Using Quality Improvement Tools to Address Equity Gaps and Improve Immunization in Ethiopia

In Ethiopia, we are helping improve the quality and equity of routine immunization services, and reaching communities that are often missed by the health system. Through the Universal Immunization through Improving Family Health Services (UI-FHS) project, the JSI team has adapted quality improvement (QI) tools into the Reaching Every District (RED) strategy to help health and immunization managers operationalize their programs in a way that can sustain results. The approach, known as Reaching Every District using Quality Improvement (RED-QI), applies QI tools to improve the implementation of the RED strategy. RED-QI is implemented to improve the quality, equity, access, and utilization of immunization services. 

Dr. Zenaw Adam is JSI’s Technical Director for the UI-FHS project. He oversees technical and programmatic aspects of the project, and engages government and non-government stakeholders within Ethiopia. 

Dr. Adam became interested in immunization shortly after he started working with the Expanded Programme on Immunization (EPI) at a rural health center in Ethiopia, a few years after smallpox was eradicated. He continued his career in international public health working across the globe on immunization-related activities, which led him to JSI and UI-FHS. 

Our team had the opportunity to talk to Dr. Adam about UI-FHS and the RED-QI approach, and their impact on improving equity in immunization.

How has the RED-QI approach created opportunities to reach zero-dose children (children that have not received any life-saving vaccines) with immunization?

It boils down to doing the five components [of RED] in the right way. For example, our approach to microplanning engages communities and is designed to reach target populations where they are. A good microplan allows us to reach unreached communities and children because we involve the local communities in the planning. The bottom-up microplan is a gateway; it opens the door to find children no matter where they are. 

For example, in Afar and Somali, we use clan leaders who are well aware of their community’s movement. We engage them during microplanning and they tell us about where a small cluster of families are in the center of the desert, and then we plan services to vaccinate them. If you can reach the unreached, there will be no one left behind, so services become equitable, acceptable, and sustainable.

How does the RED-QI approach align with global immunization plans, such as the Immunization Agenda 2030 (IA 2030) and the Gavi 5.0 Strategy?

The RED components remain the core essence of the immunization agenda now and in the future. The means to achieve the goals of these strategies to reach zero-dose and under-immunized children is RED-QI because equity is already built-in, and proper implementation of RED is the key to establishing, maintaining, and strengthening routine immunization services. JSI, through the UI-FHS project, developed the RED-QI approach to strengthen routine immunization and improve the access and utilization of immunization services. As an example, we encourage local problem solving through quality improvement teams (QITs), a small group that includes health workers and community members, to identify and address challenges with tracking and reaching underserved populations. Local solutions include expanding outreach services, tracking pregnant women, establishing defaulter and left-out tracking mechanisms, and coordination around service delivery locations.  

What has COVID-19 shown us about the resilience of health systems?

COVID-19 is teaching us a lot that we have not seen before. There are significant lessons learned over this past year. People have finally started focusing more on how health systems should be strengthened in the event of future unplanned or unforseen events. 

For example, in Ethiopia, COVID-19 spread gradually, which gave us a little time to learn from other country experiences, and plan before the pandemic picked up. It was possible to prevent serious system breakdown, particularly in delivering essential health services. We were able to conduct a measles supplementary immunization activity, which indicates that we were more or less prepared to address the direct effect of COVID-19 on immunization programs. Immunization is very sensitive to interference because two to three months of interference can negatively impact efforts overall. Fortunately, the health system in Ethiopia, particularly the health extension program, was helpful in mitigating the impact of COVID-19 on health services, including immunization services. 

There are lessons for the future; we need to strengthen and pay particular attention to the most sensitive and vulnerable programs, such as immunization and other women’s and child health programs. We cannot afford to let service delivery for these critical health interventions lapse as we focus on COVID-19; we need to focus both on addressing COVID-19 and on maintaining and improving immunization services. 

What approaches have worked well to improve equitable immunization coverage in Ethiopia?

One approach that has worked well is utilizing QITs to identify and address issues with immunization service delivery. QITs try to analyze performance and identify which health facilities are doing consistently well, and which ones are inconsistent in performance or have poor reporting. They use different tools to identify problems and also find and propose workable, local solutions to solve them. By this method, they identify small problems that they can easily solve and see their progress over time. 

But the use of QITs extends beyond that. For example, in Sodo Zuria woreda of Wolaita Zone, the QIT found that one particular health post was not located at the center of the community. Secondly, the population of that Kebele was disproportionately large compared to what a health post is supposed to serve. People had to walk long distances or the health extension worker had to travel far to conduct immunization outreach sessions. The QIT discussed how to solve this problem. They decided that there is a need to establish a new health post because geographically, the Kebele was too large for one health post to cover. They mobilized the community and resources and managed to construct a standard health post at a location closer to several population settlements. Because they involved the community and local administration, they were able to get supplies for the new health post. People were happy to have a nearby health post and attendance increased dramatically. Immunization coverage improved as well. 

This is the kind of example that is recorded by the QITs. An effective and functional QIT can create change and share lessons to other nearby woredas and health facilities. 

What advice would you share with other countries working to improve equity in immunization?

RED-QI is a strategy that can help improve routine immunization now and in the future. RED-QI is “intervention-neutral,” meaning the tools and methods can be used for other health concerns, not just immunization. You can use it for maternal health, family planning, and nutrition activities. One can implement RED-QI within an existing health system and quickly see the results. My advice to other countries is to contextualize the RED-QI approach and it will answer a lot of immunization questions that we have been struggling with—and in the end, you will see that it will benefit zero-dose and under-immunized children.

Written by Dr. Zenaw Adam, Dalia Khattab, and Nicole Davis