Transcript Experience in Ethiopia in conducting best practices measles campaign

Integrated Measles Best Practice
SIA 2010/2011
Experience from Ethioipia
Global Measles and Rubella Meeting, 15-17 March 2011,
Geneva
Outline
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Background
Measles coverage and epidemiological situation
Ethiopia SIA Experience
SIA implementation/achievement
SIA evaluation
Opportunities and challenges
Ethiopia: Background
• Projected population 2010
(census 2007): 79 million
–
–
–
–
Growth Rate:
Under-1:
Under-5:
Under-15:
2.6%
3.2% (1.9m)
14.6% (11.4m)
45% (35m)
Federal Ministry of Health
Regional Health Bureaux
(9 Regions + 2 City Administrations)
Zonal Health adminstration
(98 Zones)
• Rural: 83%
819 Woreda Health Offices
• Infant Mortality Rate:
75/1000 live-births
15,000 Kebeles
1 health post per 5,000 population) :- The
key for the success of the SIA
Reported Measles Cases and Measles
Coverage- 1990-2009, Ethiopia
8000
Follow Up 2005 - 2009
90
Administrative Coverage (%)
7000
80
6000
70
60
5000
50
4000
40
3000
30
Cases
Measles Coverage
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
0
1994
10
1993
1000
1992
20
1991
2000
1990
Number of Measles Cases
Best practice 2010
Catch Up
2002 -2004
0
Measles Outbreaks - 2010
Vaccination status of confirmed
measles cases. January – Dec 2010
1600
1400
1200
1000
800
600
400
200
0
Under 9
MOs
09mon 4 years
UNVACCINATED
05 to 09
years
10 to 14
years
Vaccinated
15 Years
& above
UNknown
Confirmed Measles cases
January - Dec 2010
Measles SIAs: 2010-2011
• Target: 8.5 million children
aged 9 – 47months
– 90.8% of target population in 2010
• Dates:
– 22 - 25 October 2010
– 18-21 February 2011
• Objectives of SIA:
– Give 2nd dose of measles vaccine
– Identify ,implement and evaluate
best practice SIA
• Integrated interventions:
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–
–
–
OPV (0-59 months)
Vitamin A (6-59 months)
De-worming (24-59 months)
Nutritional Screening (6-59 months
and pregnant and lactating women)
2010
2011
Pre-Identified SIA Best Practices
Coordination
Micro planning and Training
• National and sub national Task Force
with subcommittee's led by
government health bureau
• Weekly updates from each level for
management and monitoring of SIA
• Emphasis on Kebele level planning
with identification of hard to reach
and difficult populations
• Participatory approach in training
.
Logistics
Advocacy and Social Mobilization
• Required logistics available pre SIA
with initiation of distribution 3-4
weeks before implementation
• Flexibility in distribution mechanisms
including transport fleet for
emergency distribution
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High level political engagement
Advocacy visit to regional presidents
Evidence-based messages (KAP)
Diverse channels of communication
• radio, tv, town criers, house to house
canvassing, schools, banners, IEC,
mobile vans
Pre – Identified SIA Best Practices
Monitoring and Evaluation
• Pre campaign assessments (3-4
weeks and 1 week prior to SIA) and
feedback given to address gaps
• Different methods utilized to
monitor performance:
– Daily review meetings, with daily
coverage reporting using SMS ( second
phase)
• Administrative, rapid convenience
monitoring, independent
monitoring
Resource Mobilization
• Significant Government
contributions :- .017 cost per child
• High level cooperation between EPI
partners
• Engagement of partners at all levels:
o Human resources, transport, social
mobilization, logistics
Implementation of Best Practice
Integrated Measles SIA
Funding for 2010/11 Measles SIAs
Funding from the
Measles Initiative
Item
Total
Budget
(USD)
Vaccine and
injection
materials
5,371,901
Operational
costs
6,464,204
746,219
1,502,205
Grand Total
11,836,105
746,219
1,502,205
Target
population (<
5)
12,859,245
Cost per child
(USD)
0.92
FMOH
Nutrition
Partners
(EOS)
UNICEF
Global
Polio
Initiative
3,345,097
2,026,804
2,101,540
1,364,240
750,000
2,101,540
4,658,097
2,776,804
WHO
Coordination activities:- weekly
meeting
A National task force led by the DG of Health Promotion and
Disease Prevention Directorate, FMoH taking care of the
coordination of preparation
Regional level task force led by RHB-PHEM head
Launching Activities
Implementation
SIA Administrative Coverage,
Ethiopia, 2010-11
OPV Coverage
Measles Coverage
>=95%
90-94%
80-89%
National coverage 106%
National coverage 97%
Independent Monitoring Assessment
of Woreda Performance, Ethiopia 2010
Proportion of Children
missed during the SIA
Number of woredas for
measles vaccination
Number of woreda for
Polio Vaccination
>10%
106
107
5-10%
67
79
<5%
222
209
Source of data: Post SIA Independent monitoring, 38 6Woredas (52%) sampled
Note: Poor quality finger markers compromised the independent monitoring process in several areas
Evaluation of the Ethiopian
measles SIAs
Methodology
Objective of the Survey
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• Cross-sectional study design
• Study area: 60 Woredas
• Study Period: Nov-Dec 2010
source population: all expected
•
eligible
Target population: eligible children
in sampled households
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• Sampling: : A two stage cluster
household survey
– Systematic Random sampling of •
woredas and random sampling
of the EAs from the selected
woredas
To evaluate the overall national measles
vaccination coverage of children 9-47
months of age post the SIA and routine EPI
coverage among children 12-23 months of
age
To independently monitor the
implementation of a set of selected BP for
SIA
To explore the relationship between the set
of selected best practices and post measles
vaccination coverage of children 9-47
months of age of the SIA in select Woredas
To determine the proportion of target
children that receive other interventions
during the integrated measles SIAs
campaign
Preliminary coverage survey result
Regions
Measles
Coverage by
maternal recall
N
Measles Coverage by
Card
Wted % N
Wted %
Measles Coverage by
Either maternal recall or
card
N
Wted %
Amhara (n=405)
248
60.5
276
66.8
384
94.2
Oromia (n=963)
759
82.6
411
37.2
877
91.7
Somali (n=376)
363
97.2
155
36.3
365
97.3
SNNPR (n=526)
393
79.3
234
45.4
475
91.4
Harari (n=286)
217
72.7
202
70.3
272
91.7
Addis Ababa
(n=269)
216
81.6
203
76.3
252
93.8
Dire Dawa
(n=263)
234
89.2
115
47.8
241
91.2
Total (n=3088)
2430
77.5
1596
48.1
2866
92.7
Enhancing Routine Immunization
through SIAs
• 7 key areas identified in the
planning phase and efforts
made to maximize on RI
strengthening:
1.
