M A K E R E R E U N I V E R S I T Y - MakSPH-CDC ...

IMPROVING DPT-HepB +Hib 3rd DOSE COVERAGE AT MUNGULA HEALTH

CENTRE IV-ADJUMANI DISTRICT

BY

AMBAYO WILLIAM- BMLS (IHSU); Dip. MLT (JINJA)AMANDU KADARA ZAIDA- Dip. Nursing (LACOR); Dip.OCO, (JINJA)

MEDIUM-TERM FELLOWS (HEALTH SERVICE IMPROVEMENT)

MENTORS

DR. VIOLET GWOKYALYA – MakSPH-CDC FELLOWSHIP PROGRAM

Dr. AMBAKU MICHEAL- MUNGULA HEALTH CENTRE

FEBUARY, 2015

M A K E R E R E U N I V E R S I T Y

SCHOOL OF PUBLIC HEALTH (MakSPH-CDC FELLOWSHIP PROGRAM)

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TABLE OF CONTENTS

TABLE OF CONTENTS.................................................................................................................. ii

DECLARATION .............................................................................................................................. iv

ACKNOWLEDGEMENT ................................................................................................................ v

LIST OF ACRONYMS/ABBREVIATIONS ................................................................................. vi

EXECUTIVE SUMMARY............................................................................................................. vii

1:0 INTRODUCTION AND ORGANIZATIONAL BACKGROUND........................................ 2

1:1 INTRODUCTION....................................................................................................................... 2

1:2 ORGANIZATIONAL BACKGROUND................................................................................... 2

1:3 DPT-Hep B + Hib 3 IMMUNIZATION.................................................................................... 2

2:0 REASONS FOR IMPROVEMENT .......................................................................................... 5

2:1 PROBLEM IDENTIFICATION AND PRIORITIZATION .................................................. 5

2:2 FORMATION OF CONTINUOUS QUALITY IMPROVEMENT TEAM.......................... 6

3:0 CURRENT SITUATION ........................................................................................................... 7

3:1 DPT-Hep B + Hib 3 IMMUNIZATION SITUATION ............................................................ 7

3:2 PROBLEM STATEMENT & JUSTIFICATION.................................................................... 8

3:3 CONTINUOUS QUALITY IMPROVEMENT TARGET...................................................... 8

3.4 PROJECT OBJECTIVES .......................................................................................................... 9

3:4:1 SPECIFIC OBJECTIVES ...................................................................................................... 9

4:0 PROBLEM ANALYSIS ........................................................................................................... 10

4:1 ROOT CAUSE ANALYSIS OF THE PROBLEM................................................................ 10

5:1 IMPLEMENTATION OF COUNTER MEASURES............................................................ 12

6:0 PR OJECT RESULTS ........................................................................................................ 13

6:3 OTHER IMPROVEMENT OUTCOMES.............................................................................. 14

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6:3:1 ALLOCATION OF SENIOR STAFF FOR YCC DEPARTMENT................................. 14

6:3:2 HEALTH SERVICE MONITORING................................................................................. 15

6:3:3 HEALTH FACILITY - COMMUNITY PARTNERSHIP ................................................ 15

6:3:4 A CASE SCENARIO............................................................................................................. 15

7:0 LESSONS LEARNED AND CHALLENGES........................................................................ 16

7:1 LESSON LEARNED ................................................................................................................ 16

7:2 CHALLENGES......................................................................................................................... 16

8:0 CONCLUSIONS, RECOMMENDATIONS AND NEXT STEPS........................................ 17

8:1 CONCLUSIONS ....................................................................................................................... 17

8:2 RECOMMENDATIONS.......................................................................................................... 17

8.3 NEXT STEPS............................................................................................................................. 18

8.3.1 DISSEMINATION PLAN ..................................................................................................... 18

8.3.2 SCALE UP PLAN................................................................................................................... 18

REFERENCES ................................................................................................................................ 19

APPENDICES.................................................................................................................................. 20

APPENDIX 1: CQI ORIENTATION AND PROBLEM IDENTIFICATION MEETING .... 20

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DECLARATION

I, AMBAYO WILLIAM and KADARA AMANDU ZAIDA do hereby declare that this end-of-

project report entitled, Improving DPT-Hep B + Hib 3 Coverage at Mungula HCIV, Adjumani

District has been prepared and submitted in fulfillment of the requirements of the Medium-term

Fellowship Program at Makerere University School of Public Health and has not been submitted for

any academic or non-academic qualifications.

