Strengthening Routine Infant Immunization in EMR Partners for Measles Advocacy February, 2007 Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Trends in DTP3 and MCV1 Coverage in the EMR, Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Reported Routine Immunization Coverage, EMR0, Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Reported Infants Routine Immunization Coverage (2003) 90% Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Distribution of Unvaccinated Infants in EMR, 2003 PAK IRQ AFG SOM SUD YEM Others Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Insecurity (AFG, SOM, SUD, IRQ) Poor management Ongoing polio activities Weak Health Systems –Human resources –Logistics Financial resources ???? Key Constraints to Raising EPI Coverage Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

REGIONAL PRIORITY 2003 Increase routine coverage in the 6 priority countries Capacity development RED approach Vaccine management Financial sustainability planning Targeted technical assistance RWG-GAVI SSAs & STPs Monitoring –District-level coverage –Frequent country visits Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Palestine Bahrain 05/2001 $7,255,000 02/2001 $32,508,000 10/2001 $8,968,500 05/2001 $4,342,000 05/2002 $3,393,500 05/2002 $271,000 Immunization Services Strengthening Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Reported Routine Immunization Coverage, EMR0, Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Reported DPT3 Routine Immunization Coverage in Priority countries AFGDJIIRQPAKSOMSUDYEM Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization 2005 Measles Partnership Meeting, Washington, DC, USA, February 2007

Impact of RED on District Performance ( ) Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization AFGDJIIRQPAKSUDYEMSOM DPT3<50%50<DPT3<79%DPT3>=80% % of districts

Program Management Reform Sudan (2001 – 2005) 1.Governance tools designed & strengthened; 1.Strategic planning addressing all program components/ DC 2.Effective coordination 3.Knowledge & Information (strong database and M&E system) 2.Resource development; 1.Capacity building (TOT training 100%, Refresher 70%, SOPs) 2.Rehabilitation of the infrastructure (Cold chain, communication & Transport > 2 million $) 3.Mobilization of local resources (using GAVI money) 3.Service delivery; 1.Addressing Access & Utilization issues (RED approach) 2.Quality Immunization & safety issues 3.Integration? (District Health System)

Components of RED in Sudan 1.Re-establishment of outreach vaccination… 2.Supportive supervision… 3.Link between community and service… 4.Monitoring for action… 5.Planning and management of resources…

Re-establishing Outreach Vaccination Services in Sudan

Sustaining Outreach services… –Deliver immunization services on basis of periodic contact to people with limited or no access –Community participation is vital… –Campaign and/or outreach depending on operational constraints like distance, population density and terrain.

Supportive supervision… Planned, joint activity… On- site training… Use DQS as a tool (2005)… Performance was carefully measured using quality indicators… Good performance was acknowledged and rewarded…

Link with community… Advocacy meetings to revitalize the political commitment/ ICC… Establishing EPI friends Associations in some states (NIDs’ volunteers)… Use existing community structure to trace & retrieve the defaulters… Use of polio campaigns to advocate for routine immunization/ IEC… Feedback to community (still Ad Hoc)…

Monitoring for action…Sudan Use maps, graphs and charts to; –Map vaccination coverage and drop-out rates by health facility & each district… –Follow trend of performance of each health facility & each district. –Send regular feedback & feed forward…

Monitoring for action…2 Conduct regular (monthly “State” and quarterly “Federal”) review meetings: –Opportunity for on- site training… –Problem solving… –Feedback…

Planning and management of resources…1  Set up teams (Federal/ State/ Locality): 1.Technical support and need assessment… 2.Familiarization of participants on the RED approach and its implementation…  District planning workshops; the 5 steps were followed to develop the districts micro-plans…  Rational use of polio infrastructure/ experience… The 5 steps:

Prioritization for implementation

Operational considerations for implementation of RED approach: Effective and efficient logistics management which includes; –Vaccine management –Cold chain management –Maintenance management for all equipments

Group (1): Good performing States, Achievements White Nile S. Kordofan Blue Nile Gezira River Nile Gedarif

Group (2): Medium Performing States, Achievements 2002 – 2005…1 Northern W. Kordofan Red Sea N. Kordofan Sennar Kassala

Group (2): Medium Performing States, Achievements 2002 – 2005…2 N. Darfur S. DarfurKhartoum W. Darfur

Group (3): low performing States, Achievements Jongli E. Equatoria Upper Nile Bahr Algabal Unity W. B. Gazal Upper Nile Jongli N. B. Gazal

EPI Performance Sudan, DTP3 in 2003 DTP3 in 2002 DTP3 in 2004 > 80% 50 – 79% < 50% DTP3 in 2005

Summary Strengthening Routine EPI in the EMR Impact of GAVI input: –SUD, YEM & AFG ++++ –PAK & DJI ++ –SOM & sSUD: ?? Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Summary Strengthening Routine EPI in the EMR Lessons learned –PAK: Channeling financial resources to operational level Devolution Rigidity in financial rules –DJI: Human resources issue –SOM & sSUD: Insecurity Poor coordination between partners –ALL: Health system barriers not/poorly addressed End of 5 years ISS support +++ Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization Measles Partnership Meeting, Washington, DC, USA, February 2007

Eastern Mediterranean Regional Office Vaccines Preventable Diseases & Immunization GIM Meeting, New York, USA, February 2007