Strengthening Routine Immunization Services in Ethiopia

The Universal Immunization through Improving Family Health Services (UI-FHS) project focused on improving availability, use, quality, and sustainability of immunization services in Ethiopia. UI-FHS ended in February 2021, after 10 years of operation. We spoke with Dr. Zenaw Adam, UI-FHS technical director, to learn about the project’s capacity strengthening work and impact.

This interview has been edited for length and clarity.

What three UI-FHS achievements are you most proud of?

First, we introduced Reaching Every District Using Quality Improvement (RED-QI), a flexible, versatile, and simplified approach to the health system. As a result, thousands of children got vaccines and high-quality health services. Second, immunization is often considered the responsibility of health workers or the Ministry of Health alone, but it requires more people. We engaged community leaders, non-health stakeholders (e.g., civil authorities), and quality improvement teams (QITs) in the implementation of RED-QI. The QITs included health workers and community members who helped us identify problems with health service delivery and develop and apply local solutions. Third, we emphasized the importance of using high-quality data for decision-making and programming. This allowed health workers and community and district immunization managers to see where performance was strong or weak, and act accordingly. In areas where data were unreliable and scarce, we used methods like data triangulation, looking at information from different sources to analyze how immunization was performing.

Whose capacity did you focus on strengthening, and why?

We focused on strengthening the capacity of health workers directly involved in providing immunization services at the health facility level. We also focused on strengthening the capacity of immunization managers at district and regional levels because they are involved mobilizing resources, reviewing data and adjusting strategies accordingly, and advocating the program among politicians and local chiefs. We applied multiple methods of capacity strengthening: classroom-type training, field visits, and supportive supervision in which both the supervisor and supervisee learned about local problems and found solutions. These methods provided opportunities for different types of experience exchange—between peers and levels of health system, and formal and informal.

Can you talk about why UI-FHS operated in areas where the health system did not regularly reach?

RED-QI is a pro-equity approach. We can reach 80–90 percent of the total population with vaccines, but the remaining 10 percent are most important. And they can be deprived of these vaccines due to various inequity dimensions. Although we worked in areas where services were poorly developed and infrastructure was inadequate with thinly staffed facilities, the project focused mostly on the geographic dimension. The people who weren’t vaccinated lived in remote communities and were mostly nomadic. They were spread thinly across vast areas, making tracking challenging. So we used a flexible strategy that took their movement into consideration; today you might vaccinate them at site A, but for the second round, they were somewhere else and we needed follow them. We supported health workers to design and operationalize mobile or outreach strategies that engaged the community. The key factor here was bridging the equity gap and ensuring that vaccines were effective and available to every child, wherever they were. We left tools that are still in use in most of the health facilities in these areas, so this work continues.

Photo by Shehzad Noorani for JSI.