Integrated Measles Best PracticeSIA 2010/2011

Experience from EthioipiaGlobal Measles and Rubella Meeting, 15-17 March 2011,

Geneva

OutlineOutline

• Background• Measles coverage and epidemiological situation• Ethiopia SIA Experience• SIA implementation/achievement• SIA evaluation• Opportunities and challenges

Ethiopia: BackgroundEthiopia: BackgroundFederal Ministry of Health

Regional Health Bureaux(9 Regions + 2 City Administrations)

Zonal Health adminstration(98 Zones)

819 Woreda Health Offices

15,000 Kebeles 1 health post per 5,000 population) :- The

key for the success of the SIA

• Projected population 2010 (census 2007): 79 million– Growth Rate: 2.6% – Under-1: 3.2% (1.9m)– Under-5: 14.6% (11.4m)– Under-15: 45% (35m)

• Rural: 83%

• Infant Mortality Rate: 75/1000 live-births

Reported Measles Cases and Measles Reported Measles Cases and Measles Coverage- 1990-2009, EthiopiaCoverage- 1990-2009, Ethiopia

Catch Up 2002 -2004

Best practice 2010

Measles Outbreaks - 2010Measles Outbreaks - 2010Vaccination status of confirmed

measles cases. January – Dec 2010Confirmed Measles cases

January - Dec 2010

Measles SIAs: 2010-2011Measles 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:– 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 PracticesPre-Identified SIA Best PracticesCoordinationCoordination• 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

LogisticsLogistics• Required logistics available pre SIA

with initiation of distribution 3-4 weeks before implementation

• Flexibility in distribution mechanisms including transport fleet for emergency distribution

Micro planning and TrainingMicro planning and Training• Emphasis on Kebele level planning

with identification of hard to reach and difficult populations

• Participatory approach in training .

Advocacy and Social MobilizationAdvocacy and Social Mobilization• 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 Pre – Identified SIA Best Practices Monitoring and EvaluationMonitoring 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 MobilizationResource 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 Implementation of Best Practice Integrated Measles SIAIntegrated Measles SIA

Funding for 2010/11 Measles SIAs Funding for 2010/11 Measles SIAs

Item

Total Budget (USD) FMOH

Nutrition Partners

(EOS)

Funding from the Measles Initiative

Global Polio

InitiativeWHO UNICEFVaccine and injection materials 5,371,901 3,345,097 2,026,804

Operational costs 6,464,204 746,219 1,502,205 2,101,540 1,364,240 750,000

Grand Total 11,836,105 746,219 1,502,205 2,101,540 4,658,097 2,776,804Target population (< 5) 12,859,245

Cost per child (USD) 0.92

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 ActivitiesLaunching Activities

ImplementationImplementation

SIA Administrative Coverage, SIA Administrative Coverage, Ethiopia, 2010-11Ethiopia, 2010-11

>=95%

90-94%

80-89%

Measles Coverage OPV Coverage

National coverage 106% National coverage 97%

Independent Monitoring Assessment Independent Monitoring Assessment of Woreda Performance, Ethiopia 2010of 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%) sampledNote: Poor quality finger markers compromised the independent monitoring process in several areas

Evaluation of the Ethiopian measles SIAs

Methodology Objective of the Survey

• 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• 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 resultRegions Measles

Coverage by maternal recall

Measles Coverage by Card

Measles Coverage by Either maternal recall or card

N Wted % N Wted % 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 Enhancing Routine Immunization through SIAsthrough SIAs

• 7 key areas identified in the planning phase and efforts made to maximize on RI strengthening:

1. Micro planning2. Training3. Logistics Management4. Advocacy and Social

Mobilization5. AEFI monitoring and

management6. Surveillance7. 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 Effect of Measles SIA on the Routine System, EthiopiaRoutine System, Ethiopia

  Regions

Addis Ababa Oromiya SNNPR SomaliPre-SIA Post SIA Pre-SIA Post-SIA Pre-SIA Post SIA Pre-SIA Post-SIA

Presence of a micro plan for EPI

50% 76.9% 98.8% 98.8% 100% 100% 60% 73.3%

Monthly monitoring of immunization coverage

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 SuccessKey Factors Contributing to SIA SuccessSIA 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 evaluation

•Daily review meetings•Intra- SIA monitoring (Daily SMS Reporting, RCM, Independent monitoring)

Key Challenges of the SIAKey Challenges of the SIASIA Component Challenges addressed in the second phase

Micro planning and Training

• 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 StepsNext Steps

• Finalize ongoing evaluationso Coverage surveyo 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

AcknowledgementAcknowledgement

Ethiopia Federal Ministry of Health

Local Partners: CORE GROUP, L10K, IFHP