Implementation and evaluation of the Reaching Every District (RED) strategy in Assam, India, 2005–2008☆
Introduction
The northeastern Indian state of Assam is home to an ethnically and tribally diverse population of 26 million people, 87% of whom lived in rural areas in 2001 [1]. Although survey data indicated that coverage with the third dose of diphtheria, tetanus, and pertussis vaccine (DTP3) among children 12–23 months of age had increased from 38% in 1998–1999 to 45% in 2005–2006, vaccination coverage in Assam was lower than the national average [2]. This coupled with the fact that only 67% of children had received the first dose of DTP vaccine in 2005–2006 [2], indicated problems with both access to and utilization of vaccination services. In 2004, the Ministry of Health and other immunization program stakeholders in Assam studied reasons for low routine vaccination coverage, and identified remediable barriers in administration and planning (e.g., weak microplanning, inconsistent funding for supervision, and lack of medical staff involvement in supervision and monitoring of vaccination services); staffing (e.g., high personnel vacancy rates, including at supervisory posts); and supplies (e.g., inconsistent funding for vaccine procurement and irregular vaccine supply) (Directorate of Health Services Meeting unpublished minutes, April 2004, Assam, India). Among these barriers, most could be addressed at the sub-national level.
The Reaching Every District (RED) approach, developed in 2002 in the African Region by the World Health Organization, is a strategy designed to improve immunization services, by strengthening core sub-national routine vaccination program functions. These include re-establishing outreach services; providing supportive supervision; monitoring and using data for action; improving planning and resource management; and increasing community links with service delivery [3]. A preliminary evaluation of countries where the RED approach had been implemented was conducted in the African region in 2005, and demonstrated the potential of the strategy to strengthen vaccination programs [4].
In an effort to strengthen routine immunization services in Assam, to provide additional data about the impact of the RED approach, and to investigate its applicability to other regions, the U.S. Centers for Disease Control and Prevention (CDC), in collaboration with United Nations Children's Fund (UNICEF)/India, undertook a 2-year evaluation trial of the RED approach in Assam, beginning in 2005 (Fig. 1). The objectives were to strengthen immunization service quality (measured by increased vaccination coverage and decreased dropout rates); and to evaluate factors associated with successful (or unsuccessful) implementation.
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Selection of districts and RED implementation
Eleven (47%) of Assam's 23 districts participated in the intervention. In 2 districts (Barpeta and Darrang) the intervention consisted of needs assessments, advocacy meetings, RED training from CDC/UNICEF, regular monitoring from UNICEF, and a full-time local UNICEF Immunization Consultant who provided oversight and supervision; these districts were referred to as Comprehensive-RED districts. They were selected based on documented low vaccination coverage, accessible security, established
Vaccination coverage pre- and post-intervention
Baseline coverage levels among children aged 12–23 months of age in the 2 Comprehensive-RED districts were 73.3% for DTP1 (95% CI: 66.6–79.0), 52.2% for DTP3 (95% CI: 46.2–58.1), and 47.1% for the first dose of measles vaccine (95% CI: 41.0–53.2); 40.6% (95% CI: 35.0–46.4) of children were fully vaccinated. In the 3 comparison districts, baseline coverage levels were 65.4% for DTP1 (95% CI: 60.5–70.0), 38.4% for DTP3 (95% CI: 34.1–43.0), and 35.1% for the first dose of measles vaccine (95% CI:
Discussion
Significant increases in vaccination coverage occurred during the 1-year intervention in both RED intervention and comparison districts. However improvements in process indicators suggest that greater program quality improvements occurred in RED districts with trainings and additional Immunization Consultant supervisory visits than in comparison districts. It is not clear why differences in vaccination coverage between the RED and comparison districts were not observed, despite significant
Conclusions
Introduction of the Comprehensive-RED approach in 2 districts in Assam, especially frequent, high-quality supervisory visits, improved the quality of immunization service performance indicators in the intervention districts, and these improvements appeared to continue during the year following the intervention. Building upon these interventions, as well as increasing education in order to improve community knowledge and demand for vaccination, should be priorities for enhancing immunization
Acknowledgements
We would like to thank the staff from the Assam Ministry of Health for their assistance in implementing and evaluating this intervention. We would also like to acknowledge the Immunization Consultants for their dedicated efforts.
Contributors: Tove Ryman (analysis and interpretation of data, drafting the article and final approval of the version to be published); Ajay Trakroo (interpretation of data, revising of article for critically important intellectual content and final approval of the
References (7)
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- Implementing the Reaching Every District (RED) Approach: a guide for District Health Management Teams....
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The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention.