A Quality Improvement Approach Assists Health Systems to Develop Problem Solving Skills Focused on Routine Immunization: The ARISE-SI Project, Masaka, Uganda
African regions with relatively high (80%) routine iimmunization (RI) rates often have difficulties in sustaining these rates and reaching the WHO-recommended 90% rate or higher for herd immunity. It is especially difficult for higher performing districts to improve and sustain coverage beyond 80%.
In partnership with Dartmouth College, Makerere University, John Snow Inc., we supported the development of the ARISE-SI improvement project (African Routine Immunization Essentials – Systems Innovation). This research project aims to test the applicability of the Dartmouth Microsystem Quality Improvement approach a higher performing district, with the aim “ to reach the unreached” in order to control further outbreaks of vaccine-preventable diseases.
ARISE-SI started in January 2011 and is being implemented in Masaka, a resource-poor, rural district in Uganda, with relatively high RI performance. Within the district, the project is being implemented in five Health Units (HU) namely: Masaka Municipal Council, Bukeeri, Butende, Kiyumba, and Kyanamukaka. These HU represent the different levels of service delivery infrastructure in the health system of Uganda.
With support from ARISE-SI, UNEPI and Masaka District Health Inspector, each HU formed a multidisciplinary Health Unit Improvement Team (HUIT) comprised of unit staff, Village Health Team members (VHT), and local leader. The District formed a District Health Improvement Team.
Using the Dartmouth Microsystem Quality Improvement Approach and a curriculum that was adopted to the Ugandan context, UNEPI, Dartmouth and Makerere faculty worked with the Masaka District leadership to conduct four interactive, participatory workshops, visit HUs on a regular basis to provide further technical support and intensive coaching on the development of HU specific improvement projects.
* We helped HUITs develop an understanding of their own context and of factors influencing RI using the domains of Patients, Professionals, Process, Patterns and Purpose (the ‘Five P’ baseline assessment).
* We taught both the HUITs and the District Health Team (DHT) basic quality improvement principles and methods, helped them identify opportunities for improvement, select specific aims, develop measures, select changes for implementation, conduct Plan-Do-Study-Act cycles.
* Teams were allowed to select their own specific aims based on their assessment of their priorities and available resources.
* We trained and supported a Ugandan professional to coach the teams over the duration of the project through regular phone and in-person contact.
* The Coach provided technical help about improvement, improvement tools, reminders, encouragement, reflection and motivation using interactive approaches.
* UNEPI coached HU staff about the recommended practices and skills for ordering, storing, using vaccines and the tools used to document immunizations.
HUIT members identified several improvement activities and creative solutions that they could implement even with limited resources. Since May 2011, HUITs have shown promising initial improvements in structural and process measures of RI such as number of outreach clinics, waiting time, staffing patterns, maintenance of cold chain and caregiver interactions. HUITs have reopened outreach clinics to provide immunization, increased the regularity of these outreach clinics, trained additional personnel to provide immunization, decreased the waiting time for and become more affable with caregivers bringing children for immunization, and have also worked with community health workers (Village Health Team members) to identify and refer unimmunized children. The DHT has developed a system for procuring, providing and monitoring gas cylinders so that every health unit in the Masaka district has two gas cylinders per unit.
Improvement team members were eager to improve their performance and apply QI tools and methods to locally identified RI issues. When assisted in identifying problems and finding solutions, they are able to do so provided that on-going coaching is available. By including community leadership and VHTs as active members of the improvement teams we created an awareness of their potential to effect improvement. Seeing the results of the improvement work seemed to energize all members of the improvement teams including the HU staff, VHTs, and DHT. The team concept created a shared sense of ownership for the issues of RI and awareness that solutions for entrenched problems can be found at the community, Health Unit, and District levels, as well as at the Ministry level.