreach sites. Outreach sites increased again in 2009 to
a total of 72. Recent key events in the development of the RI system in Alage are depicted in
the chronology made in consultation with country stakeholders at the workshop in July 2011
(Figure 12).
Vaccination is offered on a daily basis at the HCs, and on a monthly basis in health posts and
through outreach. Staff reported that in the previous year they had succeeded in holding
all planned vaccination sessions. Activities conducted as part of periodic intensification of
RI efforts, including Child Health Days and ERIAs, are conducted during quarterly nutrition
screenings. Workers review vaccination cards and identify defaulters who have missed routine
doses. Target groups include children less than one year of age and children one year of age
or older.
In 2008, the Reaching Every District approach was introduced in Alage. Health center
heads and supervisors were trained, and they in turn trained HEWs and community health
volunteers. The team developed microplans that expanded HEW activities and increased
community engagement. HEWs and CHVs/health promoters began to register births and
actively trace immunization defaulters starting in 2010. The woreda also introduced routine
supervision of HEWs in 2008. The study team found supervisory reports at health facilities
from the WoHO, regional health offices, and development partners (who introduced a
supervision checklist). Pathfinder, IntraHealth, and WHO provide support for EPI in Alage.
The number of supervisors remained constant over the past three to four years. Respondents
reported that supervision and review meetings are held quarterly.
Driver Pathways to Improved Routine Immunization Coverage
At every interview, the study team explored with respondents their analysis of the most
important factors responsible for the recent improvements in RI performance in the woreda.
They reviewed the timing of interventions and the impetus for and the effect of each driver
mentioned. The team analyzed the rich qualitative data and compared it with the performance
indicators and the RI situation analysis reported above to see if the purported changes in
coverage could be validated and explained. Taking all of the evidence together, the team
reached a consensus that Alage had achieved its high performance mainly through its service
delivery capacity; the effective actions of the new HEW workforce; the remarkable efforts of
communities and local administration who worked in concert with the health teams; and the
regular use of monitoring, incentives, supervision, and accountability. Support from local partners
also played a role in coverage improvement in Alage.
An important aspect of Alage’s success in RI was the solid service delivery system in place in
Tigray. Cold chain was suficiently maintained at the HCs, the numbers of staff were for the
most part adequate (although one HC reported the need for additional nurses), and vaccine
supply was reliable. The Health Extension Program introduced in 2003 also provided a strong
foundation for coverage improvement through increasing the size and focus of the health
workforce and the number of ixed and outreach vaccination sites.
40
Figure 12. Chronology of Events in Alage Woreda, Tigray Region
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
41 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
Beyond capacity and human resources for immunization, however, the work of the health staff
and the strategies they used to make service delivery effective and to improve community
demand for services played perhaps the most critical role in driving RI improvements. For
example, the way in which HEWs worked in the community made immunization efforts
particularly effective. These workers, trained and paid by the government, are typically female,
recruited from the community, and work closely with local volunteers. Key aspects of their
work, such as visiting people in their homes to deliver health education and to encourage use
of health care and trace defaulters, were reported to have had a direct effect on immunization
uptake. Moreover, HEWs’ knowledge of their community enables them to rearrange service
schedules according to the seasonal calendar—they are most active during the agricultural low
season when community members or mothers have more time to pay attention to a HEW’s
message—and to take services into the community on a regular basis. Alage’s recent penta1
and penta3 trends reflect efforts to reduce both left-outs and drop-outs through the work of
the HEWs and community volunteers to trace and vaccinate all children in their woreda.
A second performance driver was the work of communities in promoting and delivering
immunization. Tigray has long-term experience in community organization for social
development. Alage was notable for its extensive volunteer network, with one volunteer
covering five or more households to encourage sound health practices and support other
development activities. HEWs and other members of the health team worked closely with
the local administration to organize services, spread the word about the importance of
immunization, and build local credibility for the immunization and health program.
Finally, the HEWs collaborated closely with kebele leaders to jointly monitor RI program
performance and held regular review meetings to discuss successes and challenges. The
challenges were addressed with a problem-solving mindset. The local administration ranked
health posts, HCs, and woredas based on DTP3/penta3 performance, and this approach
encouraged open accountability and healthy competition. The health workers and the
local political and administrative leaders also introduced the model family concept to
encourage families to achieve the highest levels of task adherence to a wide variety of public
health activities through public recognition and rewards. Performance review and related
accountability and incentives practices extended to the community with the use of a certificate
for a fully vaccinated child given to families whose child completed the vaccination schedule.
TOKE KUTAYE WOREDA, OROMIA REGION
Background
Toke Kutaye was the second woreda visited where immunization coverage had improved.
The woreda was established in January 2006. It contains 31 rural and four urban kebeles.
Major crops include teff, maize, and barley. The Gudar, Colle, Indris, and Kolba rivers flow
through the woreda. Respondents estimated that roughly one-third of the kebeles are
inaccessible by vehicle during some parts of the year. Total population of Toke Kutaye in 2010
was 122,582.
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
Figure 13. Location of Health Facilities in Toke
Kutaye Woreda, Oromia Region
Health service
The Woreda Health Office
supports two HCs and 31
health posts. The HCs were
built in 2008. Between 2006
and 2010, the number of
health posts increased to 31
from 10. Figure 13 is a local
map of the woreda that
shows the location of the
health facilities.
Woreda methodology
The study team stayed in
Ambo, which is the capital
of the West Showa zone
and located three hours by
car from Addis Ababa. Toke
Kutaye is approximately 12
kilometers from Ambo. The
team conducted fieldwork
for four days, visiting both HCs and four of the 31 health posts. The researchers conducted
31 interviews with representatives of the ZHDs and WoHOs, woreda administration, HCs
and health posts, and NGOs, as well as with members of the community. The team met two
times to debrief during the fieldwork, wrote up interviews, and met to discuss woreda findings
in Addis immediately following the field visit. The team reviewed and verified its findings with
woreda-level representatives at the stakeholder workshop in July 2011.
Routine immunization performance
The target population for DTP1/penta1 is 4,339 children under one year of age. Penta3
coverage increased to 94% in 2010 from 78% in 2006, with a dip in 2007 that likely was a
result of the use of new census data to adjust denominators from 2007 onward (see Figure
14 and Table 3). Figure 14 illustrates, in dark green, a decline in recent years in the number of
children who were left out—never reached by immunization services—for penta1. The dropout rate—children who received penta1 but did not receive the third penta dose (noted in
dark purple)—has also declined in the past three years. Health staff linked this reduction in
left-outs and drop-outs to the woreda health team’s efforts to establish a systematic defaulter
tracing system in the woreda, with particular focus on the health post level.
Routine immunization service sites
Vaccination services were offered at all fixed sites, including the two HCs and 31 health posts,
as well as from 62 outreach sites. The team found that a working cold chain was available in
43 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
Figure 14. Penta1 and Penta3 Vaccination Coverage, Toke Kutaye Woreda,
Oromia Region, 2006-2010
*
Source of population data: estimate based on national census.
Table 3. Population Estimates and Pentavalent Coverage for Toke Kutaye
Woreda, 2006-2010
2006
2007
2008
2009
2010
Total population*
119,519
122,980
126,546
123,166
122,582
Surviving infants **
4,422
4,550
4,366
4,064
4,339
Penta1 coverage
(%) ***
84%
74%
93%
99%
95%
Penta3 coverage
(%) ***
78%
65%
84%
95%
94%
Penta1-3 drop-out
(%) ****
7%
12%
10%
4%
1%
*
Source of population data: estimate based on national census.
Surviving infants are the number of children who survived to their irst birthday (the target used for all nonbirth EPI doses such as penta1 and 3).
Penta1 and penta3 data from woreda administrative reports.
****
[doses penta1 – doses penta3] x 100 ÷ doses penta1.
**
***
44
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
both HCs. Only seven of the 31 health posts had a functioning cold chain (either electric or
kerosene). A respondent at the health-post level reported that the cold chain had been out of
order for the past six months.
Human resources for vaccinations
The woreda health team includes a Woreda Health Head, woreda deputy head, an MCH/
Planning offcier, an EPI officer, a data manager, and a surveillance officer. The EPI officer
managed the cold chain. Vaccines are administered by nurses and HEWs. The number of
HEWs increased to 62 in 2010 from six in 2006. However, there were five vacant posts
related to staff qualified to vaccinate. In Toke Kutaye, a network of volunteers supports the
health service and particularly the immunization services. One respondent reported that the
policy aims to assign one health volunteer for every five households. An estimate of the total
number of volunteers working in the health sector was not available.
Cold chain and vaccine supply
All HCs had functioning cold chain. The study team observed good vaccine-handling practices
at the HCs. Each refrigerator was equipped with a temperature-monitoring chart that was
up to date and showed twice-daily temperature recordings within normal range. No dateexpired vaccine vials or vaccine vials with changed monitors (indicating that vaccine should be
discarded) were observed. Staff reported a TT stockout in the past month at the zonal level,
which they said stemmed from a stockout at the regional level. In addition, a batch of OPV
showed exposure to heat the past month and was destroyed. Respondents reported that in
the past UNICEF provided funds for vaccines, but recently the government had assumed this
responsibility. Since then, there have been periodic stockouts.