Signed ………………………………… Date…………………………………..

Mr. AMBAYO WILLIAM (Medium-term Fellow 2014)

Signed ………………………………… Date…………………………………….

Mrs. KADARA ZAIDA AMANDU (Medium- term Fellow 2014)

Signed ………………………………… Date…………………………………..

Dr. AMBAKU MICHEAL (Institution Supervisor/Mentor)

Signed ………………………………… Date…………………………………..

Dr. VIOLET GWOKYALYA (Academic Supervisor/Mentor)

All the fellows actively participated in the activities related with the implementation of the Quality

Improvement Project and Mungula HC IV.

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ACKNOWLEDGEMENT

We are grateful to a number of people who guided us in the design and eventual implementation of

the project. Our sincere thanks go to institutional mentor who provided us with the technical

support but also created an enabling environment for us to attend the course. We are also indebted

to our academic mentor for all the advice throughout the design and implementation of the project.

Lastly, we are thankful to our families for the moral and spiritual support.

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LIST OF ACRONYMS/ABBREVIATIONS

DPT-Hep B + Hib Diphtheria, Pertusis, Tetanus –Hepatitis B + Heamophilusinfluezaetype b

EPI Expanded Program for Immunization

GAVI Global Alliance for Vaccine Initiative

HCIV Health Centre Level Four

MoH Ministry of Health

WHO World Health Organisation

YCC Young Child’s Clinic

VHT Village Health Team

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EXECUTIVE SUMMARY

The series of immunizations known as DPT-Hep B + Hibcan prevent diphtheria, pertusis

(whooping cough) and tetanus, hepatitis B and Heamophilusinfluezae type B but these diseases still

kill 600,000 children and afflict millions of others every year in developing countries

WHO/UNICEF, 2012.To be fully protected, children must receive three doses of the vaccine,

administered at the ages of six (6) weeks, ten (10) weeksand fourteen (14) weeks. Completing the

immunization schedule helps a child to get adequate protection from all the immunisable diseases

such as polio, measles, whooping cough, diphtheria, pertusis and tetanus. In Uganda, Immunization

remains a key priority of the Minimum Health Care Package by the health sector. Despite efforts to

accelerate immunization coverage in general and DPT-Hep B + Hib 3in particular, about 22%

districts in Uganda were below the national target of 90% in the July to September quarter of

2013/2014 financial year. Almost all the districts in the West Nile region except Arua performed

poorly with regard to this target. Against this background, the mid-term fellows at Mungulu HC IV

identified lowDPT-Hep B + Hib 3coverage as a priority problem to address.

With support from the fellowship program, a QI project was designed aiming atincreasingthe

percentage coverage of DPT-Hep B + Hib 3immunization completion at Mungula HCIV from 68.6

% to 95% by end of November 2014. In the five months of the project implementation, impressive

results have been achieved as follows; July 79%, August 114%, September 112%, October 116%

and November 125%. The capacity of the YCC clinic was also improved through the allocation of

senior nurses and a community partnership for mobilization was also established. Finally, a

performance monitoring review that was established has resulted into improved performance as it

provides an opportunity for staff to assess performance and lay strategies for improvement.

The biggest lesson learnt from this project is that community partnerships are very important in the

success of immunization campaigns. Consequently, it is recommended that other health workers

should get opportunities to train in CQI.

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1:0 INTRODUCTION AND ORGANIZATIONAL BACKGROUND

1:1 INTRODUCTION

The series of immunizations known as DPT-Hep B + Hib can prevent diphtheria, pertusis

(whooping cough) and tetanus, Hepatitis B and Heamophilus influezae type b infections but these

diseases still kill 600,000 children and afflict millions of others every year in developing countries

WHO/UNICEF, 2012. To be fully protected, children must receive three doses of the vaccine,

administered at the ages of six (6) weeks, ten (10) weeksand fourteen (14) weeks; completing the

immunization schedule helps a child to get adequate protection from all the immunisable diseases

such as polio, measles, whooping cough, diphtheria, pertusis and tetanus. The percentage of

children receiving the final dose (DPT-Hep B + Hib 3) is therefore a revealing and vital gauge of

how well countries are providing immunization coverage for their children.

