The RED Strategy

Reaching Every District (RED) is a strategy to achieve the goal of 80% immunisation coverage in all districts and 90% nationally in the World Health Organization (WHO) member states. RED aims to fully immunise every infant with all vaccines included in the national immunisation schedule of countries. In order to achieve this goal, the strategy focuses on building national capacity from district level upward to maximise access to all vaccines, old and new, and to address common obstacles to increasing immunisation coverage, with a focus on planning and monitoring. In brief, the RED approach encourages countries to use coverage data to make an analysis of the distribution of unimmunised infants, and thereby prioritise districts with poor access and utilisation of immunisation, while districts are encouraged to make microplans to identify local problems and adopt corrective solutions.

Far from being a programme or separate initiative, the approach outlines 5 operational components that are specifically aimed at improving coverage in every district:

1. Re-establishing outreach services - Ideally, a minimum of 4 contacts per year are required to fully immunise an infant. For some communities, access can only be provided irregularly, and may require mobile teams to provide outreach, which will involve resources beyond the health facility and district level. Outreach sessions also present opportunities to provide other interventions (e.g., administering vitamin A and deworming tablets) with immunisation.
2. Offering supportive supervision - This involves providing on-site training to health workers at the time of a supervisory visit or at regular district meetings. Supervisors (themselves trained) should make regular schedules for visits, help to solve problems locally, and follow up regularly with supply and resource issues.
3. Linking services with communities - The idea is that involving the community with the planning and delivery of the service will encourage community ownership and improve attendance. Identifying community volunteers providing them with a role, such as follow up of defaulters, and holding regular meetings are suggested steps toward building a link with the community.
4. Monitoring and use of data for action - This implies not only the timely collection of data at district level but also the use of the data to solve problems. Some simple tools, including wall charts that display access and utilisation, require little training but are useful to take action according to monthly progress. Not only do districts collect coverage data but also a large amount of other information, including logistics, supply, and surveillance - all of which should be used to improve the immunisation system. Some qualitative data may not be available in regular reports and may need to collected though supervisory visits.
5. Planning and management of resources - The district micro plan is the key to the RED strategy. The micro plan should be based upon a local situation analysis which involves every health facility and through them the community they serve.

In addition to the WHO, many immunisation partners in the GAVI Alliance such as the United Nations Children's Fund (UNICEF), the Centers for Disease Control and Prevention of the United States (US) Department of Health and Human Services (CDC), Program for Appropriate Technology in Health (PATH), Immunization Basics, and the US Agency for International Development (USAID), have been involved in the development and implementation of the RED strategy.

Most countries in the WHO regions of Africa, Eastern Mediterranean, Europe, South-East Asia, and the Western Pacific have adopted and have been implementing the RED strategy since RED's adoption in July 2002. RED priority countries are those with large population and a high number of unimmunised infants such as India, Indonesia, Nigeria, Ethiopia, Pakistan, and China.

An evaluation of the RED strategy in 5 countries in Africa (Democratic Republic of Congo, Ethiopia, Zimbabwe, Kenya, and Madagascar) in 2005 showed that the RED approach contributed significantly to strengthening immunisation systems and improving the delivery of vaccines. Between 2002-2004, the total number of districts with diphtheria, pertussis (whooping cough), and tetanus (DTP3) coverage over 80% increased from 70 to 197, while the number of districts with less than 50% coverage declined from 377 in 2002 to 222 in 2004. The number of unimmunised children in these 5 countries was reduced from 3 million in 2002 to 1.9 million in 2004. While it was not possible to conclude which RED components or which factors contributed most to increasing coverage, the common factor in all these countries was a focus on micro planning at the district level.

An analysis of coverage data supports the findings of the evaluation in Africa. It shows that in the 53 countries that started to implement RED between 2003 and 2005, DTP3 coverage (as estimated by WHO and UNICEF) increased between 2002 and 2005 in 34 (64%) countries, and decreased in only 7 (13%). Writing in the Bulletin of the World Health Organization, Jos Vandelaer, Julian Bilous, and Deo Nshimirimana note that most of the 53 countries have functional immunisation information, logistics, and supply systems and have implemented district training.

Furthermore, the RED (Africa) evaluation showed that the extra resources needed to implement the RED strategy are relatively modest. These resources are mainly used in micro planning activities, workshops, and training and to cover other supervisory and monitoring costs. WHO regional offices have been involved in several RED planning activities and implementing RED meetings and workshops. Within countries, WHO and UNICEF staff are able to provide technical support in the development of the national Expanded Programme on Immunization (EPI) programme RED planning and implementation.

Vandelaer, Bilous, and Nshimirimana say: "We believe that the RED approach of district microplanning based upon local data using simple operational components and supported by supply and logistics has the potential for the successful delivery of other child health interventions, especially during outreach."