Transportation
The team found that no four-wheeled vehicles had been assigned to the WoHO or the HCs
since the formation of the Toke Kutaye woreda in 2006. Four motorbikes were assigned to the
woreda; two of them were working and two were in need of repair. Respondents noted that
fuel shortages for the motorbikes had become more frequent. Previously, the local gas stations
allowed workers to purchase fuel on credit, and the woreda would provide funds from the
Extended Outreach Strategy budget. Now that this source of funding is ending, there is no
budget for motorbike fuel, so workers must travel by foot, horse, or donkey, or use their own
resources to secure transport.
EPI policies, strategies, and operations
The woreda has an EPI plan that includes targets, but not specific strategies for reaching them.
Staff estimate that 30% of immunization services are delivered at fixed sites and 70% through
outreach services. Vaccines are available on a daily basis in HCs and once or twice a month
at health posts and outreach sites. The frequency of outreach has increased considerably
since 2006, mainly because the number of outreach sites has nearly doubled (Figure 15). Staff
conduct minicampaigns every three months with a focus on tracing defaulters and immunizing
45 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
them. This strategy was introduced
to reduce drop-out rates. The
woreda conducts monthy supervision
at HCs and weekly supervision visits
at various health posts. The woreda
holds a monthy review meeting for
staff. Health workers and kebele
representatives hold meetings twice
a month. Recent key events in the
development of the RI system in
the woreda are depicted along a
timeline developed in consultation
with country stakeholders at the
workshop in July 2011 (Figure 16).
Driver Pathways to Improved
Routine Immunization Coverage
Figure 15. Number of Outreach sites in Toke
Kutaye Woreda, Oromia Region, 2006-2010
Source: Toke Kutaye Woreda Health Ofice
As in Alage, the study team
analyzed all of the qualitative interview data, observations, and results of the RI situation
analysis to determine the most important factors responsible for the recent improvements
in RI performance in Toke Kotaye. Taking all of the evidence together, the team reached a
consensus that the woreda had improved coverage through many of the same drivers that
emerged in Alage.
Health extension workers were again central to coverage improvement. Respondents
described the wide range of activities that HEWs carried out, including: vaccination at health
posts and through outreach, defaulter tracing, birth registration, and house-to-house visits
for raising awareness and vaccinating. The HEWs work with health facilities or keep their
own records to track the families within their communities and monitor their use of health
services. A HEW in Toke Kutaye explained,
“We give community members an appointment to visit us at our outreach sites. If they
do not show up, we visit their house to deliver vaccination. We carry vaccine carriers with
us on such defaulter tracking house visits. We visit each house to determine immunization
status and if we find an unimmunized child we immunize on the spot.”
Toke Kutaye health staff also testified to the importance of recruiting HEWs locally and
building on these local ties to gain access to community events and meetings and relay
health messages. HEWs in Toke Kutaye developed six-month plans that included such tasks
as conducting health education at church gatherings, training religious leaders to pass on
heath messages, working with micro-credit groups, and attending kebele council meetings
or community meetings of more than 200 people. The HEWs’ use of multiple channels for
reaching the community was a key strategy. A woreda health manager noted: “Prior to 2008,
when HEWs arrived, awareness was very low in the community. HEWs inform the people
46
Figure 16. Chronology of Events in Toke Kutaye Woreda, Oromia Region
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
47 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
about immunization at every chance and visit house-to-house. When there is a social gathering
in the community they use the opportunity to talk to people about immunization.”
In Toke Kutaye, kebele leaders and health supervisors both supported and supervised HEWs.
Supervisors follow up with individual families directly to determine whether the HEWs have
carried out vaccination as planned. Supervisors are expected to visit each health post once
a week; however, the study team could not verify whether these visits took place regularly.
Nevertheless, direct reports from HEWs conirmed the beneits of supervisory practices. HEWs
reported that supervisors provide verbal guidance to help the HEWs deine the right approach
to reaching speciic communities or families with health messages, and supervisors leave written
reports to which they refer during subsequent visits. In addition, the kebele leaders help the
HEWs solve problems related to the organization of community vaccination sessions or the
encouragement of those who are reluctant to vaccinate their children to attend the outreach
sessions. The kebele leaders also meet with the HEWs regularly to plan services and receive
reports of vaccination activities conducted during the week. This style of formalized teamwork
between the health system and the community ensures that the HEWs have a strong network
of support.
Toke Kutaye also employed a transparent and data-driven strategy to motivate health facility
teams and health workers, reward good performance, and promote cross-site learning. Woredalevel review meetings that coincided with the distribution of salaries used coverage-based rating
to compare HCs and kebeles in terms of vaccination coverage or targets reached. Between
regular review meetings and routine supervision, support for and assessment of HEWs was
continuous and deemed helpful by many HEWs. As in Alage, Toke Kutaye promoted peer
exchange and knowledge sharing about best practices and challenges among the well-performing
and poor-performing health posts and HCs, and these activities reportedly fostered an
environment of mutual learning and open competition.
Health workers noted that they received widespread support for RI activities in the woreda,
including from the woreda head who lent them vehicles, community volunteers, members of the
kebele cabinet, model families, women’s groups, youth associations, and leaders of “30-family”
clusters. However, compared with Alage, the volunteer network in Toke Kutaye was less
extensive and less motivated. Health workers reported that volunteers come and go based on
expectations related to inancial incentives that are provided for immunization campaigns, and
they also expressed concern that incentives are not available for routine immunization.
Finally, Toke Kutaye’s immunization activities beneited from the involvement of national and
local-level development partners. WHO provided inancial resources and surveillance oficers;
UNICEF provided support for the cold chain; Pathinder provided technical assistance; and local
NGOs, such as the Toke Mission clinic, provided services directly. The Toke Mission has been
delivering health care in the area since 1989 and is estimated to vaccinate up to 30% of the
children in the woreda annually. Abebech Gobena, a local NGO, also trained and supported
community volunteers and traditional birth attendants and delivered other services.
48
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SEKOTA ZURIA WOREDA, AMHARA REGION
Background
Sekota Zuria was the third woreda visited that had shown recent improvements in RI
coverage. Sekota Zuria is located in the northeastern highlands of Ethiopia, in Amhara region
bordering Tigray. The woreda is 720 and 430 kilometers from Addis Ababa and Bahir Dar
(the capital of the Amhara region), respectively. Amhara region is characterized by rugged
mountains, extensive plateaus, and scattered plains separated by deep gorges, with altitudes
ranging from 600 to 4,600 meters. In Amhara region, about 90% of the population lives in
rural areas and is engaged in agriculture. Approximately, 35% of the 33 kebeles within the
Sekota Zuria are inaccessible at some time of the year, especially during the big rains from June
through October. Total population in Sekota Zuria in 2010 was 142,728.
Figure 17. Location of Health Facilities in Sekota
Zuria Woreda, Amhara Region
Health service
The WoHO suppor ts seven
HCs and 33 health posts.
Since a Health Management
Information Systems
training in December 2010,
the woreda has been
computerizing all of its data
by health post and HC.
Figure 17 provides a local
map depicting the location
of most health facilities.
Woreda methodology
Driving from Addis Ababa
to the woreda takes at
least a full day, so the study
team used the woreda
headquarters as its base
of operations. The team
conducted fieldwork for three days. Researchers visited two HCs and five health posts and
conducted a total of 18 interviews with representatives of the Zonal Health Department and
WoHO, woreda administration, HCs and health posts, and NGOs, as well as with members of
the community. The team met once to debrief during the fieldwork and held a half-day analysis
workshop in Addis Ababa immediately following the field visit. The team reviewed and verified
its findings with woreda-level representatives at the stakeholder workshop in July 2011.
49 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
Routine immunization performance
The target population for penta1 is 4,704 children under one year of age (Table 4). Penta3
coverage increased to 95% in 2010 from 73% in 2007. Figure 18 illustrates (in dark green)
a reduction in recent years in the number of children who were left out for penta1
immunization. The drop-out rate for children reached by penta1 but not penta3 (shown in dark
purple) decreased from 2008 onward and has remained under 10% since then. Respondents
linked this decline in drop-outs to focused efforts to find all children eligible for vaccination and
to trace children who failed to return for a second or third dose of pentavalent vaccine.
Routine immunization service sites
Vaccination services were offered at fixed sites, including seven HCs and 33 health posts, and
through outreach. The number of health posts increased to 33 in 2010 from five in 2006. A
working cold chain was available in six of the HCs and six of the health posts.
Human resources for vaccinations
The woreda health team includes a Woreda Health Head, a deputy head, an MCH/planning
officer, an EPI officer, a nutrition officer, and a surveillance officer. The EPI officer also manages
the cold chain. Vaccines are administered by nurses and HEWs. The number of HEWs
increased from six to 62 between 2006 and 2010. A network of volunteers supports the health
service, particularly the immunization services.
Cold chain and vaccines supply
The six HCs with functioning cold chains used either electric- or kerosene-fueled equipment.
Two health posts had cold chain equipment that had been out of order for six months.