In Uganda, Immunization remains a key priority of the Minimum Health Care Package of the health

sector. Over the past years, implementation of the expanded program for immunization

revitalization and strategic plans has accelerated government efforts to achieve better health for the

children and women of Uganda, thereby contributing to the enhancement of the quality of life and

productivity.

1:2 ORGANIZATIONAL BACKGROUND

Mungula HCIV, is a government health facility located in Itirikwa Sub County about 23kms south

of Adjumani town, it serves a catchment population of 12,227 persons. The health facility provides

diverse health care services within various departments including Outpatient department,

laboratory, general ward, maternity, ANC, immunization (YCC), operating theatre etc

1:3 DPT-Hep B + Hib 3 IMMUNIZATION

Diphtheria is a disease caused by a germ called ‘Corynebacterium diphtheriae’. The germ produces

toxins that harm or destroy human body tissues and organs. One type of the disease affects the

pharynx and other parts of the throat. Another type, commoner in the tropics, causes ulcers on the

skin. The disease affects people of all ages, but mostly un-immunized children.The most effective

way of preventing diphtheria is to maintain a high level of immunization in the community.

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InUganda, Diphtheria toxoid is given together with Pertussis, Tetanus, Hepatitis B and

Heamophilus influenzae type B vaccines (DPT-Hep B + Hib).

Pertussis, or whooping cough is a disease of the respiratory tract caused by a germ called Bordetella

pertussis, which lives in the mouth, nose and throat. Many children with pertussis have coughing

spells lasting four to eightweeks. The disease is most dangerous in children aged under 1 year

especially those who are un-immunized, this bacterial infection spreads from an infected person

(droplets) through sneezing. The disease is extremely contagious, especially where people live in

crowded conditions and nutrition is poor. Infants and children under five years are the people most

likely to be infected. They may also develop life-threatening complications like bacterial

pneumonia and die from the disease. The most effective way to prevent pertussis is to immunize all

children under 1 year.

Tetanus affects people of all ages. The disease is particularly common and serious in newborn

babies where it is called Neonatal tetanus. Neonatal tetanus kills between 500,000 and 1 million

babies every year worldwide (WHO). Almost all neonates who get the disease die. Neonatal tetanus

is particularly common in rural areas where most deliveries are at home without adequate sterile

procedures. In Uganda, neonatal tetanus remains a serious problem in districts with poor

immunization coverage and unclean practices associated with childbirth. If untreated, tetanus is a

very serious disease at any age, almost every person contracting tetanus dies. All children should be

immunized against tetanus because antibodies transferred from the mother before birth last for only

a few months. Infection occurs when contaminated objects puncture or cut the skin and umbilical

cord. It can also occur during unclean delivery practices. the most important way to achieve

prevention is to immunize women of childbearing age 5 doses of TT vaccine and to ensure clean

delivery practices Children receive protection from tetanus by receiving 3 doses of DPT- HepB

+Hib vaccine.

Hepatitis B is a disease caused by the hepatitis B virus and it affects the liver. Adults who get

hepatitis B usually recover.However most infants infected at birth become chronic carriers i.e. they

continue to carry the virus for many yearsand can spread the infection to others.In the year 2000,

there were an estimated 5.7 million cases of acute hepatitis B and more than 521,000 deaths from

hepatitis B related diseases worldwide. It is estimated that there are about 350 million carriers of

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hepatitis B virus worldwide. In Uganda, it is estimated that 1.4 million people are infected with

hepatitis B (National Hepatitis B Sero survey 2005). This ranks Uganda among countries with high

endemicity. It is recommended that all infants receive three doses of hepatitis B vaccine during the

first year of life. In Uganda Hepatitis B vaccine is given in combination with Diphtheria, Pertussis,

Tetanus and Heamophilus influenzae type b vaccines as DPT-Hep B + Hib vaccine.

Haemophilus influenzae type b (Hib) is the commonest form of Haemophilus influenzae. Hib is a

leading cause of bacterial meningitis and is also responsible for about 2.7 million cases of

pneumonia in developing countries. According to WHO, 5% to 10% cases of Hib meningitis are at

risk of dying. This comes as a result of seeking health care late, improper treatment or use of

inappropriate drugs.

Low DPT-Hep B + Hib 3completion is one of the bottlenecks in attainmentof quality immunization

services in resource limited settings. Although there is a 90% increase in immunization coverage in

every district of Uganda, most districts are slow when it comes to the utilization of these services.

