Making "Reaching Every Ward" Operational

Developed in Nigeria, Reaching Every Ward (REW) is "a strategy aimed at provision of regular, effective, quality and sustainable routine immunization activities in every ward, so as to improve immunization coverage. It focuses at improving the organization of immunization services so as to guarantee equitable immunization for every child." This document describes how IMMUNIZATIONbasics (IMMbasics) Nigeria adapted the World Health Organization (WHO)'s Reaching Every District (RED) approach to its country context in the form of REW as part of its push to increase and sustain high levels of routine immunisation (RI), particularly in the Africa region.

As described in this report, in October 2006, IMMbasics, financed by the Office of Health, Infectious Disease and Nutrition, Bureau for Global Health, United States Agency for International Development (USAID), embarked on a two-and-a half year effort in Bauchi and Sokoto states to put REW into action. The 5 REW components include:

1. Planning and management of resources - e.g., through a health facility catchment area map showing every settlement, target populations, outreach sites, roads, major physical and social structures, etc.
2. Improving access to immunisation services - establishing or re-establishing both fixed immunisation sites as well as outreach or mobile immunisation sites.
3. Supportive supervision - regular visits with on-the-job training by supervisors; feedback and follow-up with health staff; promotion of use of data.
4. Monitoring for action - using tools and providing feedback for continuous self-assessment and improvement, including review meetings to promote use of data, charting of doses, and participatory mapping of the population in each health facility catchment area.
5. Linking services with communities - community participation in health services; planning and jointly identifying a role for the community; involving village development committees (VDCs), ward development committees, (WDCs), and traditional birth attendants (TBAs).

Detailed information about IMMbasics's strategies may be found in the Related Summaries links, below. But, in brief: "IMMbasics worked not only to strenghthen RI in Bauchi and Sokoto, but also to provide an affordable and practical way forward for the Federal Government of Nigeria's effort to improve RI and PHC nationally. There was no existing step-by-step reference on 'how to' implement REW in a practical way, only a Field Guide on what is generally required. Thus the work of the project was also developmental and innovative, which required committing time and staff for developing and field testing new approaches and tools. As the approach and tools became refined, the project made more and more progress on strengthening the systems and the capacity of health workers. The project directed more effort on strengthening community linkages only after improved planning, management, and monitoring and supervision systems became operational."

To make REW operational, IMMbasics undertook a 7-step process (described in depth in both the body of the report and in many appendices):

1. State planning and management of resources, which involved a review of existing documents, such as Local Government Area (LGA) monthly RI summaries, health worker staff lists and qualifications, and data on both immunisation coverage and access to immunisation services. This participatory exercise is designed to help the States realise the status of their RI services in terms of number and locations (by ward) of the health facilities actually providing RI. The States also work on revising their work plan for strengthening RI in coordination with partners such as the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), IMMbasics, and Community Participation for Action in the Social Sector (COMPASS). The State then works on improving their planning through regular meetings and by making planning a continuous, integral part of programme management. The State assessment team compiles all relevant national, State, and LGA documents and recruits consultants to collect a specific set of health systems information. This information, coupled with the data already available through both States and WHO, forms the basis of the State RI work plan and also serves as baseline data for the State for assessing their progress later on.
2. LGA planning and management of resources, which involves: (i) a sensitisation meeting held with 3-5 LGAs to introduce primary health care (PHC) teams to the coming effort; (ii) mini-review to establish baseline information in each LGA and to expose everyone in a participatory manner to the complete situation of the RI system in their LGA; and (iii) RI Planning in each LGA to identify objectives, targets, next steps, schedule, and responsibilities for strengthening RI, immediate actions to take, planning making use of local information from the LGA review and other LGA sources.
3. Systems strengthening, which first involves the LGA identifying the key RI tasks and then setting the standards for them through a series of exercises lasting an average of two days with participants including LGA PHC staff and the Joint RI Strengthening Team (JRIST). Mentorship and supervision follows. "Graphs showing comparison of individual health facility performance as well as summary graphs such as those below provide visual evidence to managers on performance improvement, and serve as encouragement for continued improvement." According to the document, "[o]ne of the most unique features of this approach for making REW operational is that: The supportive supervision system is put in place before the formal training of health workers."
4. Capacity building and training, described here as a continuous process, requiring on-the-job reinforcement and active participation. "Recognizing and practically adopting adult learning methodologies was central to the training sessions. Some of the key elements applied included: eliciting the participant's knowledge of the subject matter very early in the training, assigning roles and responsibilities, and keeping the training classes small to ensure two-way interaction between facilitators and all participants. Participants had not experienced this kind of attention or detailed hands-on training where the facilitators presented the message using various methods in a friendly manner. This definitely induced their motivation to learn and participate....Throughout training participants are encouraged to interact. They take part in role plays, share experiences, and participate in practical sessions, such as using dolls or oranges to practice giving injections. During training, the local language is used freely by both facilitators and participants. This was found to be very effective in ensuring clear understanding of the topics. Other techniques applied to encourage participation included: role play and drama, simulation games, demonstration/return demonstrations, practicing injection techniques on dolls or fruit, and field visits."
5. Efforts to increase access to services, such as by identifying or updating the health facility catchment area map. "This joint exercise allows health personnel and community members to interact and to perform the most basic, yet critical of step for building a strong primary health care system."
6. Linkages between services and communities, built through strategies such as inviting traditional leaders for various interactions with the LGA and health workers and, when training service providers, including guidance on how to plan with the community and link up with community structures, such as village development committees (VDCs) and ward development committees (WDCs).
7. Maintenance and expansion: "Strengthening RI and revitalizing PHC requires a government driven structure which provides low-cost training for health workers, periodically and continuously."

The report offers a number of lessons learned in each of the 7 elements. For instance, it is noted that REW is particularly well suited for countries with limited resources and can be implemented using low-technology methods. Neither costly equipment requiring maintenance systems nor capacity beyond that of the average health facility personnel is essential. In the "monitoring for action" area, "[s]imple charts and hand drawn graphics can be used. Compiling and using data does not depend entirely on having a computer. When staff understand the value of their own data, data quality improves....Using data effectively includes discussing and reviewing it with staff, and even local leaders, at least monthly at all levels."

In conclusion, in the context of a weak PHC system, REW's components provide "a mechanism that can overcome barriers to better quality service delivery. Many of the components contain intentionally overlapping content. This overlap between components helps to reinforce the lessons learned in each component, which strengthens the entire PHC system. Operationalizing REW is clearly a step-by-step process, implemented LGA by LGA, ward by ward and health facility by health facility. A systematic approach which does not skip any steps ensures a strengthened RI system. This strategy, using RI as an entry point, demonstrates a way forward for strengthening the entire PHC system in Nigeria."

Click here for the 74-page report in PDF format.