Respondents reported a problem with the wick function and lack of budgetary resources for
making repairs. The woreda store also had a functioning cold chain. Staff reported that the
length of kerosene stockouts for the cold chain varied, but did not exceed two months in total
over the past year. The reason cited for the stockouts was a lack of funds to purchase fuel. The
woreda experienced a three-day shortage of pentavalent vaccine during the year. Otherwise,
vaccine supply was considered reliable.
Transportation
Sekota Zuria had the use of one four-wheeled vehicle and two working motorbikes. Two other
motorcycles were available, but required basic maintenance to function. Little had changed in
transport availability between 2006 and 2010. The WoHO and HC staff reported a three- to
four-month fuel shortage in the past year. The NGO Save the Children/UK provided fuel to fill
this temporary gap.
EPI policies, strategies, and operations
The EPI plan in place has annual planned targets and activities for each kebele. Health workers
reported that the majority of vaccines were delivered through outreach services (more than
50
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
Figure 18. Penta1 and Penta3 Vaccination Coverage, Sekota Zuria Woreda,
Amhara Region, 2007-2010
*
Source of population data: woreda-based census .
Table 4. Population Estimates and Pentavalent Coverage for Sekota Zuria
Woreda, 2007-2010
2007
2008
2009
2010
Total population*
104,108
112,257
137,552
142,728
Surviving infants **
3,545
3,225
4,026
4,704
Penta1 coverage (%) ***
86%
97%
96%
99%
Penta3 coverage (%) ***
73%
86%
93%
95%
Penta1-3 drop-out (%) ****
15%
11%
3%
4%
Coverage data from 2006 were not available.
*
Source of population data: woreda-based census .
**
Surviving infants are the number of children who survived to their irst birthday (the target used for all nonbirth EPI doses such as penta1 and 3).
***
Penta1 and penta3 data from woreda administrative reports.
****
doses penta1 – doses penta3] x100 ÷ doses penta1.
51 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
85%), and that the frequency and number of outreach sites had increased in recent years to
132. Outreach also includes mobile strategies. Health staff discussed the many methods used to
ensure that children were reached through ixed and outreach services, as well as the system of
active defaulter tracking used by HEWs and a network of volunteers. Supportive supervision was
introduced in 2006. Previously, nurses at HCs supervised HEWs, but now one supervisor has
been designated for each health post. Team-based review meetings were conducted quarterly
in 2010, but were not held in 2011 (in the irst quarter) due to a shortage of funding. Recent key
events in the development of the RI system in Sekota Zuria are depicted in the chronology made
in consultation with country stakeholders at the workshop in July 2011 (Figure 19).
Driver Pathways to Improved Routine Immunization Coverage
In Sekota Zuria, the study team synthesized information from administrative records,
observations, group discussions, and interviews to identify the key resources, practices, and other
factors that drove recent RI coverage improvement. As in Alage and Toke Kutaye, vaccination
coverage in Sekota Zuria improved steadily (by 16 percentage points) between 2007 and 2010,
due to several key interventions or practices that worked together to facilitate change.
Respondents conirmed the importance of HEWs in making vaccination services more accessible,
reliable, and acceptable at the community level through regular and frequent interaction with
mothers and community members to promote the use of vaccination. HEWs in Sekota Zuria
used many of the same practices used by their counterparts in Alage and Toke Kutaye, including
defaulter tracing, birth registration, and mobilization and involvement of the community. What
distinguished Sekota Zuria’s experience from the others were the practices used to monitor
performance and reward health workers and community members for their work to promote
immunization. Respondents estimated that 85% of all vaccinations were delivered through
outreach. HEWs provided most of these vaccinations, but they were facilitated by the extensive
network of volunteers and with consistent support from local kebeles. Volunteers reported
that they worked with HEWs to ind children who had not initiated vaccination on time or
had failed to return for their second or third dose. They also helped collect vaccines from HCs
and sensitized the community to the importance of vaccination. Volunteers’ roles were clearly
deined and their participation deemed essential to the success of community-based vaccination.
One management practice that bolstered the work of the community-based teams, improving
vaccination service delivery and use was the introduction of supervision that promotes learning
and rewards the use of strategic and effective practices that tailor services to community needs.
HEWs noted that supervision improved over time with the use of a supervisory checklist and
the practice by supervisors of conducting follow-up from visit to visit to ensure that problems
identiied during previous visits were subsequently addressed. Supervisors not only provided
technical guidance for HEWs; they also promoted joint planning and problem solving among
the kebele members and the HEWs. As ties between kebeles and HEWs strengthened, HEW
credibility in the community grew along with the acceptance of the package of 16 health
interventions that HEWs deliver.
A second effective management practice was the extensive use of public incentives and
52
Figure 19. Chronology of Events in Sekota Zuria Woreda, Amhara Region
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
53 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
rewards to motivate both communities and health workers. Woreda health teams held
competitions among health facilities for meeting vaccination targets. HEWs could receive
rewards, such as tape recorders, that could be used to share prerecorded health messages, or
they were allowed to visit other health posts to share their experience or receive additional
training. At the community level, families that adopted all 16 health interventions were given
a white flag to fly above their homes to recognize them as models in the community. Kebelelevel review meetings to assess the work of HEWs created a sense of ownership over the
health services in the community. The WoHO was recognized by several respondents as
particularly adept at leading the entire health team and encouraging kebeles to focus their
work on improving health services. As in Toke Kutaye and Alage, local development partners
supported the work of the woreda with training, funds, surveillance support, strengthening of
supervision, and planning and monitoring.
TIKUR INCINI WOREDA, OROMIA REGION
Background
Tikur Incini was selected as the woreda with limited change in penta3 coverage from 2006–
2010. The woreda was established in 1996, has an estimated area of 538 square kilometers,
and includes only one urban center, Incini, the woreda capital. Geographically, Tikur Incini
has plateaus, hills, mountains, plains, and valleys. Agalo, Dabale, Mute, and Bajo are the major
mountains located in the woreda. Roughly 68% (13 out of 19) kebeles are inaccessible by
wheeled transport from July to September. Total population in Tikur Incini in 2010
was 107,536.
Health service
The Woreda Health Office
supports two HCs and 13
health posts. There were
also six additional health
posts under construction.
Previously, in 2006, there
had been only three health
posts, including one HC
that had been downgraded
to a health post. Figure 20
depicts a local map with
the location of many of the
health facilities.
Figure 20. Location of Health Facilities in Tikur Incini
Woreda, Oromia Region
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
Woreda methodology
The study team conducted fieldwork in Tikur Incini for two days. Researchers visited one
HC and two health posts and conducted 13 interviews with representatives of the WoHO,
woreda administration, HCs and health posts, and NGOs, as well as with members of the
community. In contrast to the data collection strategy in the other three study woredas,
in Tikur Incini the study team explored whether performance drivers found in Alage, Toke
Kutaye, and Sekota Zuria were present in Tikur Incini, and if present, were working effectively.
The team also explored with interview respondents the barriers to coverage improvement.
The team met once to debrief during the fieldwork and held a half-day analysis workshop in
Addis Ababa immediately following the field visit. The team reviewed and verified its findings
with woreda-level representatives at the stakeholder workshop in July 2011.
Routine immunization performance
The target population for DPT1 is 3,808 children under one year of age. Penta3 coverage was
in the range of 61% from 2006 to 2009, with a dip in 2007 likely due to use of updated census
igures. Coverage then rose to 73% in 2010. Respondents reported that coverage began to
improve only recently, due to steps taken to improve supervision and defaulter tracing. Figure 21
shows a high number of children left out, or never receiving penta1 vaccine (shown in dark green),
a trend that persisted from 2006 to 2010. The drop-out rate fell to 6% in 2010 from 35% in 2007.
Routine immunization service sites
Vaccination services were offered at fixed sites, including two HCs and 13 health posts, as
well as at 55 outreach sites. A working cold chain was available at one HC (electric) and seven
health posts (kerosene).
Human resources for vaccinations
The woreda health team includes a Woreda Health Head, an EPI officer, a nurse, a data
manager, and a disease control officer. The EPI officer managed the cold chain, and the
nurse provided backup; both had been trained in cold chain and vaccine handling practices in
2007. Vaccines are administered by nurses and HEWs. The number of HEWs in the woreda
increased to 39 in 2010 from seven in 2006. No training related to immunization programming
had been done in the woreda in the past five years.
Cold chain and vaccine supply
In general, the supply of electricity was reliable for roughly half of the woreda cold chain. Only
one HC and seven health posts had a functioning cold chain. In the past 12 months, there
had been frequent stockouts of BCG and OPV (e.g., approximately every two months). Staff
reported that when vaccines were provided, the quantity was often insufficient; staff were told
that stockouts emanated from national and regional-level shortages.
55 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
WOREDA REPORTS
Figure 21. Penta1 and Penta3 Vaccination Coverage, Tikur Incini Woreda,
Oromia Region, 2006-2010
Source of population data: National Census
Table 5. Population Estimates and Pentavalent Coverage for Tikur Incini
Woreda, 2006-2010
2006
2007
2008
2009
2010
Total population*
95,127
97,884
103,679
106,685
107,536
Surviving infants **
3,520
3,727
3,577
3,672
3,808
Penta1 coverage (%) ***
67%
62%
76%
70%
78%**
Penta3 coverage (%) ***
61%
41%
62%
66%
73%
Penta1-3 drop-out (%) ****
9%
35%
19%
6%
6%
*
source of population data: National Census
Surviving infants are the number of children who survived to their irst birthday (the target used for all nonbirth EPI doses such as penta1 and 3).
