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Strengthening routine immunization services and sustainable financing for immunization

Resources - Routine Immunization

Country Experience

IMMbasics Nigeria End of Project Review Report (2009)

IMMUNIZATIONbasics/Nigeria (IMMbasics) began a project in October 2006 to strengthen Routine Immunization (RI) in northern Nigeria. The project worked with international partners and relevant government agencies at both the national level and in two northern states, Bauchi and Sokoto. The project aimed at strengthening both human resource and system capacities for improved delivery of RI services following Nigeria’s REW (Reaching Every Ward) guidelines, which was adapted from WHO’s RED (Reaching Every District) approach for improving RI. The project had a short lifespan, only two-and-one-half years.

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Periodic Intensification of Routine Immunization (PIRI): Lessons Learned and Implications for Action (IMMbasics/USAID/WHO, pre-print release 2009)

This is paper surveys a wide array of PIRI experiences, drawing on the fragmented documentation that exists at this time. It is based on a desk review of planning documents, guidelines, website information, data on the accomplishments of these campaigns (where available) and other gray literature, plus interviews and email communication with individuals from several countries where PIRI activities have been conducted. Gathering of this information was facilitated by an initial communication from WHO/IVB in Geneva to regional immunization advisors in 2006.

Download PIRI Monograph (PDF 1.4MB)

An evaluation of infant immunization in Africa: is a transformation in progress? (WHO, 2007)

"Infant immunization is considered essential for improving infant and child survival."

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Immunizing the World's Children: Strong and Steady Wins the Race

In recent years, the field of immunization has benefited from renewed interest and a remarkable infusion of resources from public and private partners.

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Small group discussion on “Improving the routine delivery of - immunization and new vaccines introduction” (BASICS, 2001)

The Task Force on Immunization (TFI) advises WHO/AFRO on all aspects of immunization programming in Africa. At its 2001 meeting in Addis Ababa, the TFI Chairperson asked the BASICS II project to assemble a small working group to elaborate recommendations on routine immunization strengthening. These are summarized in this document.

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Participatory Country Exchange on Strengthening Routine Immunization (BASICS, 2004)

This document summarizes an exchange between various (mostly African) teams of MOH staff and their in-country partners. Participants shared their experiences in overcoming common problems, their best practices in strengthening routine immunization services, and the impact of these efforts on immunization coverage at sub-national levels.

Download Document, English (PDF 4,143KB)

Download Document, French (PDF 3,935KB)

Routine Immunisation Survey. Final Report (Communication Initiative, 2005)

This report summarizes responses from almost 100 diverse respondents on the importance of three communication-related barriers to higher routine immunization coverage and how governments, projects and development communication professionals are addressing these barriers. The report includes a description of Top Ten Lessons Learned and selected program tools and documents.

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Barriers to Immunization in the Dominican Republic and Mozambique (CHANGE Project, 2005)

This article summarizes and compares national studies in two diverse countries of barriers to higher immunization coverage. Both studies used multiple quantitative and qualitative methods.

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BASICS II Madagascar Immunization Report (BASICS, 2004)

In collaboration with the Madagascar Vaccination Service, the USAID-funded BASICS and Jereo Salama Isika projects effectively strengthened routine immunization at district and regional levels. This report highlights actions to improve data quality and use, link communities and service delivery, and improve immunization communication to reduce drop-outs and increase vaccination coverage.

Download Document (PDF, 1.45MB)

The Immunization Inter-agency Coordination Committee [ICC] Model: Example from DR Congo (BASICS, 2002)

This article describes the effective ICC in DR Congo, pulling out key elements for effectiveness. It reviews the ICC’s history, structure, functions, roles and actions. Available in English, French, and Russian (the latter supported by the Children's Vaccine Program).

Download Document, English (PDF, 334KB)

Download Document, French (PDF, 296KB)

Download Document, Russian (PDF, 792KB)

Increasing Immunisation Coverage in Uganda: The Community Problem Solving and Immunisation Strategy Development Approach (BASICS, 2003)

To raise and sustain immunization coverage, the Uganda Ministry of Health elected to pursue the Community Problem Solving and Strategy Development (CPSSD) approach, which is designed to help health workers learn to work with communities, understand community perspectives about immunization services, and encourage community support and participation in immunization delivery. These documents summarize the approach, which is consistent with the Reaching Every District (RED) strategy.

