The gas cylinder, the motorcycle and the village health team member: a proof-of-concept study for the use of the Microsystems Quality Improvement Approach to strengthen the routine immunization system in Uganda

Abstract

Background: Although global efforts to support routine immunization (RI) system strengthening have resulted in higher immunization rates, the World Health Organization (WHO) estimates that the proportion of children receiving recommended DPT3 vaccines has stagnated at 80% for the past 3 years (WHO Fact sheet-Immunization coverage 2014, WHO, 2014). Meeting the WHO goal of 90% national DPT3 coverage may require locally based strategies to support conventional approaches. The Africa Routine Immunization Systems Essentials-System Innovation (ARISE-SI) initiative is a proof-of-concept study to assess the application of the Microsystems Quality Improvement Approach for generating local solutions to strengthen RI systems and reach those unreached by current efforts in Masaka District, Uganda.

Methods: The ARISE-SI intervention had three components: health unit (HU) advance preparations, an action learning collaborative, and coaching of improvement teams. The intervention was informed and assessed using qualitative and quantitative methods. Data collection focused on changes and outcomes of improvement efforts among five HUs and one district-level team during the intervention (June 2011-February 2012) and five follow-up months.

Results: Workshops and team meetings had a 95% attendance rate. All teams gained RI system knowledge and implemented changes to address locally identified problems. Specific changes included: RI register implementation and expanded use, Child Health Card provision and monitoring, staff cross-training, staffing pattern changes, predictable outreach schedules, and health system leader--community leader meetings. Several RI system barriers prevalent across Masaka District (e.g., lack of backup HU gas cylinders, inadequate outreach transportation, and village health team underutilization) were successfully addressed. Three of five HUs significantly increased the vaccines administered. All improvements were sustained 5 months post-intervention. External evaluation validated the findings of high levels of participant engagement, empowerment to make change, and willingness to sustain improvements.

Conclusions: The Microsystems Quality Improvement Approach is a comprehensive approach, grounded in systems thinking, and coupled with intensive coaching. It provides a robust framework for engaging teams in the development of unique local solutions that strengthen RI systems in resource poor settings. The sustained improvements in local RI systems from this study provide evidence that this approach may be an effective framework for enhancing the WHO's Reaching Every District (RED) immunization strategy.

Figure 1

Microsystems approach systems strengthening model. The conceptual model for the ARISE-SI included a representation of the health system (left triangle) and the sociocultural system (right triangle). Both triangles are segmented, representing smaller aspects of each system as one moves inward in the diagram. In the center, the two triangles overlap. This represents the inextricable link between the HU and the community it serves. Together, these two segments comprise the microsystem for routine immunization.

Figure 2

ARISE-SI intervention timeline. The ARISE-SI Project began with advance preparation to establish Ugandan project partners in January 2011. Advance preparations continued with initial HU assessments and formation of HU QI teams in June 2011. The District QI team was formed in June 2011 at Workshop 1 of the action learning collaborative. The collaborative included sequential action periods, HU site visits, and workshops which continued through February 2012. Coaching provided support to QI teams between collaborative workshops.

Figure 3

Numbers of participants attending monthly HU coaching meetings. The coach held monthly meetings at each of the HUs beginning in June 2011 and continuing through January 2012. Participants for all HU meetings combined are shown for QI team members (blue diamonds), HU staff (red squares), and VHT/community members (tan triangles).

Figure 4

Interactions among different levels of systems associated with ARISE-SI. The ARISE-SI project engaged three levels of the RI system—HUs (microsystem), Masaka District (mesosystem), and UNEPI (macrosystem). The project brought representatives from each system level together for all project activities. The coach facilitated communication and interactions both within and across the three system levels.