***
Penta1 and penta3 data from woreda administrative reports.
****
doses penta1 – doses penta3] x100 ÷ doses penta1.
**
56
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
Transportation
Tikur Incini had one four-wheeled vehicle at the HC level and no working motorbikes. There
were five motorbikes in need of repair. Respondents reported that they were able to use
immunization campaign funds if required to purchase kerosene or petrol.
EPI policies, strategies, and operations
The woreda has a current EPI plan. Staff report that in the past coverage was better, but
there has been a decline in recent years. They also noted that although the number of health
staff had increased in the past two to three years, financial resources had decreased. Health
workers reported that they were beginning to take steps to address the decline in coverage.
For example, they hold minicampaigns annually, using regular woreda funds, to “catch-up” with
children who had not received any vaccination or had not received the appropriate doses.
Moreover, the Reaching Every District strategy had been initiated in 2009, which included
improved reporting and registration of children and follow-up with defaulters. Respondents
reported that review meetings are also held regularly. Recent key events in the development
of the RI system in Tikur Incini are depicted in the chronology made in consultation with
country stakeholders at the workshop in July 2011 (Figure 22)
Driver Pathways to Improved Routine Immunization Coverage
Tikur Incini woreda, in spite of its stagnant coverage from 2006 to 2009, was making a
strong effort to provide RI services to children. The basic resources required for delivering
immunization were available, including staff, cold chain, and vaccines. The woreda health team
provided outreach vaccination frequently, and the team also worked to raise community
awareness of vaccination and to motivate HEWs with regular review meetings. Nevertheless,
the study team found that many of elements that drove coverage improvement in the other
three study woredas were either very recently instituted in Tikur Incini, present but not
functioning as effectively as in the improving districts, or missing altogether.
In Tikur Incini, there had been a delay in constructing several health posts. Although the
woreda gained a large number of HEWs and doubled the number of outreach sites (Figure
23), many HEWs did not have a base in the community from which to provide services
and where they could live. The woreda health team estimated that 80% of vaccination
was delivered through outreach. However, staff reported that HEWs were traveling long
distances because they lacked a base in the community, which undermined their ability to
provide services routinely and to form strong ties to their communities. Lack of housing in the
community or an allowance to secure housing also negatively affected HEW motivation and
in some cases delayed the assignment of HEWs to some communities. Indeed, respondents
reported that HEWs had not built up trust between themselves and the community, and
community awareness and acceptance of vaccination was lacking in some areas.
The study team also learned that there was limited collaboration between the woreda health
team and the woreda administration, and this situation restricted the health team’s ability
to secure resources in a timely way or to engage the local administration in health activities.
57 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
Figure 22. Chronology of Events in Tikur Incini Woreda, Oromia Region
WOREDA REPORTS
58
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
Respondents also reported that volunteer activity had waned because the NGO that once had
provided incentives to volunteers for working on immunization campaigns had left the area.
Finally, although health staff reported to the study team that they conducted review meetings
and regularly used data to assess progress in their program, they did not raise the issue of low
coverage rates for DTP1 coverage and the need to focus on children who had never initiated
vaccination. It appears that Tikur Incini woreda was not able to benefit in the same way as the
other study woredas from increased access to services delivery sites, increased numbers of
HEWs under the HEP, and regular performance review practices.
Unlike in previous years, Tikur Incini
showed a marked improvement in
penta3 coverage from 2009 to 2010,
and this provided the study team
an opportunity to explore both
coverage stagnation and coverage
improvement in one woreda.
Health staff explained that they
had taken several steps recently to
address the lack of improvement
in the immunization program. For
example, the health team stepped up
supervision frequency and improved
the practice of supervision with the
use of a checklist. In addition, in 2009
HEWs began to conduct defaulter
tracing. The health managers linked
Source: Tikur Incini Woreda Health Ofice
the decline in the drop-out rate,
which fell to 6% in 2010 from 35%
in 2007, to the practice of regularly
locating and vaccinating children who had failed to complete the vaccination schedule.
Although respondents did not link these newly instituted practices of supervision and defaulter
tracing to RED, they did note that RED was initiated in 2009 through training.
Figure 23. Number of Outreach Sites in
Tikur Incini Woreda, Oromia Region,
2004-2010
59 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
DRIVERS OF ROUTINE IMMUNIZATION PERFORMANCE AT THE WOREDA LEVEL IN ETHIOPIA
VI. DRIVERS OF ROUTINE IMMUNIZATION PERFORMANCE AT THE
WOREDA LEVEL IN ETHIOPIA
FRAMING RI PERFORMANCE IMPROVEMENT
The expected outcome of a national or woredalevel routine immunization system—improved
penta3 coverage, in the case of this study—depends
on the context in which RI services are delivered,
the availability of essential program inputs, and the
presence of key performance improvement drivers.
Figure 24 depicts a framework that describes the
performance improvement pathway. Although the type
of pathway depicted is, in practice, rarely perfectly
linear, the diagram is useful for mapping broad steps
on the way to improved coverage. It also helps guide
policymakers and program managers in deining areas
of potential intervention for improving RI coverage.
Figure 24. Elements of
the Pathway to Routine
Immunization Performance
The following section outlines the key factors inluencing
RI performance in the study woredas. The narrative
integrates indings on the RI systems and the ive
drivers of change found to contribute to RI coverage
improvement in the case study woredas. It also reports
aspects of the national and local context that supported
coverage improvement. To qualify as a driver, a policy,
resource, action, or process had to be present in some form in the woredas that had experienced
recent gains in immunization coverage and to be absent or weak in the steady coverage woreda.
In addition, key informants must have identiied the importance of the driver, and the driver had
to have a logical link to improved coverage by either improving the supply or use of immunization
services during the period under study. Some drivers directly affect how services are delivered in
communities, while other drivers act through district health service management practices that
motivate health workers and engage the community, enabling improved access and use.
The drivers identiied in this study are not meant to represent a comprehensive list of what
is required for a successful RI program. Instead, they are drivers of the positive change that
occurred in the case study woredas in recent years. Inputs or processes that did not drive recent
improvement are not included, even though such factors may be key drivers in other districts or
different countries.
NATIONAL AND SUBNATIONAL CONTEXT OF RI PERFORMANCE IMPROVEMENT
The context in which RI is delivered influences the effectiveness of the service and may be as
important as any strategy chosen to improve coverage (Sovoronos & Mate, 2011). In Pawson
and Tilley’s realistic evaluation framework, the context is described as an organization’s
60
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
“existing reality” that needs to be factored into strategic planning, as well as analyses meant
to shed light on the outcome of an intervention (Pawson & Tilley, 1997). In Ethiopia, several
RI contextual factors created conditions that were found to support the introduction and
effective implementation of performance drivers. These factors include:
– political commitment, both current and historical, to RI;
– ongoing efforts to strengthen community structures; and
– transparent and data-based accountability for improving health outcomes.
Political commitment
Historically, and during the study period, leaders in the government of Ethiopia demonstrated high
level political commitment to improving RI services and immunization coverage. They expressed
their commitment in terms of policies, funding for immunization and primary health care (Federal
Ministry of Health of Ethiopia, 2005) and adoption of speciic strategies (e.g., RED and ERIA)
in response to reports of large numbers of unvaccinated children in many parts of the country.
In addition, the prime minister paid consistent attention to the national immunization program.
However, some respondents cited the government’s reluctance to appoint a single national EPI
program manager as a lingering gap in its political commitment to EPI.
In 2003, prior to the study period, Ethiopia introduced a new program that prioritized health
as a part of national development: the Health Extension Program. Although the government
had promoted childhood immunization for many years under the Health Sector Development
Programs,14 the introduction and rapid expansion of the HEP marked a period of intense
investment in basic health services that set the stage for the success of RI in the study woredas.
Both the content of the HEP and, more critically, the way it has been implemented at the woreda
level have improved RI performance.
The HEP’s main focus has been on improving access to health services in rural areas, by expanding
infrastructure (Health Centers and health posts) and increasing the size and skills of the health
workforce, particularly at the community level. It introduced a cadre of government-paid,
community-based, and community-focused health extension workers whose job is to deliver a
package of 16 essential health services, and it created positions for coordination and supervision
of the HEWs. The country’s serious and sustained investment in the HEP yielded remarkable
progress in increasing both geographical and social access to health care (mainly preventive,
though curative care is also part of the service package), and this trend created positive conditions
for immunization coverage improvement between 2006 and 2010 in the study woredas.15 The
majority of respondents interviewed by the study team said that they viewed the HEP as a
14 The third Health Sector Development Plan in particular afirmed government commitment to improving rural access to care and
strengthening health services.
15 The HEP is characterized by consistent and focused push by government to increase access to health services at the community
level. It increased numbers and skills of the health workforce, particularly at community level; introduced positions for coordination and supervision of HEWs; introduced a package of 16 essential health services; and made resources available to expand the
health infrastructure alongside the health workforce. The majority of respondents viewed the HEP as a positive inluence on coverage improvement, because it channeled support for immunization from the national level to lower levels and gave prominence
to immunization as part of the HEP package at the community level.
61 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
DRIVERS OF ROUTINE IMMUNIZATION PERFORMANCE AT THE WOREDA LEVEL IN ETHIOPIA
positive inluence on coverage because it channeled support for immunization from the national
level to lower levels and gave prominence to immunization services as part of the communitylevel HEP package.
Strengthening community structures
The HEP also proved vital in driving efforts to strengthen community structures, including the
networks of community-level volunteers, and to support their links to health service activity. Under
the HEP, it is expected that local government (kebele administrations) and local volunteers will
be actively involved in health and development activities, including immunization. In addition, the
program promotes the extensive use of community volunteers who work closely with the kebele
administration and the HEWs to organize services, deliver care, educate and encourage mothers
to immunize their children, and track immunization defaulters. A new approach to organizing
volunteers was emerging during the study period, deined in various ways, including “the women’s
development army,” relecting the fact that most of the volunteers are expected to be female.
Transparent and data-based accountability for improving health
The strong emphasis placed on measuring and openly reporting on progress related to health
care, including immunization, proved valuable in a number of ways. Nationally, the Ethiopian
government’s use of business process reengineering (Debela, 2009) promoted the streamlining
of performance measurement and encouraged administrative ofices at all levels to pay closer
attention to indicators relating to the Millennium Development Goals and to health. The
government has also emphasized improving the public sector’s accountability and performance.
At the woreda level, health and local government institutions and community actors are held
accountable for achieving health targets. Penta3 coverage by woreda, zone, and region is one of
several indicators reported up the administrative chain of Ethiopia’s political and health systems.
It is used to stimulate competition and motivate health managers and government administrators.
Respondents interviewed by the study team reported having received feedback from as high
as the prime minister’s ofice when coverage levels fell below expectations. The model family
initiative, which rewards families that have adopted all 16 services delivered under the HEP and
holds them up as examples for others, illustrates the use of accountability and incentives at the
community level.
Overall, the implementation of the HEP illustrates a strong expression of political commitment to
health that provided an important foundation on which three of the study woredas (Alage, Sekota
Zuria, and Toke Kutaye) were able to increase immunization coverage.
ESSENTIAL IMMUNIZATION INPUTS
To improve immunization coverage, a woreda-level immunization system requires an essential
set of program inputs that enables the health team to reliably deliver good-quality immunization
services. In Ethiopia, these inputs are mainly funded by national and regional entities with support
from development partners, and they rely on centrally managed systems, including the vaccine
supply chain and workforce planning and deployment. Through the woreda RI situation analyses,
the study team assessed the basic capacity of each woreda to deliver immunization services,
62
A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
focused on the period from 2006 through 2010, based in terms of the availability of these
essential inputs, and explored the relationship among this basic delivery capacity, RI performance
drivers, and improvement in coverage. The team collected data on the reliability and adequacy of
cold chain equipment and management; vaccine supply; the health workforce for immunization;
transportation assets, such as vehicles and motorbikes; and immunization service delivery
sites. The availability of quantitative data for tracking these essential immunization inputs over
time varied in each woreda. Thus, the team augmented the record review on service capacity
with interview responses and observations of service delivery.16 Individual woreda reports are
presented in Section V.
Vaccine supply chain, including the cold chain, is a key component of the health infrastructure.
In Ethiopia, the government and various donors have worked to improve supply chain reliability.
Investments have been made in equipment (e.g., refrigerators), supplies (auto-destruct syringes),
operating costs (budgetary resources for kerosene for refrigerators and petrol for vehicles),
and training to ensure cold chain functioning and maintenance. The most frequently mentioned
challenges to vaccine supply at every level related to transportation, including vehicle shortages and
gaps in funding for maintenance and fuel. Distribution of vaccines from centralized woreda facilities
to HCs, health posts, and outreach sites was sometimes problematic in all four woredas, mainly
because of periodic transport shortages and dificult road conditions. In addition, although HEWs
appreciated having a refrigerator in their health post—which offered the possibility of increasing
vaccine availability and reducing travel time required to collect vaccines for outreach (often two to
three hours walking in each direction)—many health posts lacked kerosene to run the refrigerators.
Thus HEWs and volunteers often walked from facility to facility to secure vaccine.
In spite of these gaps in the supply chain and transportation resources, respondents from all
four woredas reported that there were very few vaccine shortages or cold chain problems
that disrupted vaccination activities during the study period. When vaccine supply or cold chain
problems arose, the health team was able to address the problem by moving vaccines to adequate
cold storage or inding alternative transportation, such as borrowing a vehicle to collect vaccines,
using public transport, or walking.
With respect to human resources, key positions in the woreda health teams were illed. In
addition, all four woredas experienced a marked increase in size of the community-level health
workforce under the HEP. From 2006 to 2010, in two of the three woredas where coverage
improved, the number of HEWs increased tenfold. Alongside this boom in the health workforce,
each woreda gained health posts (ranging from three to 28) and experienced large increases
in the number of outreach vaccination sites. The increases in the number of health posts and
outreach sites were less dramatic in the steady woreda than in the improving woredas. However,
in most cases, the availability of essential inputs for RI did not differ greatly among the four
woredas. Table 6 compares several characteristics, including basic EPI capacity, of the woredas.
16 The situation analysis was not intended to provide a comprehensive picture of RI technical capacity. Rather it aimed to obtain
suficient information about how the routine immunization system was organized, managed, and how it delivered services within
the context of a given woreda (and with reference to the national context) to be able to pursue meaningful inquiry about drivers
of routine immunization system performance.
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Table 6. Characteristics of the Four Study Woredas and their Routine
Immunization Systems
WOREDA
ALAGE
TOKE
KUTAYE
SEKOTA
ZURIA
TIKUR
INCINI
Region
Tigray
Oromia
Amhara
Oromia
116,263
(2009)
122,582
(2010)
142,728
(2010)
107,536
(2010)
Rural
Rural/semiurban
Rural
Rural
Penta3 coverage rates in 2006 and 2009
75%; 87%
78%; 95%
73%**; 93%
61%; 66%
Dropout rates between penta1 and penta3
in 2006 and 2009
6%*; -1%
7%; 4%
15%**; 3%
9%; 6%
Number of health posts in 2006 and 2010
11; 14
10; 31
5; 33
3; 7
1: 8,304
1: 3,954
1: 4,325
1:15,360
Number of outreach sites for vaccination in
2006 and 2010
21; 72
38; 62
Unknown;
132
22; 55
Ratio of outreach sites to population, 2010
1:1,614
1: 1,977
1: 1,081
1:1,955
60%
70%
85%
80%
Number of 4-wheeled and 2-wheeled
working vehicles, 2010
6
2
3
1
Number of health extension workers
(HEWs) in 2006 and 2010
22; 35
6; 62
5; 64
7; 39
Ratio of HEW to population, 2010
1:3,321
1: 1,977
1: 2,230
1: 2,757
5
9
12
8
Population size
Characteristics of settlement
Ratio of health post to population, 2010
Estimated share of vaccines delivered by
outreach, 2010
Number of working refrigerators at health
care facilities, 2010
*
2008 data; **2007 data
WHO/UNICEF coverage estimates for 1980-2010, as of July 2011. Please note that WHO/UNICEF coverage estimates were updated in July 2012.
However, all national level coverage estimates used in this report are based on data reported by UNICEF/WHO in 2010 and 2011.
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WOREDA-LEVEL DRIVERS OF ROUTINE IMMUNIZATION PERFORMANCE
IMPROVEMENT
Respondents at the national and woreda levels cited the availability of essential immunization
inputs as an important contributor to improved coverage. However, the presence or absence
of resources and infrastructure only partly explains the differences in outcomes between the
woredas where coverage improved and the steady woreda. By comparing and synthesizing the
woredas’ experiences, the study team identified five common practices or innovative steps
that drove positive change in immunization coverage. These drivers of the performance of RI
systems were:
– locally recruited and supported HEWs,
– active community participation in RI and health,
– partnership between the woreda health team and the local government (woreda and
kebele) administrations,
– focus on accountability and performance monitoring, and
– suppor t from development partners.
This section of the report synthesizes and compares woreda experience on RI performance
drivers to address the following questions:
– What are the specific practices or processes that lead to improved RI performance?
– In which contexts are the practices most likely to be adopted?
– What factors affect the implementation of the practices?
Locally Recruited and Supported Health Extension Workers
Health extension workers were central to improvements in RI coverage. In the woredas
where coverage increased, respondents identified the HEWs more frequently than any
other factor as the primary force of change. Several recent surveys have also reported a
link between RI coverage improvement and the presence of HEWs at woreda level (Karim,
2011). These workers contribute directly to improved immunization coverage by delivering
immunization services and health messages in the community on a regular basis. Before the
HEWs were placed at health posts, outreach for immunization was conducted less frequently
in some woredas from fixed health centers by health assistants or nurses. The dramatic
growth in the size and reach of the community-focused health workforce not only increased
geographic access to immunization services; it also established HEWs as focal points in their
communities for health generally and immunization specifically. Once the HEWs arrived, a
respondent from Alage reported, “….everything changed straight away. Immunization became
their responsibility.”
HEWs provide immunization at established and newly constructed health posts and through
outreach vaccination and by making house-to-house visits. During home visits and in many
different settings in the community, the HEWs were reported to educate and inspire mothers
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to seek out vaccination for their children. Through their work
organizing vaccination sessions and raising awareness, HEWs in
the three woredas where coverage improved built trust and
rapport, which encouraged the use of immunization and other
primary health services (Bill & Melinda Gates Foundation, 2010).
The HEWs also established partnerships with community leaders
and volunteers, employing mechanisms such as registration of
newborns and immunization defaulter tracing to increase the
likelihood of mothers initiating immunization and completing it
on schedule. The drop-out rate between penta1 and penta3, for
example, declined considerably between 2006 and 2010 in two of
the woredas where coverage improved.
Several characteristics of their job enable HEWs to be effective in
community-focused health care. First, many HEWs are recruited
from the local area and are based in the community. Second, most of
them are women, and health workers interviewed by the study team
reported that their gender helps them develop close relationships
with other women and gain trust in the community. As one health
worker said: “An important factor in influencing immunization is the
fact that the HEW is a woman. It has a positive influence on MCH
activities. They have a good approach and women tell the HEWs
their personal problems. It helps with encouraging immunization and
family planning, and with other things. The HEW as a woman has a
better outcome in terms of sensitization.”
“When the HEWs arrived
they came with their
job description about
immunization and other
activities and everything
changed straight away.
Immunization became
their responsibility.”
Alage respondent
“In a typical week, HEWs
often walk several hours
each day to visit families in
the villages, in addition to
providing services at the
health post.”
Health worker
Clearly, the presence of HEWs does not always guarantee success. In
the woreda with steady coverage, the dropout trend shows a decline
that started somewhat later than in the other woredas, leaving a large share of children (25%)
unreached by immunization, even by one dose of pentavalent vaccine. The lack of parallel
improvement in the steady woreda despite HEW involvement can be traced to three factors.
First, in the steady woreda, many planned HCs and health posts had not yet been constructed
by 2010. The HEWs therefore moved in and out of the community to provide outreach
services, but unlike their counterparts in the other three woredas, they had no base to live and
work. Second, some HEWs were not recruited locally and were therefore reported to be less
effective. Toke Kutaye woreda learned this lesson early, and in its second HEW recruitment
drive, the woreda hired many local women. Finally, the relationships between the HEWs and
the local administration were not as strong as those in the other woredas. The experience of
Tikur Incini woreda suggests that while HEWs are important for RI success, their effectiveness
in driving improvement in coverage depends on several other factors. For example, the
HEW’s role was found to work best when she had support from the kebele administration,
worked closely with the network of community volunteers, and was regularly supported and
supervised by the health center or woreda health office. These complementary drivers are
discussed below.
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Box 1: Locally Recruited and Supported Health
Extension Workers
HEWs are trained, paid, locally recruited female workers
supported by community-based volunteers and development
committees to implement the Health Extension Program that
includes a package of 16 health services, including vaccination.
HEWs conduct house-to-house visits to create awareness about
the benefits of vaccination and mobilize the community to attend
vaccination clinics and outreach sessions. HEWs, communitybased volunteers, and development committees together register
children for vaccination and track vaccination defaulters who fail
to return to complete all vaccinations. The HEWs collaborate
closely with kebele leaders to jointly monitor program
performance through regular review meetings and to discuss the
challenges to improving vaccination coverage.
The placement of locally recruited health workers has
brought immunization services closer to the community; built
a relationship between the community, local administration,
and the health system; improved awareness of the value of
immunization; and increased uptake of immunization services.
“The community mobilization
and the work with the kebele
administrations have increased
in the last two years and
coverage has improved.”
Woreda level respondent
“Assignment of HEWs who
are recruited from the
community at grassroots level
and within the community
holds the lion share for
increasing vaccination
coverage among others
who are recruited from the
community.”
Sekota Zuria woreda
Active Community Participation in Routine Immunization and Health
From the local government (woreda and kebele administrations) to local networks of
volunteers, teachers, and religious leaders, the community’s role in making immunization
services effective and acceptable was undisputed in Alage, Sekota Zuria, and Toke Kutaye.
In these woredas where coverage improved, the HEWs and the community formed a solid
team that committed time and human and material resources to raising awareness of health
needs and interventions, organizing outreach vaccination, and setting high expectations in the
community for meeting health service targets.
Community structures are well defined in Ethiopia. The study team found that volunteers
are organized under a variety of structures. The most common is a local structure consisting
of 30 families, subdivided into six groups of five families, each having one volunteer leader.
In some woredas, these volunteers were known as development or work groups; in Tigray,
this structure was referred to as the “network” or “networking.” The volunteer leaders are
trained on a range of development issues, including health, and are expected to take this
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information back to families in each subgroup. Interviewees in Tigray also described a women’s
development group, referred to as an “army of women,” who volunteer for house-to-house
visits during which they validate that all eligible infants are up to date with vaccinations, and
carry out other supportive functions.
Other organizations, such as women’s affairs groups, women’s associations, and youth
associations, were described as working together with HEWs and community health
volunteers. As one respondent told the study team, “The presence of community
volunteer health workers is another factor contributing to high vaccination coverage.” Some
community volunteers help by collecting vaccines for outreach clinics and kerosene to power
refrigerators, and by tracking individuals who fail to return for second and third doses of
vaccine (“defaulters”). In the woreda where coverage remained steady, the overall number of
volunteers was low, many volunteer roles were unclear, volunteers complained that incentives
given during campaigns and by NGOs were not available for routine services, and few
volunteers were involved in tracing defaulters.
Partnership Between Health and Government Administration
An important positive force for improved RI performance in the three improving woredas
was a strong working relationship between the health and the administrative arms of the
government. The impetus for partnering came partly from the national level, where the
prime minister encouraged health-sector reform and supported the FMoH in implementing
the HEP. The study team also noted the same interplay between the administrative and
health departments at regional, woreda, and kebele levels. This type of coordination and
collaboration between administrative and health offices and workers distinguished the
three woredas where coverage improved from the woreda where coverage was steady.
Administrative and health offices worked closely together in annual planning. Kebele heads
often supervised the HEWs and helped to raise the profile of health and health workers in
the community. They met frequently with HEWs to review the HEW’s short- and long-term
work plans and assess performance as part of oversight and evaluation. In these woredas,
the local government also shared its resources to support health activities—for example, by
lending vehicles for the transport of vaccines and supervisors. Moreover, every kebele member
interviewed was well informed about immunization activities.
The study team heard from many respondents that they viewed the interpersonal relationships
between the woreda administration and woreda health office as critical for the improved
performance of the health system in general and, by extension, of immunization efforts. At the
local administrative level a kebele manager noted: “We meet with HEWs every week and we
raise different immunization and other health related issues, discuss them and solve problems
encountered as per our capacity.” HEWs confirmed the importance of kebele support. One
HEW stated: “The woreda health office and kebele leaders also urge the community to trust
us and listen to our message. This increases our credibility within the community.” Another
HEW stated, “The community mobilization and the work with kebele administration have
increased in the last two years and coverage has improved.” Enhanced coordination also
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Box 2: Strong Partnership Between Health Workers
and the Woreda and Kebele Ofices
Kebele in Amharic means “neighborhood.” The kebele is the smallest
administrative unit of local government. Each kebele cabinet has a
manager and eight members, including a chair and community leaders.
The senior of the two HEWs assigned to a kebele is also a member of
the kebele cabinet.
The woreda and kebele leaders work closely with the HEWs and
the community to achieve their immunization targets, collaborating
on planning, community mobilization, implementation, performance
monitoring, defaulter tracking, and problem solving. The woreda and
kebele leaders also lend credibility to the health workers by promoting
their work within the community. The kebele leaders and the woreda
health ofices coordinate their supervisory visits to the health facilities;
the entire process is organized and integrated. The HEWs value the
supervision because they see it as a learning opportunity. The woreda
also supports the HEWs by providing transport, such as cars or bikes,
when outreach sessions are scheduled.
This integrated, organized approach motivates the health workers to
perform their duties because they are recognized as key implementers
of the health plan they were involved in shaping
Essential elements of the HEW and administration partnership
model include:
• Health extension workers appreciate the supportive
supervision with its orientation toward problem solving.
• The community recognizes the importance being placed
on the health workers’ activities by the woreda and kebele
leaders and responds accordingly by providing volunteers
and attending the ixed site and outreach sessions.
• The good working relationship between the woreda
administration and kebele leaders leads to a coordinated
response to request for resources for immunization.
• The commitment to a harmonized approach to health is illustrated
by the presence of the HEW on the kebele cabinet, where the HEW
reports on the program activities and discusses strategies for improvement.
