Improving immunization capacity in Ethiopia through continuous quality improvement interventions: a prospective quasi-experimental study

Abstract

BackgroundStrong scientific evidence is needed to support low-income countries in building effective and sustainable immunization programs and proactively engaging in global vaccine development and implementation initiatives. This study aimed to implement and evaluate the effectiveness of system-wide continuous quality improvement (CQI) interventions to improve national immunization programme performance in Ethiopia.MethodsThe study used a prospective, quasi-experimental design with an interrupted time-series analysis to collect data from 781 government health sectors (556 healthcare facilities, 196 district health offices, and 29 zonal health departments) selected from developing and emerging regions in Ethiopia. Procedures included baseline quality assessment of immunization programme and services using structured checklists; immunization systems strengthening using onsite technical support, training, and supportive supervision interventions in a Plan-Do-Check-Act cycle over 12 months; and collection and analysis of data at baseline and at the 6th and 12th month of interventions using statistical process control and the t-test. Outcome measures were the coverage of the vaccines pentavalent 3, measles, Bacillus Calmette–Guérin vaccine (BCG), Pneumococcal Conjugate Vaccine (PCV), as well as full vaccination status; while process measures were changes in human resources, planning, service delivery, logistics and supply, documentation, coordination and collaboration, and monitoring and evaluation. Analysis and interpretation of data adhered to SQUIRE 2.0 guidelines.ResultsPrior to the interventions, vaccination coverage was low and all seven process indicators had an aggregate score of below 50%, with significant differences in performance at healthcare facility level between developing and emerging regions (P = 0.0001). Following the interventions, vaccination coverage improved significantly from 63.6% at baseline to 79.3% for pentavalent (P = 0.0001), 62.5 to 72.8% for measles (P = 0.009), 62.4 to 73.5% for BCG (P = 0.0001), 65.3 to 81.0% for PCV (P = 0.02), and insignificantly from 56.2 to 74.2% for full vaccination. All seven process indicators scored above 75% in all regions, with no significant differences found in performance between developing and emerging regions.ConclusionsThe CQI interventions improved immunization capacity and vaccination coverage in Ethiopia, where the unstable transmission patterns and intensity of infectious diseases necessitate for a state of readiness of the health system at all times. The approach was found to empower zone, district, and facility-level health sectors to exercise accountability and share ownership of immunization outcomes. While universal approaches can improve routine immunization, local innovative interventions that target local problems and dynamics are also necessary to achieve optimal coverage.

The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review

“…Recently, attention has shifted to improving services by developing the capabilities and capacity of organizations through building their knowledge, skills, and infrastructure [74]. The focus on system-level quality improvement has resulted in CQI methods being identified, and increasingly used, as an approach to enhance the quality of care and reduce costs [3][4][5][6][7][8][9]72]. Despite its effectiveness within industrial and manufacturing sectors, it remains unclear whether CQI could be successfully employed in the health care sector.…”

“…Improving the quality and safety of health care is a priority of governments, health care workers, and the public [1,2], with efforts often focused on investment in changes to the way health care is organized and delivered (system-level quality improvements) [3,4]. While there are many different approaches that may be taken, continuous quality improvement (CQI) has received considerable attention within health care [5] as a way to enhance the quality of care and reduce costs [6][7][8][9]. The use of CQI in health care has evolved since the 1990s, using quality control techniques and management theories employed in the industrial and manufacturing sectors [10][11][12][13][14].…”

Immunisation program reviews in East and Southern Africa. 2012-2018; key lessons

“…Health worker training plays an important role in improving overall performance including vaccination coverage [ 15 , 16 ]. Other studies and program reviews have also shown the critical role of human resource in immunisation program delivery [ 17 - 19 ].…”

Immunisation program reviews in East and Southern Africa: 2012-2018; key lessons

“…Health worker training plays an important role in improving overall performance including vaccination coverage [ 16 , 17 ]. Other studies and program reviews have also shown the critical role of human resource in immunisation program delivery [ 18 - 20 ]. In the 20 program reviews in this sub-region, capacity gaps are also reflected in the lack of clear managerial tools (e.g., terms of reference, job descriptions and standard orientation/training for newly assigned focal persons).…”