About 78% of districts are above the national target for DPT-Hep B + Hib 3 coverage of 90% for

the quarter (July- September) 2 013/2014;only 22% of the districts are below 90% DPT-Hep B +

Hib 3coverage for the targeted infants in that quarter(UNEPI, 2014).Accordingly all the districts in

Westnile region (Adjumani, Moyo, Yumbe, Maracha, Koboko and Nebbi) scored poorly except

Arua on the utilization of the immunizations services despite the fact that the access to these

services was good in the July-September quarter.

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2:0 REASONS FOR IMPROVEMENTMungula HCIV is public/government health facility that is mandated to provide and implement

ministry of health activities. One of the key services in the primary health care package expected to

be provided at all health centers is immunization. The goal of improving immunization coverage is

to improve quality of life through protective vaccination of children against all the immunisable

diseases; polio, measles tetanus, diphtheria, whooping cough, pneumonia hepatitis b in corners of

the country.

2:1 PROBLEM IDENTIFICATION AND PRIORITIZATION

Following module 1 of the health service improvement course, the two fellows convened staff

meeting with the aim of briefing them about the course and to engage them in a process of

identifying service delivery problems faced by Mungula Health Centre IV. Through

brainstorming,staff identified a total of 14 problems which they thought affect service delivery at

Mungula health centre. The team then focused on selecting/prioritizing only one main problem for

improvement through a voting process.The votes were cast by show of hands using a scale of scores

1-5. Results of this exercise are shown in the table 1.

Table 1 list of areas that required improvement

PROBLEMCODE

PROBLEM SCORES/VOTES

TOTAL SCORES

A Absenteeism of staff 3 15B Not following ethical standards 2 10C Negative attitude towards work 1 5D In adequate community sensitization 2 10E Irregular CME 2 10F Late arrivals of staff on duty 2 10G Low DPT-Hep B + Hib 3coverage 5 25H Poor documentation 4 20I Low post natal coverage 2 10J Low 4th ANC visit 3 15K Poor infection control 2 10L Low IPT2 coverage 2 10M Stock out of vaccines 1 5N Late HMIS monthly reporting 4 20

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From the results above low DPT-Hep B + Hib 3coverage emerged as the most pressing problem

which the staff selected as the facility project. Officers present during this meeting are listed in

Appendix 1

2:2 FORMATION OF CONTINUOUS QUALITY IMPROVEMENT TEAM

A continuous quality improvement team was formed; it comprised members from all the

departments as listed in Table 2 below. To achieve administrative support and as required by the

Fellowship program guidelines, the medical officer, in charge of the facility was selected as the

overall head of the team since he is the head of the institution and Supervisor of the Fellows.

Table 2 Composition of Quality Improvement Team

Institution Name Cadre /Officer

Mungula HCIV Dr. Ambaku Michael Medical Officer/Chairperson

Mr. Ambayowilliam Laboratory Technologist/Project Team Leader (MakSPHFellow)

Mrs. KadaraAmanduZaida Assistant Nursing Officer(MakSPH Fellow)

Mr. Mamawi Henry Clinical Officer

Sr. Moriku Joyce Nursing Officer

Mrs. Utua rose Lillian Assistant Nursing Officer

Mrs. Otema Christine Assistant Nursing Officer

Mr. Asobasi Gilbert Records Assistant

Mrs. Lebu Priscilla Assistant Nursing Officer

Mrs. Odaru Judith Registered Midwife

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3:0 CURRENT SITUATION

3:1 DPT-Hep B + Hib 3 IMMUNIZATION SITUATIONMungula HCIV is equipped with essential tools required to provide immunization services. The

ministry of health is responsible for supply of all vaccines in the facility and maintenance of cold

chain equipment such as refrigerators through UNEPI program. The health facility also receives

funding to cater for immunization outreaches on quarterly basis. Immunization services at Mungula

HC IV are provided in the young child clinic (YCC) routinely as mothers bring their children for

first time vaccination or return visits (static Mode). In addition, the facility conducts outreaches in

the community once a week as provided for in the facility work plan and when resources permit.

During outreaches, prior notifications are given to village health teams to inform community

members on the planned health facility visits for immunization activity.

Review of health facility DPT-Hep B + Hib 3immunization data showed during the period of

2013/2014 financial the health facility had indicated projected target population of 521children<1yr

for DPT-Hep B + Hib 3 completion and monthly target completion of 43 children. A further review

ofreports from Jan-June 2014was conducted to assess the performance of the coverage. This was

intended to ascertain average percentage of DPT-Hep B + Hib 3completion. The results of the

review revealed that the average monthly percentage ofDPT-Hep B + Hib 3completion was at 68.6

below HSSP target by 14.4% (fig 1).

Figure1 percentage of DPT-Hep B + Hib 3completion at Mungula HCIV (Jan- June 2014)

Source: Biostatistics Department, Adjuman District Health Office

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3:2 PROBLEM STATEMENT & JUSTIFICATION

The M.O.H and W.H.O guidelines recommends that all children <1 yr complete their vaccination

against all the immunisable killer diseases for adequate/complete protection. However, the target

population of DPT-Hep B + Hib 3completion among children <1 yr for 2013/2014 (n=521) at

Mungula HCIVwasn’t achievedthus the facility recorded below coverage during the period of Jan-

May compared to HSSIP target of 83% indicating a gap of 14.4%; this has been attributed to

inadequate community awareness on the benefits of immunization coupled with circulation of

rumors and misconceptions about immunization, lack of follow up of DPT-Hep B + Hib 3dropouts

from the community and poor delivery of immunization to clients/mother by health

workers.Although there is immunization activities taking place both static and outreach, DPT-Hep

B + Hib3 coverage continues to perform below national target. Therefore, if this trend is not

addressed it could result into sudden outbreak of immunisable diseases leading to secondary effects

detrimental to the quality of life, It is against this background, the quality improvement project at

Mungula HC IV targeted to sensitize village health teams (VHTs) on EPI in 100% of villages by

November 2014, reaching every child in homestead and conducting health facility review meetings

to check immunization progress and improve on the information delivery to clients on benefits of

completing DPT-Hep B + Hib 3rd dose vaccination.

3:3 CONTINUOUS QUALITY IMPROVEMENT TARGETThe project targeted to increase the percentage coverage of DPT-Hep B + Hib 3completion at

Mungula HCIVfrom 68.6% to95% by end of November 2014 (Figure 2)

Figure 2: Project QCI target for increasing DPT-Hep B + Hib 3 completion and coverage at

Mungula HCIV, Adjumani District (July- Nov 2014)

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3.4 PROJECT OBJECTIVES

To improve DPT-Hep B + Hib 3coverage from the current average of 68.6 % to 95 % in order to

improve health services delivery in Mungula health center IV from July –November 2014

3:4:1 SPECIFIC OBJECTIVES

1. Sensitization of community stake holders and village health teams

2. Establish monitoring and defaulter follow up mechanism

3. Create linkage between VHT registers (HMIS 097) and child register (HMIS 073) for

tracking purposes

4. Supplement on immunization community outreaches

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4:0 PROBLEM ANALYSIS

4:1 ROOT CAUSE ANALYSIS OF THE PROBLEM

Toestablish the root causes for low DPT-Hep B + Hib 3coverage, members listed in appendix brain

stormed through focused group discussion to present depiction of immunization practices at the

facility. In addition, all immunization reports were reviewed. The root causes were identified and

classified in to four main categories. Namely, the community, clients/mothers, staffs and supply as

summarized in the fish bone analysis (figure). The big bone that had many bone branches was

considered to be the main contributor to the problem which when addressed could significantly

improve on DPT-Hep B + Hib 3coverage.

Figure 3: Fish Bone analysis to identify root causes for low DPT-Hep B + Hib 3coverage againstthe target among children <1 yr at Mungula HCIV, Adjumani District.

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Figure: 4 MakSPH Fellows Facilitating a Quality Improvement Meeting at Mungula HCIV,

Adjumani District

Figure 5: Officers attending a quality improvement meeting convened by MakSPH fellows at the

health facility below

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5:0 PRACTICAL COUNTER MEASURES

5:1 IMPLEMENTATION OF COUNTER MEASURES

ProblemStatement

Identified Root Causes Counter Measures Implemented

Low DPT-Hep B +Hib 3Coverage

Poor documentation becausestaff don’t update childhealth register aftercommunity outreachimmunization

Updated child health registers

Developed standard operatingprocedure for outreach immunizations

Conducted on job mentorship oncompleteness of immunization reports

No community defaulterfollow ups because of poortracking mechanism

With support of the project funds,staffs and VHTs followed outdefaulters in the community

Activated utilization of village childregister for children <1 yr as adefaulter monitoring mechanism

Poor information delivery forclients to examineimmunization benefitsbecause of limited IECmaterials to guide staffsduring Health Education.