69 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
“There is a framework
between the woreda
admin and health ofice
to carry out immunization
activities in a transparent
and planned manner and
based on the agreed share of
responsibilities.”
Toke Kutaye woreda
“Supervision is done in an
integrated and coordinated
manner. The woreda
health ofice and woreda
administration ofice work
together in integrated and
coordinated way. They go
out together and assess the
progress of the activities.”
“The kebele administration
organizes the community
and helps us call people for
meetings. They are inluential
and help us to gather people
whenever we need them.”
Sekota Zuria woreda
DRIVERS OF ROUTINE IMMUNIZATION PERFORMANCE AT THE WOREDA LEVEL IN ETHIOPIA
stimulated greater participation of other community members, including religious leaders and
school personnel, and enabled the health teams to secure additional resources to fill gaps in
the health budget. For example, the health and woreda administration might share vehicles to
ensure that vaccines are transported to the health posts.
Focus on Accountability and Performance Monitoring
This driver represents a group of actions or mechanisms by which the
program manager and health staff routinely employ data to monitor
program performance. The steps are taken to ensure accountability
“We get encouragement
from all stakeholders, recognize achievement, promote learning, and
focus stakeholders on a common goal. A sharp focus on accountability
and advice [at review
and improving the performance of the RI system was woven into the
meetings] and continuous
partnership between the HEWs and the local administration in all study
follow-up. The monthly
woredas. At the woreda and community level, program performance
review meetings help us
review takes the form of quarterly meetings of woreda health and
to strengthen our skills.”
administrative staff and regular supervision. At the community level,
Health worker
HEWs, kebele representatives, and community members meet to
review progress and trace defaulters, guided by reports of children who
are behind in their vaccinations or who have not been vaccinated at
all. Ranking health facilities and woredas based on coverage and other
indicators is also common. In addition to ensuring accountability, these practices are used to
recognize achievement, promote learning, and focus stakeholders on a common goal. Data on
immunization coverage is deemed “data for action” that focuses volunteers, health workers,
and local government representatives on areas where targets are being met and areas where
progress is lacking.
What makes these simple management tasks effective are their regularity and the managers’
commitment to following up reports with specific actions to rectify poor performance, the
peer learning approach, public recognition of achievement, and the centrality of data. Several
examples are discussed below.
Supervision
Supervision varied across all woredas in terms of frequency, level of training of supervisors,
location of the supervisor, and use of supervisory tools, such as checklists. However, several
common practices emerged in the woredas where coverage improved. In each of them,
woreda staff planned to conduct supervision on a quarterly basis, and they reported to the
study team that they had carried out the majority of planned visits. The study team confirmed
that supervisors conducted visits because they left notes and suggestions for the staff. More
critically, supervisors and respondents reported that supervision visits not only involved a
review of performance; they also involved the introduction of problem-solving approaches
and the setting of new objectives for the coming quarter. Health workers told the team
that they greatly appreciated the follow-up from supervisors from one visit to the next and
the constructive support for addressing obstacles to achieving service delivery goals. Some
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aspects of supervision in Tikur Incini, the woreda with steady coverage, were clearly different.
Supervision visits were frequently canceled due to budget shortfalls. In addition, supervisors
did not begin using a checklist until 2011.
Supervisors also collect examples of effective HEW practices and innovative community
strategies and share them with fellow workers at team meetings and during regular rounds
of supervision. The workers reported a direct benefit from this peer-learning approach and
from the public recognition of achievement, which they said motivated them and gave them
credibility in their communities. The HEWs reported that supervisors encouraged the use of
local data to guide immunization activities and strategies. Supervisors, through their work with
HEWs, learned how HEWs met their targets and then shared this knowledge with others. An
HEW reported that at health center review meetings, the “stronger HEWs help to give advice
and share ideas with others.”
Review meetings
Regular team meetings are held at different levels of the system to review performance, share
experience, and solve problems. At regional and zonal levels, respondents reported that
they held quarterly meetings with woredas to review work using a standard set of indicators.
Vaccination coverage for penta3, BCG, and sometimes measles are included on the list of
performance markers. Each woreda reviews progress during the past quarter and develops an
action plan for the coming quarter. The region then ranks the woredas on past performance,
and some woreda representatives present their statistics and their plan. The study team found
that this type of data-driven performance review occurred at various levels of the system. For
immunization, woreda staff use the data from monthly reports (usually penta3 coverage and
drop-out rates) and supervision visits (usually planned versus conducted activities) as the basis
of their reports.
On the community side, review meetings occurred at varied times and frequency across the
three improving woredas. One woreda repeatedly cited weekly meetings at the kebele level
where discussions focused on what was achieved with respect to immunization sessions versus
what was planned. Since the HEW is part of the kebele cabinet, the kebele management
meetings were also named as an important avenue for highlighting achievements and gaps in
health, including immunization.
Woreda and health staff reported that they conduct monthly review meetings at health
facilities that are often scheduled to coincide with when HEWs come to collect their
monthly salaries. During these meetings, they discuss the achievements of health facilities
and the problems faced by poor performers. The meeting engenders healthy competition
since expectations ar ound performance are high. However, these meetings are also used
to exchange information and experience, discuss progress and challenges faced, and explore
strategies for overcoming obstacles. Respondents reported that HEWs and supervisors who
have performed well are asked to explain how they managed to achieve high performance.
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Box 3: Promoting Accountability Through Regular
Review Meetings and Supervision Using Data
The health extension workers and the kebele leaders work
closely to monitor performance, as measured by DTP3/penta3
coverage. The kebele leaders set clear monthly performance
targets, which are reviewed during their monthly or quarterly
meetings with subdistricts or facilities. Facilities that perform well
are publicly recognized and praised. Staff at poor-performing
facilities discuss their challenges with supervisors with a problemsolving mindset. The regular review meetings also serve as
platforms for the exchange of knowledge and information about
best practices and challenges between well-performing and poorperforming health facilities, and such exchanges often foster an
environment of mutual learning and healthy competition.
The regularly scheduled performance review meetings hold
the health workers, the local administration, and the network
of community volunteers accountable for achieving their target
vaccination coverage. Consequently, data on births, catchment
areas, vaccination targets, and defaulters are carefully monitored
to inform decisions on service delivery and community
mobilization. The public recognition of good performance as an
incentive serves to motivate the health workers in their work,
and HEWs often respond by working hard to improve access
to services.
“There have also been visits
of the lower ranked health
posts to see how the higher
ranked health posts work.
This helps not only to discuss
what the good health posts
are doing, but to see what
they are doing too.
There are lots of
opportunities at the quarterly
review meetings for HEWs
to discuss how they do
their work, so that others
learn. For example, the top
three health posts not only
discussed their practices, but
also had health posts in the
same catchment area visit
them, and then later health
posts from other catchment
areas visited them.”
Alage woreda
Support from Development Partners
Development partners contribute to improving RI performance at all levels of the system.
However, the study team concluded that development partners acted more as enablers
than direct drivers of improvement in RI system performance. Major international agencies,
such as the World Health Organization, the United Nations Children’s Fund, and the Global
Alliance for Vaccines and Immunization, historically have made substantial contributions to
the National Immunization Program in Ethiopia and continued their assistance between 2006
and 2010. Among their contributions, the groups provided guidance on policy and technical
issues; support for EPI posts, training, EPI surveys, and rapid assessments; and support for
the development of ERIA guidelines. From the woreda perspective, however, respondents
were more likely to link improvements in RI coverage with the contribution of NGOs than to
major funders or advisers. In the three woredas where coverage improved, NGOs provided
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equipment, training, fuel, vehicles, and technical assistance. They also helped to build capacity
by providing training on all 16 HEP interventions to woreda health administrators, health care
providers, and HEWs. In addition, to strengthen the supervision of HEWs, the NGOs provided
training, introduced checklists, and mentored in supportive supervision. Several NGOs provided
the primary support to community health volunteers through training for advocacy, creating
awareness, and conducting social mobilization, in addition to building capacity. In contrast,
there was no equivalent support from NGOs in the woreda with steady coverage, and health
managers considered this an obstacle to improving RI system performance.
73 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
IMPLICATIONS
VII. IMPLICATIONS
To improve and sustain RI coverage, woredas need a supportive political and policy context, as
well as essential immunization infrastructure. The national Health Extension Program provided
the impetus and the resources to bring about a dramatic improvement in geographic access
to immunization (and other health interventions). Longstanding national commitment to RI
and the support of development partners ensure the availability of vaccines and equipment.
In the three woredas where coverage improved, the relatively consistent availability of these
essential inputs provided the foundation on which the five RI performance drivers were able
to move penta3 coverage to as high as 94%, up from around 75% prior to the study period.
Without these inputs from the national government and international development partners
for the maintenance of an RI system’s basic infrastructure, commodities, workforce skills, and
operations, the performance drivers could not work effectively to bring about positive change
in immunization coverage.
