Reach Every District (RED)/Reach Every Community (REC) Strategy Evaluation Pakistan (2014-18)

"Reaching the most marginalized communities with life-saving vaccination services required a bold, collective vision and an unprecedented degree of coordination..."

The United Nations Children's Fund (UNICEF) commissioned a third-party evaluation to assess the extent to which the Reaching Every District (RED)/Reaching Every Community (REC) strategy fulfilled its intended objective of strengthening the delivery of routine immunisation services in Pakistan by improving access to marginalised and vulnerable communities. Conducted by Contech International in collaboration with Department of Public Health, Institute of Social and Cultural Studies, University of Punjab, the evaluation documented the process, strengths, weaknesses, opportunities, and challenges observed out of the implementation of the RED/REC strategy. This report provides findings on the strategy's relevance, effectiveness, efficiency, impact, and sustainability across cross-cutting areas (including gender, equity, human rights, and disaster risk reduction). The scope of the evaluation covered the period from 2014-18, focusing on the planning and implementation of the strategy at provincial, district, and sub-district levels.

In 2002, the RED/REC strategy was jointly developed by the World Health Organization (WHO), UNICEF, and other partners in the GAVI Alliance to ensure equitable immunisation coverage within communities. The RED/REC strategy was adopted by the government of Pakistan to reach socially, economically, and geographically marginalised children under the age of 1 year. The RED/REC strategy utilises primarily the existing network of the Expanded Programme on Immunization (EPI) to deliver the interventions, which fall into 5 operational components: re-establishing outreach services; supportive supervision; linking services with communities; monitoring and use of data for action; and planning and management of resources. Activities feature, for example, the participation of community outreach/lady health workers (LHWs), who work at the grassroots level to promote healthy behaviours and provide basic curative services for both female and male children, without any discrimination. In this sense, the strategy empowers females (e.g., LHWs) to act as an agents of change through social mobilising and changing behaviours of parents/caregivers (mothers and fathers) at community levels - ultimately improving the quality, coverage, and equity regarding routine immunisation.

Geographically, the scope of evaluation was 56 intervention districts across Pakistan, from the provinces of Punjab, Sindh, Balochistan, Khyber Pakhtunkhwa (KP), Newly Merged Districts (NMD), Azad Jammu & Kashmir (AJK), and Gilgit Baltistan (GB), where the RED/REC Strategy was being implemented. Contech adopted representative sample size, which made selection of 12 districts. Primary and secondary data were collected, comprising of desk reviews, 47 key informant interviews (KIIs), and 36 focus group discussions (FGDs), whereas quantitative research included an immunisation checklist and secondary analysis of key indicators of immunisation coverage. Moreover, administrative data were collected from the sampled districts to present immunisation-coverage-related indicators.

In brief, the evaluation revealed that an increase in vaccination coverage validated the effectiveness of RED/REC strategy in terms of improvement in childhood morbidity and mortality. All major components of RED/REC strategy have been taken up and merged into provincial EPI programmes to maximise the coverage of immunisation. Key findings include:

• Relevance: The evaluation found that RED/REC strategy objectives were aligned with national and provincial set priorities, particularly in addressing the needs of marginalised and vulnerable communities. The selection of intervention districts for implementing RED/REC Strategy were based on evidence, where priority was given to worst performing or hard-to-reach areas. Further, micro-planning based on social mapping has ensured inclusion of most vulnerable populations. (Social maps provide an overview of the whole population to identify priority communities for addressing barriers in reaching population in un-covered areas. These maps are generated with support from local vaccinators and communities.)
• Effectiveness: Findings of the evaluation highlighted that the RED/REC Strategy has promoted equity-based immunisation services, addressing the gender gap. In this regard, a high availability of updated micro-plans at lowest operational level (union councils - UCs) proved beneficial, focusing on hard-to-reach areas. Willingness of federal and provincial government was also evident from their concurrence on RED/REC strategy, its uptake in support of routine immunisation activities, and its institutionalisation within the EPI. Although data gathered through e-monitoring systems has been used for evidence-based decision making and course correction, monitoring and evaluation (M&E) mechanisms adopted by the government remain deficient and lack uniformity. The inclusion of LHWs as injectors has been instrumental in increasing outreach twofold, but the initiative is facing resistance, such as low acceptance by EPI officials, resistance by the LHW programme in accepting more workload, lack of adequate skills and experience for vaccination, low educational attainment, and lack of trust in their role as injectors from communities. A dearth of engagement of local civil society organisations (CSOs) and community influentials in addressing cultural, social, and gender barriers and equity related to immunisation was observed. The element of social accountability in the current strategy seems to be missing.
• Efficiency: Variance was observed in districts regarding availability of complete and computerised micro-plans and their updating. The evaluation revealed that the RED/REC strategy has added value by enhancing outreach services and strengthening capacities and competencies for routine immunisation.
• Impact: Though there was appreciable improvement in immunisation coverage in all provinces/regions, the absolute goals of RED/REC are yet to be achieved at district and national levels. Significant cross-cutting impacts were observed in non-intervention districts for ownership and implementation of RED/REC components as uniform policy to increase routine immunisation. Improved coverage in fully immunised children in the target districts/UCs was evident, particularly with increase in diphtheria-tetanus-pertussis (DTP3) coverage.
• Sustainability: The evaluation found that political will and commitment were evident from the stress drawn on vaccinating every child in Pakistan's National Health Vision, as well as provincial health policies and sector strategies. Ownership of the RED/REC strategy was evident, for example, in its institutionalisation and scale-up by provincial governments through adoption of its 5 components within non-intervention districts. The role of UNICEF was found to be fully supportive to the government in operationalisation of RED/REC strategy. However, consistent focus and financial support to supervisors remain a challenge for the government in sustaining the strategy.

Based on the key findings, the following are recommendations - with a focus here on communication-related elements - under each of the 5 components of RED/REC strategy:

1. Re-establishing outreach services - for example, augment routine immunisation coverage through mobile teams while promoting engagement of other cadres in routine immunisation service delivery; explore possibilities and mechanisms for sustainable staff incentives; increase visibility of extended health houses (EHH)/kit stations to enhance utilisation of immunization services; and engage communities and establish coordination platforms for enhancing ownership and outreach services.
2. Supportive supervision - for example, build competencies and supervisory skills, particularly in use of information technology (IT) of supervisory staff; minimise cumbersome requirements of documentation through use of IT and mobile technology; and promote constructive feedback for improved performance and regularity.
3. Linking services with community - for example, augment social mobilisation activities with a focus on re-establishing linkages of communities with facility-based immunisation services; strengthen and enhance the role of community-based organisations (CBOs/CSOs) in improving immunisation coverage at community and facility levels; re-vitalise the network of community volunteers, who reach out to the most marginalised and underserved populations.
4. Monitoring and use of data for action - for example, engage in concerted evidence-based advocacy efforts with political leadership at all levels for buy-in and sustained will and commitments; integrate monitoring platforms for enhanced use of data for action; use federal-, provincial-, district-, and sub-district-community-level mechanisms for sharing of information and lessons learned from best practices; and improve the quality, availability, and use of reliable immunisation data at all levels.
5. Planning and management of resources - for example, take an integrated approach to avoid duplication of efforts; build local capacities for effective planning and management of resources; ensure an appropriate number of EPI staff, especially vaccinators and additional community-based vaccinators (LHWs) as per need of micro-plan; leverage resources (including human resource (HR) capacities) through advocacy and involvement of relevant stakeholders; and scale up the RED/REC strategy, as a standard in routine immunisation programme intervention at district and sub-district levels.

Click here for the 116-page main report in PDF format.
Click here for the 107-page annexes in PDF format.