title: The gas cylinder, the motorcycle and the village health team member: a proof-of-concept study for the use of the Microsystems Quality Improvement Approach to strengthen the routine immunization system in Uganda.
abstract: BACKGROUND
  Although global efforts to support routine immunization (RI) system strengthening have resulted in higher immunization rates, the World Health Organization (WHO) estimates that the proportion of children receiving recommended DPT3 vaccines has stagnated at 80% for the past 3 years (WHO Fact sheet-Immunization coverage 2014, WHO, 2014). Meeting the WHO goal of 90% national DPT3 coverage may require locally based strategies to support conventional approaches. The Africa Routine Immunization Systems Essentials-System Innovation (ARISE-SI) initiative is a proof-of-concept study to assess the application of the Microsystems Quality Improvement Approach for generating local solutions to strengthen RI systems and reach those unreached by current efforts in Masaka District, Uganda.
  
  
  METHODS
  The ARISE-SI intervention had three components: health unit (HU) advance preparations, an action learning collaborative, and coaching of improvement teams. The intervention was informed and assessed using qualitative and quantitative methods. Data collection focused on changes and outcomes of improvement efforts among five HUs and one district-level team during the intervention (June 2011-February 2012) and five follow-up months.
  
  
  RESULTS
  Workshops and team meetings had a 95% attendance rate. All teams gained RI system knowledge and implemented changes to address locally identified problems. Specific changes included: RI register implementation and expanded use, Child Health Card provision and monitoring, staff cross-training, staffing pattern changes, predictable outreach schedules, and health system leader--community leader meetings. Several RI system barriers prevalent across Masaka District (e.g., lack of backup HU gas cylinders, inadequate outreach transportation, and village health team underutilization) were successfully addressed. Three of five HUs significantly increased the vaccines administered. All improvements were sustained 5 months post-intervention. External evaluation validated the findings of high levels of participant engagement, empowerment to make change, and willingness to sustain improvements.
  
  
  CONCLUSIONS
  The Microsystems Quality Improvement Approach is a comprehensive approach, grounded in systems thinking, and coupled with intensive coaching. It provides a robust framework for engaging teams in the development of unique local solutions that strengthen RI systems in resource poor settings. The sustained improvements in local RI systems from this study provide evidence that this approach may be an effective framework for enhancing the WHO's Reaching Every District (RED) immunization strategy.
authors.affiliation: Community Engagement, the Prevention Research Center at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 35 Centerra Parkway, Lebanon, NH, 03766, USA. Dorothy.A.Bazos@dartmouth.edu.|, 501 South Street, Bow, NH, 03304, USA. Dorothy.A.Bazos@dartmouth.edu.
authors.forename: Dorothy A
authors.initials: DA
authors.lastname: Bazos
authors.affiliation: JSI Research & Training Institute, Inc., Community Health Institute, 501 South Street, 2nd Floor, Bow, NH, 03304, USA. lea_ayers-lafave@jsi.com.
authors.forename: Lea R Ayers
authors.initials: LR
authors.lastname: LaFave
authors.affiliation: Pediatrics and Community & Family Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, 1 Rope Ferry Road, Hanover, NH, 03755, USA. Gautham.K.Suresh@hitchcock.org.
authors.forename: Gautham
authors.initials: G
authors.lastname: Suresh
authors.affiliation: SAC Health System, Department of Family Medicine, Loma Linda University School of Medicine, Suite 206-A, Loma, Linda, CA, 92354, USA. knkshannon@gmail.com.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Shannon
authors.affiliation: Disease Control and Prevention, Makerere University School of Public Health, PO Box 7072, Kampala, Uganda. nuwahaf@yahoo.co.uk.
authors.forename: Fred
authors.initials: F
authors.lastname: Nuwaha
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice and Community and Family Medicine, Geisel School of Medicine at Dartmouth, 30 Lafayette Street, Lebanon, NH, 03766, USA. marksplaine113@gmail.com.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Splaine
mesh_terms: D002648:Child; D003150:Community Health Workers / Q000193:education / Q000458:organization & administration; D015721:Diphtheria-Tetanus-Pertussis Vaccine / Q000627:therapeutic use; D006801:Humans; D017589:Immunization Programs / Q000458:organization & administration* / Q000592:standards; D009049:Motorcycles / Q000600:supply & distribution; D058996:Quality Improvement / Q000458:organization & administration; D012034:Refrigeration / Q000379:methods; D014454:Uganda / Q000453:epidemiology
chemical_list: D015721:Diphtheria-Tetanus-Pertussis Vaccine