Global Measles and Rubella Meeting, 15-17 March 2011,
Geneva

• Background
• Measles coverage and epidemiological situation
• Ethiopia SIA Experience
• SIA implementation/achievement
• SIA evaluation
• Opportunities and challenges

Federal Ministry of Health
• Projected population 2010
(census 2007): 79 million
– Growth Rate: 2.6%
– Under-1: 3.2% (1.9m)
– Under-5:
– Under-15:
14.6% (11.4m)
45% (35m)
Regional Health Bureaux
(9 Regions + 2 City Administrations)
Zonal Health adminstration
(98 Zones)
• Rural : 83%
819 Woreda Health Offices
• Infant Mortality Rate:
75/1000 live-births
15,000 Kebeles
1 health post per 5,000 population) :The key for the success of the SIA

8000
Reported Measles Cases and Measles
Coverage- 1990-2009, Ethiopia
Catch Up
2002 -2004
Best practice 2010
Follow Up 2005 - 2009 90
7000
80
70
6000
60
5000
4000
3000
50
40
30
2000
20
1000 10
0 0
Cases Measles Coverage

Vaccination status of confirmed measles cases. January – Dec 2010
800
600
400
200
0
1600
1400
1200
1000
Under 9
MOs
09mon -
4 years
UNVACCINATED
05 to 09 years
Vaccinated
10 to 14 years
15 Years
& above
UNknown
Confirmed Measles cases
January - Dec 2010

• Target: 8.5 million children aged 9 – 47months
– 90.8% of target population in 2010
• Dates:
– 22 - 25 October 2010
– 18-21 February 2011
• Objectives of SIA:
– Give 2 nd dose of measles vaccine
– Identify ,implement and evaluate best practice SIA
• Integrated interventions:
– OPV (0-59 months)
– Vitamin A (6-59 months)
– De-worming (24-59 months)
– Nutritional Screening (6-59 months and pregnant and lactating women)
2010
2011

Coordination
• National and sub national Task Force with subcommittee's led by government health bureau
• Weekly updates from each level for management and monitoring of SIA
Logistics
• Required logistics available pre SIA with initiation of distribution 3-4 weeks before implementation
• Flexibility in distribution mechanisms including transport fleet for emergency distribution
Micro planning and Training
• Emphasis on Kebele level planning with identification of hard to reach and difficult populations
• Participatory approach in training
.
Advocacy and Social Mobilization
• High level political engagement
• Advocacy visit to regional presidents
• Evidence-based messages (KAP)
• Diverse channels of communication
• radio, tv, town criers, house to house canvassing, schools, banners, IEC, mobile vans

Monitoring and Evaluation
• Pre campaign assessments (3-4 weeks and 1 week prior to SIA) and feedback given to address gaps
• Different methods utilized to monitor performance:
– Daily review meetings, with daily coverage reporting using SMS ( second phase)
• Administrative, rapid convenience monitoring, independent monitoring
Resource Mobilization
• Significant Government contributions :.017 cost per child
• High level cooperation between EPI partners
• Engagement of partners at all levels: o Human resources, transport, social mobilization, logistics

Funding from the
Measles Initiative
Item
Vaccine and injection materials
Operational costs
Total
Budget
(USD)
5,371,901
FMOH
Nutrition
Partners
(EOS) WHO UNICEF
Global
Polio
Initiative
3,345,097 2,026,804
6,464,204 746,219 1,502,205 2,101,540 1,364,240 750,000
Grand Total 11,836,105 746,219 1,502,205 2,101,540 4,658,097 2,776,804
Target population (<
5) 12,859,245
Cost per child
(USD) 0.92

A National task force led by the DG of Health Promotion and
Disease Prevention Directorate, FMoH taking care of the coordination of preparation Regional level task force led by RHB-PHEM head

OPV Coverage
Measles Coverage
>=95%
90-94%
80-89%
National coverage 106%
National coverage 97%

Proportion of Children missed during the SIA
Number of woredas for measles vaccination
Number of woreda for
Polio Vaccination
>10%
5-10%
<5%
106
67
222
107
79
209
Source of data: Post SIA Independent monitoring, 38 6Woredas (52%) sampled
Note: Poor quality finger markers compromised the independent monitoring process in several areas

