Drivers of routine immunization performance in Αfrica: Results from three countries

Why does routine immunization coverage improve in some settings and not in others? This paper describes the results of in-depth case studies in three countries (Cameroon, Ethiopia, and Ghana) to explore and describe the factors underlying performance improvement in routine immunization (RI) in Africa. The African Routine Immunization System Essentials (ARISE) project employed a mixed-method multiple case study strategy in 12 districts to define the pathways through which specific drivers improved coverage. Country cases were selected based on WHO/UNICEF estimates of DTP3/Pentavalent3 coverage from 2000 to 2009 and background variables. Three districts with recent coverage improvement (2006 – 2010) were chosen in each country to explore improvement experiences. For comparison, we chose one district per country where coverage remained unchanged over the same period. Initial coverage in all districts was estimated at 65% - 75%. When district findings were compared and synthesized, six drivers of RI performance improvement emerged. These drivers worked in synergy to bring about conditions and actions that resulted in better supply of immunization services and increased acceptance and use of immunization. Enabling drivers included: political and social commitment to RI and development partner actions. Direct drivers included: cadre of community-centered health workers; health system and community partnership; regular review of program and health worker performance; and services tailored to community needs. Results suggest the importance of a supportive national context; a solid immunization infrastructure; creative, adaptable strategies; strong partnerships; and capable managers to channel resources effectively. They are relevant for a range of district health programs.