JSI Explores "Reaching Every District" with Interventions Beyond Immunization

JSI's USAID-funded IMMUNIZATIONbasics project, which comes to a close in September 2009, has spent a good deal of the project's five-year lifespan helping selected countries' (India, Nigeria, East Timor, DRC, Madagascar) ministries of health apply the Reaching Every District (RED) approach in order to raise immunization coverage.

The World Health Organization (WHO) and its partners (UNICEF, USAID and other members of the GAVI Alliance) developed RED in response to stagnating and sometimes declining immunization coverage in the developing world. The RED approach was introduced in 2002 to improve countries' immunization systems—particularly in areas with low coverage. RED focuses on the district as the operational level and builds capacity at the district, health facility, and community levels to overcome common barriers facing a routine immunization system.

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

THE FIVE RED COMPONENTS

Planning and Management of Resources – better management of human and financial resources
Reaching Target Populations – improving access to immunization services by all
Linking Services with Communities – partnering with communities to promote and deliver services
Supportive Supervision – regular on-site teaching, feedback and follow-up with health staff
Monitoring for Action – using tools and providing feedback for continuous self-assessment and improvement

Since 2003, RED has been implemented in 53 developing countries to various degrees, mostly in Africa and South and Southeast Asia. All 53 countries belong to the groups of lower income and lower-middle income countries, as per World Bank classification. In 2005, an evaluation of five countries in Africa that had implemented RED found that in four of the five countries, immunization coverage had increased since the implementation of RED, and that the proportion of districts with DTP3 (three-dose diphtheria, tetanus and pertussis vaccine) coverage above 80% had more than doubled. The number of unimmunized children in these five countries was reduced from three million in 2002 to 1.9 million in 2004.

Interestingly, the report notes that outreach services, one of the five components of RED, were often used to deliver other interventions beyond immunization, such as Vitamin A, deworming, family planning, or distributing insecticide-treated bed nets. This indicates that implementation of RED components may start to have an impact beyond immunization services alone.

This is a key issue as IMMUNIZATIONbasics comes to an end and USAID's funding for routine immunization gets folded into the agency's new flagship maternal and child health project (better known by the acronym MCHIP), which JSI is implementing in partnership with several other organizations, including Jphiego and Save the Children.

Fresh on the heels of experiencing RED's successes vis-à-vis immunization, JSI has begun spearheading the dialogue on how this approach might be applicable for other child health interventions. At two recent meetings (a JSI-hosted roundtable discussion in Washington, DC and the 2009 Global Health Council conference), this subject was explored with great interest by the maternal and child health community, including USAID staff and MCHIP partners.

Practitioners in the maternal and child health community are exploring two different methods for applying RED to other child health interventions. The first, integration, is when a stand-alone program such as immunization is used as a platform for delivering other maternal and child health services (family planning, antenatal care, malaria prevention).

With the second method, adaptation, the five RED components can be tailored to fit the needs of other interventions. For example, RED's microplanning techniques can be used to identify eligible populations, estimate commodity needs, allocate human resources, and develop service delivery schedules regardless of the package of interventions being planned. For instance, Zambia has used the RED approach in relation to HIV and AIDS interventions.

MCHIP has begun exploring the issue of offering integrated services using the RED approach. The project plans to work with three to four countries to expand and adapt the RED components in order to successfully offer other child health interventions during immunization outreach sessions. Indeed, the adaption and integration of the RED approach has the possibility of exciting implications not only for immunization programs, but also for the larger maternal and child health package of services.

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