CPSSD - Summary Document (PDF, 273KB)

CPSSD - Introduction to the Approach and Description of Facilitator Training (PDF, 273KB)

CPSSD - Facilitators' Guide: Consultation I (PDF, 3,789KB)

CPSSD - Facilitators' Guide: Consultation II (PDF)

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Reaching Every District (RED) Strategy

Reaching every district (RED) approach to strengthen routine immunization services: evaluation in the African region, 2005 (T. Ryman, R. Macauley, D. Nshimirimana, P. Taylor, L. Shimp, K. Wilkins in the Journal of Public Health, June 2009)

Evaluation of the RED implementation process provided evidence of improvement in delivery of routine immunization services. The RED framework should continue to be used to strengthen the immunization delivery system to meet continuing new demands, such as the introduction of new vaccines and integrated delivery of other child survival interventions.

Abstract and Link to the Full Article

Summary Document: Making Reaching Every District Operational (IMMbasics, 2009)

The World Health Organization, USAID and other partners designed the Reaching Every District (RED) approach in 2002 as an innovative method to improve and sustain performance of routine immunization programs, particularly in the Africa region. IMMUNIZATIONbasics implemented Nigeria's adaptation of this approach in two northern states. In addition to strengthening the routine immunization system at state and Local Government Area/district levels, the approach also helped to improve the primary health care system as a whole. Read this summary document, or the more detailed in-country version below.

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Nigeria Version: Making Reaching Every Ward Operational (IMMbasics, 2009)

In 2006, USAID floated the IMMUNIZATIONbasics project to assist in strengthening the routine immunization systems in Bauchi and Sokoto States. As part of its efforts in doing so, IMMUNIZATIONbasics project rolled out in a very practical manner the REW approach. This booklet summarises the experience of IMMUNIZATIONbasics staff, as well as that of the Bauchi State Primary Health Care Development Agency and the Sokoto State Ministry of Health working with service providers in the Local Government Areas implementing the REW components.

Download Document (PDF, 3.39MB)

Implementing the Reaching Every District Approach: A Guide for District Health Management Teams (WHO/AFRO, revised 2008)

This revised guide includes the new monitoring tool for each of the 5 RED components and aims to provide national immunization programs with the information and tools necessary for implementation of the RED approach.

Download Document - English (PDF, 6.73 MB)

Download Document - French (PDF, 5.9 MB)

In-Depth Evaluation of the RED Approach in the African Region (WHO, UNICEF, CDC, USAID/IMMUNIZATIONbasics, 2007)

This evaluation covers the health systems contexts in which immunization programs operate as well as the degree of implementation of the five components of RED and major lessons learned in scaling up. Recommendations indicate the way forward.

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What is "Reaching Every District" (RED) in Immunization? (BASICS, 2003)

A presentation from a workshop on "Monitoring Communication for Improved Immunization Coverage and Quality", held in Johannesburg, South Africa in June 2003.

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Bringing Immunization Services Closer to Communities: The RED Experience in Ghana (WHO/Ghana, 2005)

RED can provide a framework for improving priority interventions in a coordinated and integrated manner. Under RED, districts have demonstrated their ability to perform well if they get the necessary support--putting Ghana on the road to achieving desired goals in immunization service delivery.

Download Document (PDF, 442KB)

Implementing RED Approach: A Guide for District Health Management Teams (WHO/AFRO, 2004)

This guide aims to provide national immunization programs with the information and tools necessary for implementation of the RED approach.

Download Document (PDF, 6,813KB)

Reaching Every District Strategy Implementation in the Africa Region: Evaluation Report (WHO, USAID, CDC, UNICEF, 2005)

The 2005 RED evaluation revealed remarkable increases in immunization coverage in four of the five countries reviewed—the fifth country had a decline in coverage between 2003 and 2004, due largely to political factors. In the five countries evaluated the total number of districts with DPT3 coverage over 80% increased dramatically from 70 to 197, while the number with coverage under 50% declined from 377 to 222.

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Planning and Monitoring Routine Services

Routine Immunization Checklist (IMMUNIZATIONbasics, 2005)

Developed by IMMUNIZATIONbasics, this document lists 12 indicators to help district and national-level staff strengthen the performance of their routine immunization programs.

Download Document, English (PDF, 62KB)

Download Document, French (PDF 63KB)

The CAPA Handbook: A "How-To" Guide for Implementing Catchment Area Planning and Action, Community-Based Child Survival Approach (BASICS, 2004)

This manual provides step-by-step guidelines for implementing the CAPA (Catchment Area Planning and Action) approach developed by BASICS and partners in Nigeria. CAPA places the locus of health program development at the community level with the intent of creating community ownership, promoting public and private sector partnerships, and stimulating demand.

Download Document (PDF, 1,045KB)

Catchment Area Planning and Action Module 1: Routine Immunization (BASICS, 2004)

The objective of the module is to facilitate a step-by-step method in which partners can plan child survival activities, with emphasis on increasing the number of infants immunized.