With support from other UNHCRImplementing partners such as ACFand CONCERN WORLDWIDEprovided enough IEC materials

Poor duty allocation becausethere is overwhelming workat YCC

With health facility Administrativesupport, 2 staffs were allocated tomanage the work at YCC

Communication gap withcommunity leaders/stakeholders

Conducted immunizationregularsensitization meetings with VHTs,Local councils (LCs), Religiousleaders

Availed community immunizationoutreach programs to VHTs beforeanticipated outreach date.

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6:0 PROJECT RESULTS

6:1 Percentage of DPT-Hep B + Hib 3Coverage at the end of November 2014 at Mungula HCIV,Adjumani district

Significant improvements were realized regarding monthly immunization coverage at Mungula HC

IV throughout the five months of project implementation. As reflected in figure 6 below, from

August to November 2014. This success can be attributed to increased frequency of outreaches,

update of linkage of VHT/ICCM and Child health registers, practical implementation of

immunization standard operating procedure (SOPs) during static and outreaches sessions especially

completeness and update of information in the registers.Improved data capture in particular led to

identification of immunization status of many children and defaulters were easily tracked in all the

villages. The identified defaulters were then tracked and immunized accordingly. Figure 6 below

reflects the results of this activity.

Figure 6: Continuous quality improvement achieved (July-Nov 2014) for DPT-Hep B + Hib

3completion at Mungula HCIV, Adjumani District

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Figure 7: Average Improvement Achieved Compared to the Set Improvement Target

Review of the continuous improvement showed that an average improvement of 109.2% was

achieved over a five months’ period (July to November 2014) compared to the set improvement

target of 95% and this revealed that an average improvement achieved surpassed the target by 14%

as illustrated in Fig.

6:3 OTHER IMPROVEMENT OUTCOMES

6:3:1 ALLOCATION OF SENIOR STAFF FOR YCC DEPARTMENT

Before the implementation of this CQI project, a nursing assistant managed the YCC department at

Mungula HCIV. However, following re-allocation of heads of departments, Assistant Nursing

Officer was identified to head the YCC department assisted by the former and other rotational staffs

deployed to manage the demanding job force. This was done in anticipation that the enhanced job

force would be a concrete/base for sustainability of continuous quality improvement in YCC and

the health facility at large. It is also paramount to observe that staffs obtained knowledge on quality

immunization practices following on job mentorships conducted during the project.

0

68.6

109.2

14

95

0

20

40

60

80

100

120

1 2 3 4

Ave

rage

per

cent

age

of D

PT

-Hep

B +

Hib

3co

vera

ge

Baseline (June 2014)

Achieved (July-Nov 2014

Surpassed

Improvement Target by End ofNov 2014

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6:3:2 HEALTH SERVICE MONITORING

Prior to the implementation of the CQI project, there was no health facility based performance

monitoring and action plan reviews at Mungula HCIV. Though, there is still inconsistency when it

comes to bi- weekly performance review and action plan meetings, the project implemented this

activity with hope of easily identifying and addressing root causes of problems of low health

services performance against the set targets. It must also be noted that during the implementation of

activities strategies were continuously changed according to bi-weekly reports on immunization

challenges, achievement and action plans.

6:3:3 HEALTH FACILITY - COMMUNITY PARTNERSHIP

Previously, there was poor partnership with the community. During the implementation of these

CQI project activities through sensitization of VHTs/stake holders namely Local Councils and

religious leaders on child immunization a very strong partnership was formed that led to easy

identification of children who were not fully immunized through strengthening utilization and

update of village child registers. Such children were able to complete their immunizations to stay

protected against immunisable killer diseases.

6:3:4 A CASE SCENARIO

At some point in the project partnership improved, complete immunization was attained. A case of

one religious leader who identified a mother with male child of 2 months delivered from home and

never brought for immunization for fear of being criticized. This prompted the health facility to

recognize negative community perception of inappropriate language used by health workers.

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7:0 LESSONS LEARNED AND CHALLENGES

7:1 LESSON LEARNED

One of main lessons learnt was that community leaders/stakeholders and village health

teams play a fundamental role in realization of increased immunization coverage,

continuous quality improvement provision of basic services in the health care systems. This

was because all became active and motivated towards seeing the health facility attains

widerimmunization coverage as result during the project, wider coverage was reached that

surpasses the projected improvement target by 14.2% from July-November 2014.Such a

support enabled health workers to save time for other duties.