Methodology
• Cross-sectional study design
Objective of the Survey
• To evaluate the overall national measles vaccination coverage of children 9-47 months of age post the SIA and routine EPI
• Study area: 60 Woredas
• Study Period: Nov-Dec 2010 coverage among children 12-23 months of age source population: all expected eligible
Target population: eligible children
• To independently monitor the implementation of a set of selected BP for
SIA in sampled households • To explore the relationship between the set
• Sampling : : A two stage cluster of selected best practices and post measles household survey woredas and random sampling vaccination coverage of children 9-47 months of age of the SIA in select Woredas
– Systematic Random sampling of
• To determine the proportion of target children that receive other interventions of the EAs from the selected during the integrated measles SIAs woredas campaign

Regions Measles
Coverage by maternal recall
N Wted % N
Measles Coverage by
Card
Wted % N
Measles Coverage by
Either maternal recall or card
Wted %
Amhara (n=405) 248 60.5
Oromia (n=963) 759 82.6
276
411
66.8
37.2
384
877
94.2
91.7
Somali (n=376) 363 97.2
SNNPR (n=526) 393 79.3
Harari (n=286)
Addis Ababa
(n=269)
217 72.7
216 81.6
Dire Dawa
(n=263)
234 89.2
Total (n=3088) 2430 77.5
155
234
202
203
115
1596
36.3
45.4
70.3
76.3
47.8
48.1
365
475
272
252
241
2866
97.3
91.4
91.7
93.8
91.2
92.7

• 7 key areas identified in the planning phase and efforts made to maximize on RI strengthening:
1.
Micro planning
2.
Training
3.
Logistics Management
4.
Advocacy and Social
Mobilization
5.
AEFI monitoring and management
6.
Surveillance
7.
Monitoring and Evaluation
• Methods: used to evaluate the effect of SIA on RI
- Focus Group Discussions
(caretakers)
- In depth interviews (health workers)
- Observations (health facility + session)
- Participation and feedback in post
SIA review meetings
• Target:
- Caretakers
- Health workers

Regions
Presence of a micro plan for EPI
Monthly monitoring of immunization coverage
Addis Ababa Oromiya SNNPR Somali
Pre-SIA Post SIA Pre-SIA Post-SIA Pre-SIA Post SIA Pre-SIA Post-SIA
50% 76.9% 98.8% 98.8% 100% 100% 60% 73.3%
58% 62% 83% 84% 55% 67% 33 % 53%
Monitoring chart up to date
Number of health facilities which had adequate functional cold chain
Number of health facilities which had adequate safety boxes
50%
83%
83%
63%
100%
92%
35%
26%
96%
99%
22%
99%
100%
32%
96%
100%
14%
100%
60%
80%
93%
64%
80%
100%
Number health workers who know the use of additional doses of measles immunization
75% 92% 46% 74% 76% 100% 27% 87%

SIA Component Major Elements of Success
Coordination • Task Force and subcommittee establishment at all levels with engagement of key partners
Micro planning and training
• Early start from Kebele level with administration involvement in the planning process
• Identification of knowledge and skills gaps for emphasis in training
• Practical and participatory methods approach
• Development of pocket guide in local language
• Pre-and post test and training evaluation for quality training
Advocacy and
Social
Mobilization
Logistics
Monitoring and evaluation
• Development of messages based on analysis of gaps and concerns of the community
• Involvement of political leadership at all levels in advocacy
• Utilization of diverse channels of communication including house to house canvassing for mobilization
•
Distribution to all woredas from the federal level with pre planning of bundle logistics distribution
• Daily review meetings
• Intra- SIA monitoring (Daily SMS Reporting, RCM, Independent monitoring)

SIA Component
Micro planning and
Training
Funds transfer
Implementation
Logistics
Monitoring and
Supervision
Challenges addressed in the second phase
• Delays in translated materials (4 languages) resulting in late distribution to sub national level
• Finding accurate conversion factor for 9 to 47 months
• Delayed funds disbursement from central level to some regions due to late liquidation of funds
• Accurate screening of target age group
• Shortages of vaccines experienced in some zones
• Poor quality of finger markers (utilize screening card for monitoring)
• Inability to effectively transmit daily coverage achievements to the next level intra campaign(Daily using SMS)

• Finalize ongoing evaluations o Coverage survey o Routine EPI strengthening (6 months follow up)
• Finalize documentation of the best practice
SIA
• Maximizing on gains from the SIA to strengthen routine EPI

• Identification of country-specific BP for incorporation in the micro planning and training
• Emphasis on the best practices concept raised commitment at all levels
• Implementation of a best practice concept improves resource allocation to most critical areas
• Bottom -up planning from Kebele level with engagement of HEWs, local administration and stakeholders
• Establishment and functionality of coordination structures at all levels
• Efforts were made to strengthen the routine system through the SIA which need to be sustained

Ethiopia Federal Ministry of Health
Local Partners: CORE GROUP, L10K, IFHP