Download Document (PDF, 895KB)

Increasing Coverage at the Health Facility Level (WHO, 2002)

Designed as a resource for training, supervision and monthly meetings with health workers, this publication provides practical suggestions for improving coverage and access to routine immunization. It focuses on use of data for action, strengthening facility/community links, revitalizing outreach and supportive supervision. Available in English, French and Russian.

Download Document, English (PDF 591KB)

Download Document, French (PDF, 138KB)

Download Document, Russian (PDF, 653KB)

Identifying and overcoming obstacles to increased immunization coverage (WHO, 1997)

This training course is used to teach facility-based health workers how to gather information from the community and how to communicate effectively with mothers about immunization. It is designed for self-learning with the support of a facilitator/supervisor.

The Immunization Data Quality Self-Assessment (DQS) Tool (WHO, 2005)

"The DQS is a flexible toolbox" that guides the evaluation of immunization monitoring methods and tools. This document is intended to guide staff or consultants in adapting the toolbox for diagnosing problems and making improvements in "collecting and using immunization data at the national, provincial, or district levels."

Download Document, English (PDF, 8.76MB)

Improving the Monitoring of Immunization Services in Kyrgyzstan (Health Policy and Planning, 2000)

This case study describes how the collection, analysis and use of local information can improve programs: “…. giving health workers the basic epidemiologic skills to monitor their own work measurably improved the quality of the data, and by acquiring the new skills, the workers developed a sense of pride in their work.”

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Glass of Water (BASICS, 2002)

This tool enables local volunteers and health workers to observe monthly progress towards achieving the coverage targets for individual immunizations and other interventions and to determine whether the target population is completing the immunization series or dropping out.

Download Document (figure, Excel 62KB)

Download Instructions (PDF 12KB)

Community tool for self-monitoring and health education. "My village is my home" (BASICS, 2003)

This is a simple tool for helping community members to list newborns by name and to track and visualize their progress in getting all children under one year of age immunized.

Download Document (PDF, 379KB)

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Sustainable Outreach

Guidelines for Mobile Brigades (Mozambique/MOH, Project HOPE, CHANGE Project, 2005)

Mobile brigades account for more than 20 percent of immunizations in Mozambique. Based on a national study of mobile brigade performance, these guidelines provide simple, clear recommendations for improving planning and performance, along with explanations for each recommendation.

Download Draft Document, English (PDF, 93KB)

Download Draft Document, Portuguese (PDF, 39KB)

Sustainable Outreach Services (SOS): A Strategy for Reaching the Unreached With Immunization and Other Services (WHO, 2000)

This document proposes that immunization programs reach populations that are geographically isolated through outreach that may or may not be monthly. To help absorb the high costs of this type of outreach, the authors recommend partnerships between national programs, international donors, NGOs, local governments and communities. The addition of other interventions to the immunization base is another way to improve the cost effectiveness of outreach.

Download Document, English (PDF 822KB)

Download Document, French (PDF, 492KB)

Download Document, Spanish (PDF, 380KB)

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Linking Communities and Health Facilities

Community Involvement in Maternal and Child Health in Madagascar: Example from immunization (USAID)

This document describes the Madagascar experience of community and health system collaboration working in an engaged and systematic way that ensures integration and establishes the notion of coordinated preventive and curative care for all target populations. In Madagascar, the engagement of health teams and communities, and the standardization of services around a Minimum Activity Package at all levels is assisting with achievement of the target goal to lower the mortality rates for women and children.

Download Document, English (PDF 709 KB)

Download Document, French (PDF 548 KB)

Increasing Immunisation Coverage in Uganda: The Community Problem Solving and Immunisation Strategy Development Approach (BASICS, 2003)

To raise and sustain immunization coverage, the Uganda Ministry of Health elected to pursue the Community Problem Solving and Strategy Development (CPSSD) approach, which is designed to help health workers learn to work with communities, understand community perspectives about immunization services, and encourage community support and participation in immunization delivery. These documents summarize the approach, which is consistent with the Reaching Every District (RED) strategy.

CPSSD - Summary Document (PDF, 273KB)

CPSSD - Introduction to the Approach and Description of Facilitator Training (PDF, 273KB)

CPSSD - Facilitators' Guide: Consultation I (PDF, 3,789KB)

CPSSD - Facilitators' Guide: Consultation II (PDF 988KB)

EPI Refresher & Training of Trainers; Module 0, Facilitating Adult Learning; Module 4, Communicating with caretakers and communities for improved routine immunization coverage (Amhara Regional Health Bureaus, ESHE Project, 2004)

Developed by Essential Services for Health in Ethiopia based on materials and lessons learned in training in many countries, these materials support the planning and implementation of training of front-line health workers in skills needs to effectively communicate and work with clients and their communities. A synopsis of principles of adult learning is included.