Completeness and update of information in registers at health facility and in the villages

eases tracking and monitoring immunization status of every child <1yr.

7:2 CHALLENGES

Throughout the implementation of the CQI project, there were challenges experienced as reflected

below;

1. It was observed that mobilization of general staff became difficult thus communicating

information to the every staff was difficult especially on outreach practices and performance

progress. This is mainly because management takes long to convey staff meetings.

Consequently not all staffswere involved in continuous quality improvement activities as

required by CQI principles.

2. Challenges related to migration in the community were also observed during follow up of

defaulters, this was noted mainly among refugee camps.

3. During the implementation of this project, some substantial CQI team members showed less

commitment towards the project. This was because most of members in the team were naïve

on CQI principles and health services delivery performance indicators.

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8:0 CONCLUSIONS, RECOMMENDATIONS AND NEXT STEPS

8:1 CONCLUSIONS

In a period of 5 months (July to Nov 2014) of implementing counter measures for this CQI project,

the average percentage of DPT-Hep B + Hib 3coverage at Mungula HCIV increased from average

68.6% in June 2014 to 109.2% by end of November 2014. Although the 95% target was surpassed,

the average 109.2% improvement achieved within this period demonstrated that regular

immunization outreaches, defaulter follow up, strengthened utilization and update of master village

child register for easy identification of defaulters and establishment every child’s immunization

status in every house hold.

8:2 RECOMMENDATIONS

To standardize and uphold the improvement achieved, the following recommendations are

proposed:

To improve every staff involvement in CQI activities, it is recommended that the health

facility management should address some managerial gaps such lack of routine and

consistent mobilization of general meetings, performance review meetings. Through this

approach, team work can be enhanced.

To sustain quality improvement projects, there should be managerial will to formulate a

very strong CQI team members based on performance and personnel’s commitment not by

seniority or administrative hierarchy.

To expand and reach a bigger multiplier result on acquaintance and skills of CQI concepts,

it is recommended that in prospect Fellowship projects, MakSPH-CDC considers providing

an abridged training to the other team members who work with the main stream Fellow.

This will enable the permanence long after the Fellow stir on.

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8.3 NEXT STEPS

8.3.1 DISSEMINATION PLAN

The next step in thoughtfulness is to publicize in February 2015 the achievements, deliverable and

outputs attained in this CQI project to MakSPH-CDC that sponsored and synchronized this Program

implementation.

8.3.2 SCALE UP PLAN

Besides Itirikwa sub-county, Mungula HCIV in particular, there some health facilities with low

DPT-Hep B + Hib 3coverage noted in sub-counties of Arinyapi Sub-County (Arinyapi HCIII),

Ukosijoni Sub-County (Ukosijoni HCIII), Pacara Sub-County (Pacara HCIII), and Ofua Sub-

County (Ofua HCIII). As a plan hence, a similar CQI project focusing on improving immunization

coverage will be proposed for implementation at these sub-counties and health center IIIs.

8.3.3 SATELITE TRACKING, MONITORING AND FOLLOW UP OF CHILDREN

It was observed that as common practice, children born at Mungula HCIV coming outside the

facility’s population catchment area were not registered in the health center child register after the

first immunization. Instead they were referred to continue from the nearest health facility of their

origin. Therefore, it is important that Mungula HCIV, the facilities of referral and village leaders

conduct a joint tracking, monitoring and follow up to ensure such children are not lost but rather

complete their immunization. In the future plans, it is planned that monthly systematic inter-facility

data review will be instituted and adhered to by service providers as an path to improve quality of

service delivery.

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REFERENCES

1. Uganda National Expanded ProgrammeOn Immunization Multiyear Plan 2010 – 2014

2. Immunization Practice In Uganda, A Manual For Operation Level Health Workers, 2nd

Edition ,August-2007

3. WHO/UNICEF Immunization Summary Data, 2012, 2nd Edition 2014

4. http://www.newvision.co.ug/news/650408-uganda-s-immunisation-coverage-improves.html

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APPENDICES

APPENDIX 1: STAFF ATTENDANCE LIST OF THE CQI ORIENTATION ANDPROBLEM IDENTIFICATION MEETING

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