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JSI’s Universal Immunization through Improving Family Health Services (UI-FHS) project strengthens the immunization system in Ethiopia through the Reaching Every District using Quality Improvement (RED-QI) approach. RED-QI gives program managers and health workers tools to enable the timely identification and vaccination of every eligible child. A core set of activities in each district included training and post-training follow up through supportive supervision, review meetings, and exchange visits. Nearly 900 health facilities and 85 district health offices established Quality Improvement Teams (QIT) that identified problems and provided local solutions using data from the immunization program. JSI implemented RED-QI as a pilot project in three districts of Ethiopia and then scaled the approach from three to 103 districts. Two-thirds of the scale-up districts were in regions with low resources, fragile health systems, and populations that are largely nomadic. UI-FHS used an adaptive management approach to continuously learn and adapt RED-QI implementation to meet the needs of these particular contexts.

BACKGROUND AND TECHNICAL APPROACH To understand the project’s impact and implementation fidelity/quality, UI-FHS collected data in a variety of ways, including qualitative operational research on the uptake of QI in health facilities, a mid-program review that assessed the program’s implementation in its most challenging contexts, and ongoing monitoring of key indicators at 280 facilities that received repeated support (i.e. ≥ 3 supportive supervision visits). Through these methods, UI-FHS synthesized learning to identify key findings that facilitate uptake and scaling of innovative QI approaches into a larger, complex health ecosystem.

METHODS

Integration into the existing health system was an essential step for scaling RED-QI. Implementers must also be willing to compromise on the fidelity of a technical ap-proach to allow for organic adaptation. Lastly, capacity building requires ongoing, iterative support to reinforce classroom learning.

CONCLUSION

92% 86%

41%47%

68%

District (n=84)*

Baseline*baseline not available Final supervision visit

Health Centers (n=97) Health Posts (n=99)

Figure 1: Percent of facilities in UI-FHS districts with QITs established (of facilities that received ≥ 3 supervision visits)

Figure 2: Average of total “yes” responses and percent improvement over time by region on district immunization-specific supervision checklist (of districts that received ≥ 3 supervision visits)

First supervision visit Final supervision visit

Afar

12.7

19.4

15.5

19.9

11.8

17.9 17.4

23.9

7.415.0

13.0

19.3

Benshangul Gumuz

Gambela SNNPR Somali Overall, 5 regions

“When training is given, women health workers usually do not ask questions in training halls though they have misunderstandings. However, when they meet us during supportive supervision, they ask questions and we also identify many gaps they have during supervision, and then we show them on the spot. Therefore, the on-job training brings magnificent change in improving the knowledge and skill gaps of the health workers.”

– District Health Office respondent

FINDINGS

FINDINGS SUGGESTED THREE KEY LESSONS IN SCALING UP INNOVATIVE QI APPROACHES:

UI-FHS leveraged existing working groups within health facilities to introduce QI tools/processes into their ongoing work. At the community level, QITs were formed largely from already existing groups; these groups were asked to help the health worker improve immunization in their communities by meeting once per month to discuss local problems. Qualitative findings from operational research found that using these existing groups strengthened facility-community linkages and helped communities break down the root causes of problems in immunization service delivery. Overall, QITs were successfully established in a majority of facilities (see Figure 1).

Through the project’s adaptive management approach, QI implementation changed over time in two major ways: 1) in particularly fragile health system settings, basic health service functionality was established before introducing QI concepts; and 2) in districts where capacity was low and the health system most constrained, QI approaches extended to sub-district level health facilities but not to the lowest level of the health system. Ultimately, these adaptations represented a natural evolution in introducing complex interventions into varied contexts who have dif-ferent needs, skills, and/or system constraints. Implementers must be willing to compromise on the fidelity of a technical approach, allowing for organic adaptation as it is introduced in new contexts.

Ongoing capacity building must be built-in to the approach for uptake. Iterative support in UI-FHS supported districts resulted in a 49% increase in immunization checklist scores from first to final visit (see Figure 2), suggesting that on-job coaching and other follow-up activities helped improve immunization performance. This finding was also echoed in qualitative interviews conducted during UI-FHS’ Mid-Program Review, where respondents stated they felt health worker perfor-mance, especially at the lowest level of the health system, had improved since they started providing supportive supervision (see quote box).

2. The scale up model must be adapted based on context.

1. Scale up is facilitated if the approach can easily integrate into the existing health system.

51% 28% 52% 37% 104% 49%

To learn more, visit uifhs.jsi.com

3. Capacity building requires orientation and iterative support.

Tewodros Alemayehu; Adriana Almiñana; Lisa Oot; Natasha Kanagat; Quail Rogers-Bloch

FROM 3 DISTRICTS TO 103: LESSONS LEARNED AND CONSIDERATIONS FOR SCALING UP INNOVATIVE QI APPROACHES

Photo: Natasha Kanagat