Download EPI Refresher & Training of Trainers. Facilitators’ Guide (PDF, 1,425KB)

Download Module 0, Facilitating Adult Learning (PDF, 99KB)

Download Module 4, Communicating with caretakers and communities for improved routine immunization coverage (PDF 839KB)

Reaching Every Child for Primary Immunization. An Experience from Parsa District, Nepal (BASICS, 2004)

This document describes the activities and achievements of an effective approach used in Nepal to involve community leaders and local health workers, volunteers, and organizations in tracking children who had dropped out or not started their basic immunizations, and motivating their caregivers.

Download Document (PDF 33KB)

The CAPA Handbook: A "How-To" Guide for Implementing Catchment Area Planning and Action, Community-Based Child Survival Approach (BASICS, 2004)

This manual provides step-by-step guidelines for implementing the CAPA (Catchment Area Planning and Action) approach developed by BASICS and partners in Nigeria. CAPA places the locus of health program development at the community level with the intent of creating community ownership, promoting public and private sector partnerships, and stimulating demand.

Download Document (PDF, 1,045KB)

Catchment Area Planning and Action Module 1: Routine Immunization (BASICS, 2004)

The objective of the module is to facilitate a step-by-step method in which partners can plan child survival activities, with emphasis on increasing the number of infants immunized.

Download Document (PDF, 895KB)

Community tool for self-monitoring and health education. "My village is my home" (BASICS, 2003)

This is a simple tool for helping community members to list newborns by name and to track and visualize their progress in getting all children under one year of age immunized with DPT3.

Download Document (PDF, 379KB)

Strengthening Immunization Programs: The Communication Component (BASICS, 2004)

This document provides an overview of the key elements of immunization communication that are needed for immunization programs in developing countries. A case study from Madagascar illustrates how these communication elements come together into a comprehensive approach.

Download Document, English (PDF, 1,410KB)

Download Document, French (PDF, 1,412KB)

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Supportive Supervision

Guidelines for Implementing Supportive Supervision (WHO, PATH, Children's Vaccine Program, 2003)

This document defines supportive supervision and shows how it can improve immunization programs; outlines major steps in introducing and implementation; and provides country examples, lessons learned and tools for supportive supervision.

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Logistics and Cold Chain

E06 Temperature monitoring devices performance specifications and verification protocols (WHO, 2007)

Link to WHO immunization standards webpage:

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Preventing Freeze Damage to Vaccines (WHO, 2007)

This aide-memoire summarizes WHO guidance on prevention of vaccine freezing in a concise document that can be used as a reminder of previously published material and is ideally suited as a communications tool, job-aid or learning resource.

Download Document (PDF, 415KB)

Ensuring the Quality of Vaccines at the Country Level Guidelines for Health Staff (WHO, 2002)

These guidelines were prepared for country program managers and regulatory authority personnel, UNICEF and WHO country staff, as well as staff of partner and support agencies who handle, store and use vaccines. They describe procedures for ensuring vaccine quality from production through administration.

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Temperature Sensitivity of Vaccines (WHO, 2006)

With increasing emphasis on vaccine management to protect vaccines from both heat and cold, new tools and new training initiatives are being developed. This document offers detailed information on vaccine management related issues; concerns about freeze sensitive vaccines being exposed to freezing temperatures; vaccine vial monitors; the future of the cold chain and how to exploit the stability of each vaccine to the greatest possible extent; and detailed information on the use of the shake test.

Download Document (PDF, 871KB)

Effective Vaccine Store Management Initiative: Modules 1-4 (WHO-UNICEF, 2004)

The WHO-UNICEF Effective Vaccine Store Management Initiative is designed to assist national programs "to procure and maintain equipment and to adopt management and training practices that fully protect vaccines in primary and intermediate vaccine stores." The four modules include self-assessment tools, guidelines and model standards directed to improve the quality of their vaccine storage and distribution.

Download Document, English (PDF, 873KB)

The Challenge of Getting Vaccines Delivered and Used
(IMMUNIZATIONbasics, 2006)

Presentation given by Robert Steinglass at Global Health Council 33rd Annual Conference: Discovery, Development and Delivery: The Promise and Challenge of Vaccine Innovations

Download Document (PDF, 1.83MB)

For other logistics and cold chain resources, see Immunization Essentials (Chapter 5: Vaccine Supply and Quality and Chapter 6: The Cold Chain and Logistics), Immunization in Practice ((Module 3: The Cold Chain)), Mid-Level Management Course for EPI Managers (Block III: Logistics).

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Resources