Implementing a Best Practice Measles SIA: Ethiopia’s Experience

1. Implementing a Best Practice Measles SIA:Ethiopia’s Experience Dr Fiona Braka WHO Ethiopia Measles Initiative Meeting, Washington DC, 13-14 September 2011

2. Ethiopia: Background Federal Ministry of Health Regional Health Bureau (9 Regions + 2 City Administrations) Zonal Health Administration (98 Zones) Woreda Health Offices (819 Woredas) Kebeles/Health Post (15,000 HP, 1 per 5,000 popln) • Projected population 2010 (census 2007): 79 million • Growth Rate: 2.6% • Under-1: 3.2% (2.6m) • Under-5: 14.6% (11.4m) • Under-15: 45% (35m) • Rural: 83% • Infant Mortality Rate: 75/1000 live-births

3. Measles cases and MCV1 admin coverage in Ethiopia, 1990 - 2010 Catch Up 2002 -2004

4. Measles Epidemiology, Ethiopia, 2010 Age and vaxn status of confirmed measles cases. 2010 (n=3527) Spot map of confirmed measles cases. 2010 (n=3527)

5. Second opportunity measles vaccination through SIAs

6. Measles SIAs: 2010-2011 2010 2011 • Target: 8.5 million (9 – 47 months) • Phased in 2: • October 2010 (90.8%) • February 2011 (9.2%) • 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)

7. SIAs Best Practices Best Practices • “Best Practices” • Activities known to lead to predictably good results without using up too much resources • Based on local realities and challenges • Identified in Ethiopia through: • Extensive review of previous reports • Detailed internal consultations • Experiences from other AFR countries

8. Areas of Focus for Best Practices • Coordination • Micro planning and training • Logistics • Advocacy and communication • Resource mobilization • Monitoring and evaluation • Strengthening routine EPI

9. Coordination of the Best Practices SIA- Ethiopia • National Task Force (NTF) with subcommittees led by FMoH • NTF Chaired by FMoH DG • Weekly meetings started 5 months prior to SIAs • ~ 7 – 10 people in every meeting • Each meeting for >2hrs == >400 person-hours • Task Forces established at regional, zonal and woreda levels – weekly feedback to NTF

10. Micro planning and Training • Emphasis on Kebele level planning with • local knowledge of needs • hard to reach populations • Work with Statistics Agency for best denominators • Focus on training quality • Pre/post testing • Participatory and practical • Schedule based on need not time allotment • Standard agenda • Evidence-based standard training materials: Field guide and translated pocket guides

11. Logistics • Required distribution of logistics 3-4 weeks before implementation • PFSA took on distribution role to Woreda level • Distribution flexibility including transport fleet for emergency distribution • Bundling of supplies

12. Advocacy and Communication • Advocacy visits to Regional Presidents • 1-2 months prior to SIA • Joint team: FMoH and partners • Evidence-based messages • Sensitization and engagement of political leaders, Women’s Groups, Pediatric Society, Clinicians • Diverse channels of communication • Mass media: radio/ TV/ billboards, mobile vans • Town criers • Schools (notified via Ministry of Education) • Door to door visits by community volunteers (some places responsible for participation)

13. Resource Mobilization • Government contributions • High level cooperation between EPI partners • Engagement of partners at all levels: • Human resources, transport, social mobilization, logistics

14. Implementation • High level launch at national level by HE The President and at regional levels by Presidents/ dignified authorities • Approximately 178,320 vaccination teams including 66,870 health workers and more than 72,870 volunteers • Daily monitoring of performance through review meetings and SMS text messaging in phase 2

15. Monitoring Multiple Data Sources (Tigray) • Pre campaign assessments (3-4 weeks and 1 week prior to SIA) and feedback given to address gaps • Different methods utilized to monitor performance: • Methods: Daily review meetings (with administration), supervision • Data Sources: Administrative, rapid convenience monitoring, independent monitoring • Improving data flow through use of SMS text messaging

16. Administrative follow-up measles SIAs coverage. Ethiopia. • 106% measles • 97% polio • >95% coverage: • - 81/95 (85%)Zones • - 740/ 814 (91%) Woredas • 93% measles >=95% Admin coverage, 2010 - 2011 Admin coverage, 2007- 2009 90-94% 80-89% <80%

17. Independent Monitoring Assessment of Woreda Performance Source of data: Post SIA Independent monitoring, 395 Woredas sampled Note: Poor quality finger markers compromised the independent monitoring process in many areas

18. Evaluation of the SIA 1.Post SIA coverage survey • To assess coverage estimates for all interventions • 80 woredas in the 2 phases of the SIA; 4,420 children 2. Best practices evaluation • To determine best practices implemented and their effect on coverage • 20 woredas 3. Strengthening of routine EPI through the SIA • 4 regions: 8 zones; urban and rural representation 4. Impact assessment

19. Post SIA Coverage Survey, 2010-2011 Phase 1: 87.8% Phase 2: 93.1% Limitations: assessment of finger marking compromised by quality of markers and timing of phase 1 survey; non availability of screening card in some areas

20. Best Practices Evaluation

21. Enhancing Routine Immunization through SIAs • 7 key areas identified in the planning phase and efforts made to maximize on RI strengthening: • Micro planning • Training • Logistics Management • Advocacy and Social Mobilization • AEFI monitoring and management • Surveillance • Monitoring and Evaluation

22. Impact of Measles SIAs on the Routine Immunisation System, Ethiopia. KAP Surveys Pre-SIA (6wks) vs Post-SIA (2wks)

23. Outcomes of the SIA Confirmed measles cases, Ethiopia, 2007-2011 Measles incidence, Ethiopia, 2006-2011 Age shift (~70% above 5 years)

24. Major Lessons Learned • Early identification of best practices at the country level • Strong federal government leadership and ownership • Micro planning should be bottom up • Include both technical and administrative officials • Adjustments after submission should be shared back down • Evidence-based social mobilization and training materials • Interpersonal communication (door-to-door where feasible) is effective • Daily intra campaign monitoring is essential for real-time results to ensure all children are reached. • Routine Immunization strengthening should be included in all aspects of planning, implementation and review, especially maintaining coordination structures

25. Future Perspectives for Measles Elimination in Ethiopia • Consideration of wider age group for the next SIA in view of ongoing transmission • Local resource mobilisation for measles control efforts based on SIA experience • Partnerships forged and strengthened • Routine system strengthening • Use of SIA Coordination structures for future SIAs and routine EPI activities such as new vaccine introduction • Pre-SIA registration of target children and identification of hard to reach populations useful for subsequent SIA and RI • Capacity building of PFSA in logistics management • Local partnerships for RI and SIAs

26. Acknowledgement • FMOH (Neghist Tesfaye) • Balcha Masresha • Meseret Eshetu • Pascal Mkanda • Gavin Grant • Sisay Gashu • Luwei Pearson • Tirsit Assefa • Habtamu Belete • Yodit Hailemariam • Halima Dao • David Brown • Kathleen Wannemuehler • Theresa Diaz • Edward Hoekstra • Mitike Molla • National SIA Task Force • MEDCO

27. Acknowledgement Ethiopia Federal Ministry of Health Integrated Family Health Partnership JSI Research & Training Institute, Inc.