1. Integrated Measles Best Practice SIA 2010/2011 Experience from Ethioipia Global Measles and Rubella Meeting, 15-17 March 2011, Geneva

2. Outline Background Measles coverage and epidemiological situation Ethiopia SIA Experience SIA implementation/achievement SIA evaluation Opportunities and challenges

3. Ethiopia: Background Federal 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

4. Reported Measles Cases and Measles Coverage- 1990-2009, Ethiopia Catch Up 2002 -2004 Best practice 2010

5. Measles Outbreaks - 2010 Vaccination status of confirmed measles cases. January – Dec 2010 Confirmed Measles cases January - Dec 2010

6. 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 2 nd 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

7. Pre-Identified SIA Best Practices Coordination National and sub national Task Force with subcommittee's led by government health bureau Weekly updates from each level for management and monitoring of SIALogistics 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 Training Emphasis on Kebele level planning with identification of hard to reach and difficult populations Participatory approach in training. Advocacy 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

8. 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

9. Implementation of Best Practice Integrated Measles SIA

10. Funding for 2010/11 Measles SIAs Item Total Budget (USD)FMOH Nutrition Partners (EOS) Funding from the Measles Initiative Global Polio Initiative WHOUNICEF Vaccine and injection materials 5,371,9013,345,0972,026,804 Operational costs 6,464,204746,2191,502,2052,101,5401,364,240750,000 Grand Total 11,836,105746,2191,502,2052,101,5404,658,0972,776,804 Target population (< 5)12,859,245 Cost per child (USD)0.92

11. 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 preparationRegional level task force led by RHB-PHEM head

12. Launching Activities

13. Implementation

14. SIA Administrative Coverage, Ethiopia, 2010-11 >=95% 90-94% 80-89% Measles Coverage OPV Coverage National coverage 106% National coverage 97%

15. 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%106107 5-10%6779 <5%222209 Source of data: Post SIA Independent monitoring, 38 6Woredas (52%) sampled Note: Poor quality finger markers compromised the independent monitoring process in several areas

16. 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

17. Preliminary coverage survey result Regions Measles Coverage by maternal recall Measles Coverage by Card Measles Coverage by Either maternal recall or card NWted %N N Amhara (n=405)24860.527666.838494.2 Oromia (n=963)75982.641137.287791.7 Somali (n=376)36397.215536.336597.3 SNNPR (n=526)39379.323445.447591.4 Harari (n=286)21772.720270.327291.7 Addis Ababa (n=269) 21681.620376.325293.8 Dire Dawa (n=263) 23489.211547.824191.2 Total (n=3088)243077.5159648.1286692.7

18. Enhancing Routine Immunization through SIAs 7 key areas identified in the planning phase and efforts made to maximize on RI strengthening: 1.Micro planning 2.Training 3.Logistics Management 4.Advocacy and Social Mobilization 5.AEFI monitoring and management 6.Surveillance 7.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

19. Effect of Measles SIA on the Routine System, Ethiopia Regions Addis AbabaOromiyaSNNPRSomali Pre-SIAPost SIAPre-SIAPost-SIAPre-SIAPost SIAPre-SIAPost-SIA Presence of a micro plan for EPI 50%76.9%98.8% 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% 60%64% Number of health facilities which had adequate functional cold chain 83%100%26%22%32%14%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%

20. Key Factors Contributing to SIA Success SIA ComponentMajor 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)

21. Key Challenges of the SIA SIA ComponentChallenges 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)

22. 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

23. 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

24. Acknowledgement Ethiopia Federal Ministry of Health Local Partners: CORE GROUP, L10K, IFHP