The ARISE exploration of district-level RI reveals, however, that it is the way in which each
improving woreda implemented RI that triggered coverage improvements, giving rise to
the RI performance drivers discussed above. Comparing the woredas, there was not much
difference in terms of health infrastructure. Rather, woreda experience differed in relation
to the choices that woreda health teams made in managing their resources and the shared
commitment of the health system, the local government, and the community to improving
immunization coverage. Such positive relationships and enhanced coordination motivated a
range of community members, including volunteers, religious leaders, and school personnel, as
well as health workers to promote RI. In addition, in woredas where relationships between the
woreda administration and health offices were strong, resource pooling, such as the sharing of
vehicles, was reported to be crucial to an effective immunization system, particularly for the
distribution of vaccines to health posts and outreach clinics. In the steady coverage woreda,
many of the performance drivers, including performance review, HEWs’ work in defaulter
tracing, and raising community awareness, were either very recently instituted, present but not
functioning as effectively as they were in the improving woredas, or missing altogether.
Throughout Ethiopia, there is a wide variation in woreda-level vaccination coverage. The
ARISE case study woredas were not among the highest performing woredas in the country,
nor were they among the poorest performers. The three woredas whose coverage improved,
however, do represent the experience of woredas that have reached a certain level of
performance (around 75% for penta3) and and increased coverage to around 90% within three
to four years.
The ARISE study in Ethiopia explored the pathways to RI system performance to understand
how and why performance improves in different settings, Table 7 summarizes the pathway
of these RI performance drivers, key contextual elements, and the role of basic
immunization infrastructure.
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Table 7. Context, Essential Immunization Infrastructure, and Performance
Drivers Work Together to Improve Coverage of Routine Immunization (ARISE
Case Studies of Four Ethiopian Woredas)
FOUNDATION AND
DRIVERS
MECHANISMS
PATHWAYS TO RI SYSTEM PERFORMANCE
IMPROVEMENT
• Policies and funding that:
CONTEXT:
Political commitment
to RI
Supportive policies
FOUNDATION:
Essential immunization
infrastructure in health
facilities
DRIVER:
Locally-recruited and
supported health
extension workers
(HEWs)
DRIVER:
Active community
participation in RI and
health
DRIVER:
Partnership between
health and government
administration
DRIVER:
Focus on accountability
and performance
DRIVER /ENABLER:
Development partner
support for health and
immunization
– focus on increasing access to care
– focus on community-based health
– focus on performance measurement
and improvement
• Regular supply of vaccines and basic inputs
for immunization
• Services move closer to the community
• Maintain vaccine supply chain
• Increase community-focused health
workforce
• Motivate staff and promote accountability
• National political commitment through HEP
& well-functioning immunization program
• Cold chain equipment and basic transport
at every health facility offering ixed services
• Increase in the size of community-focused
health workforce
• Maintain the vaccine supply chain
• Maintain an adequate number of vaccination
providers
• Increase opportunities for ixed-site and
outreach vaccination
• HEW characteristics: female, from the
community, living in the community
• HEW partners with kebele administration
• HEW teams with extensive volunteer
network
• Community-based vaccination, defaulter
tracing, awareness raising
• Establish personal links between health
workers and community
• Provide regular vaccination clinics, defaulter
tracing, and health education
• Increase community and health partnership
• Support the credibility of vaccination and
HEWs
• Regular interaction of community health
volunteers with RI program
• Strong partnership of HEW and kebele
administration
• Involvement of communities in decisions
about service delivery
• Increase capacity to mobilize community
support, trace defaulters, and educate
communities about health
• Increase resources for health service
delivery
• Joint planning and implementation of RI
• Regular supervision by woreda, HC, and kebele
• HEW sits on kebele cabinet
• Joint review of RI performance
• Motivate health workers and community
• Increase community involvement
• Improve access to resources for
immunization
• Clear performance targets
• Monthly or quarterly meetings with health
teams to review performance
• Praise for and correction of performance
• Peer exchange of service delivery solutions
• Supervision using data and peer learning
• Motivate staff
• Use data to inform decision making
• Increase skills to improve community-level
service delivery
• Emphasize problem solving
• Capacity building
• Resources to support immunization services
• Technical tools and guidance
75 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
• Improve service quality
• Improve service consistency
• Motivate health workers
INVESTMENT TO IMPROVE ROUTINE IMMUNIZATION PERFORMANCE
VIII. INVESTMENT TO IMPROVE ROUTINE IMMUNIZATION
PERFORMANCE
The results of the study of drivers of routine immunization performance in four woredas in
Ethiopia may have a number of practical policy implications for other sub-Saharan African districts.
First, Ethiopia’s success with taking vaccination into the hearts of communities through health
extension workers suggests that a community-focused, community-based health workforce
may catalyze the uptake of immunization services and completion of vaccination schedules.
Closer physical proximity to services and the trust built from regular interaction with HEWs
worked together to increase the availability of RI and the commitment of community members
to take their children for vaccination.
Second, historic investment in establishing functional RI systems imbued with basic technical
capacity to deliver services has clearly been effective in some woredas in Ethiopia and in other
African countries. The study team found that few respondents even considered that vaccines,
the cold chain, or trained health workers served as drivers of coverage improvement. Yet
without continued attention and investment to sustain the supply of essential EPI elements,
no RI program can deliver potent vaccines effectively and build the credibility for RI within a
community that is required to sustain acceptance and use of vaccination. As countries gradually
introduce new vaccines into the routine system, maintaining these basic service inputs is
critically important.
Third, respondents may have placed less weight on the role of essential RI program inputs
in driving coverage improvement, because the study woredas had become competent in
maintaining those inputs. From 2006 onward, no major changes—positive or negative—
in service supply were reported. Respondents instead traced coverage improvement to
decisions and actions related to management and the motivation of staff, to the coalitions
formed between health and community actors, to the regular use of data, and to learning
to focus workers on reaching targets. Many of the performance drivers were not specific
to immunization programs, but could be generalized to the basic practices and functions of
a health system as a whole. Effective woreda-level RI services benefit from health systems
that channel resources and services as close to the community as possible. These health
systems engage ordinary citizens and leaders and influential people alike in the management of
community health services and, through shared work, build commitment to a common goal.
Effective health systems also use data to hold health and community workers accountable for
the system’s performance and use program review techniques to motivate workers to stay
focused on performance goals. Data quality becomes particularly relevant for making this
performance improvement strategy effective. All of these drivers are potentially as important
to other basic health services as they are to immunization.
Fourth, in the woredas where coverage improved, no single driver could account for coverage
improvement. Rather, drivers tended to work in concert to influence RI system performance.
Managers and policymakers are therefore cautioned about looking for one key driver of
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A STUDY OF THE DRIVERS OF ROUTINE IMMUNIZATION SYSTEM PERFORMANCE IN ETHIOPIA
coverage improvement. When addressing complex systems with limited resources, the use
of multiple strategies for achieving better immunization service delivery and increased use of
vaccination is needed.
Finally, the responsibility for determining which performance drivers are effective in a particular
woreda, and for managing resources to apply and adapt performance drivers, rests mainly with
woreda (or district)-level health teams. These teams were effective advocates for strategies
that worked, and they channeled resources toward effective actions, such as the use of data
for regular performance review and for motivating HEWs. As the study of how three woredas
in Ethiopia improved their immunization systems suggests, investment is needed to enable
local health managers in Africa to work strategically to improve health service capacity and
effectiveness and increase the use of health services. In this effort, they will require resources,
skills, and the authority to use different strategies and adapt them as needed to the local
context in order to make optimal use of resources and maximize chances of program success.
Post Script:
Following the ARISE stakeholder work shop, the project conducted a stakeholder consultation
to discuss how to translate study indings into action. Stakeholders were asked to recommend
potential steps to improve RI performance based on the RI performance drivers that emerged
from the research and to identify any enabling or constraining factors to implementing the
recommended actions. A report of this stakeholder consultation is available on www.arise.jsi.com.
77 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
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79 | AFRICA ROUTINE IMMUNIZATION SYSTEM ESSENTIALS (ARISE) PROJECT
FURTHER READING (AVAILABLE AT HTTP://ARISE.JSI.COM/)
1. LaFond, A.K., Kanagat, N., Sequeira, J.M., Steinglass, R., Fields, R., & Mookherji, S. (2012). Drivers of Routine
Immunization System Performance at the District Level: Study Findings from Three Countries, Research Brief No. 3.
Arlington, VA: JSI Research & Training Institute, Inc./ARISE Project for the Bill & Melinda Gates Foundation.
2. Larson, A., Kanagat, N., Biellik, R., LaFond, A.K., & Amegah, K. (2012). A Study of the Drivers of Routine Immunization
System Performance in Ghana. Arlington, VA: JSI Research & Training Institute, Inc./ARISE Project for the Bill & Melinda
Gates Foundation.
3. Niang, C., Sequeira, J.M., Gasse, F., LaFond, A.K., Ate, C & Ngo-Likeng, J.L. (2012). A Study of the Drivers of Routine
Immunization System Performance in Cameroon. Arlington, VA: JSI Research & Training Institute, Inc./ARISE Project for
the Bill & Melinda Gates Foundation.
4. Fields, R., & Kanagat, N. (2012). Notes from the Field: Health System and Community Partnerships. Arlington, VA: JSI
Research & Training Institute, Inc., ARISE Project for the Bill & Melinda Gates Foundation.
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ARISE Project
John Snow, Inc./DC Office
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