2.
3.
4.
5.
6.
7.
Micro planning
Training
Logistics Management
Advocacy and Social
Mobilization
AEFI monitoring and
management
Surveillance
Monitoring and Evaluation
• Methods: used to evaluate the
effect of SIA on RI
- Focus Group Discussions
(caretakers)
- In depth interviews (health
workers)
- Observations (health facility +
session)
- Participation and feedback in post
SIA review meetings
• Target:
- Caretakers
- Health workers
Effect of Measles SIA on the
Routine System, Ethiopia
Regions
Addis Ababa
Oromiya
SNNPR
Pre-SIA Post SIA Pre-SIA Post-SIA Pre-SIA
Post SIA
Somali
Pre-SIA
Post-SIA
Presence of a micro plan
for EPI
Monthly monitoring of
immunization coverage
50%
76.9%
98.8%
98.8%
100%
100%
60%
73.3%
58%
62%
83%
84%
55%
67%
33 %
53%
Monitoring chart up to
date
50%
63%
35%
99%
100%
100%
60%
64%
Number of health
facilities which had
adequate functional cold
chain
83%
100%
26%
22%
32%
14%
80%
80%
Number of health
facilities which had
adequate safety boxes
83%
92%
96%
99%
96%
100%
93%
100%
Number health workers
who know the use of
additional doses of
measles immunization
75%
92%
46%
74%
76%
100%
27%
87%
Key Factors Contributing to SIA Success
SIA Component Major Elements of Success
Coordination
•Task Force and subcommittee establishment at all levels with engagement of key
partners
Micro planning
and training
•Early start from Kebele level with administration involvement in the planning
process
•Identification of knowledge and skills gaps for emphasis in training
•Practical and participatory methods approach
•Development of pocket guide in local language
•Pre-and post test and training evaluation for quality training
Advocacy and
Social
Mobilization
•Development of messages based on analysis of gaps and concerns of the
community
•Involvement of political leadership at all levels in advocacy
•Utilization of diverse channels of communication including house to house
canvassing for mobilization
Logistics
• Distribution to all woredas from the federal level with pre planning of bundle
logistics distribution
Monitoring and •Daily review meetings
evaluation
•Intra- SIA monitoring (Daily SMS Reporting, RCM, Independent monitoring)
Key Challenges of the SIA
SIA Component
Micro planning and
Training
Challenges addressed in the second phase
• Delays in translated materials (4 languages) resulting in
late distribution to sub national level
• Finding accurate conversion factor for 9 to 47 months
Funds transfer
• Delayed funds disbursement from central level to some
regions due to late liquidation of funds
Implementation
• Accurate screening of target age group
Logistics
• Shortages of vaccines experienced in some zones
Monitoring and
Supervision
• Poor quality of finger markers (utilize screening card for
monitoring)
• Inability to effectively transmit daily coverage
achievements to the next level intra campaign(Daily
using SMS)
Next Steps
• Finalize ongoing evaluations
o Coverage survey
o Routine EPI strengthening (6 months follow up)
• Finalize documentation of the best practice
SIA
• Maximizing on gains from the SIA to
strengthen routine EPI
Conclusions from Best Practice SIA
• Identification of country-specific BP for incorporation
in the micro planning and training
• Emphasis on the best practices concept raised
commitment at all levels
• Implementation of a best practice concept improves
resource allocation to most critical areas
• Bottom -up planning from Kebele level with
engagement of HEWs, local administration and
stakeholders
• Establishment and functionality of coordination
structures at all levels
• Efforts were made to strengthen the routine system
through the SIA which need to be sustained
Acknowledgement
Ethiopia Federal Ministry of Health
Local Partners: CORE GROUP, L10K, IFHP