Session 4: Service Delivery Strategies

This session highlights various strategies used to deliver immunization services.

Provision of Routine Immunization Services

Immunization services can be delivered through fixed facilities, outreach, or a mobile strategy.

Delivery through fixed facilities involves regular delivery of vaccinations in a health facility during

specified days of the week and hours of the day. Larger facilities may give vaccinations whenever
eligible clients come to the facility.
Outreach involves the delivery of services to people who cannot easily get to a health facility and is
usually conducted within 5 km to 15 km of the facility. Services at outreach sites are usually
completed within a day, allowing health workers to return the same day and avoid prolonged periods
of absence from their post. To make efficient use of resources, outreaches should be scheduled in
intervals of at least one month to provide children at those sites with consecutive doses.

Mobile services usually involve trips of more than one day by health workers to deliver services to
people living in remote areas. Mobile teams may spend several days traveling to multiple sites on a
given circuit.

In general, the cost per vaccination is higher when services are provided through outreach and
mobile strategies than through fixed services, because health workers spend more time to reach
each child and because transportation and per diem costs are involved. However, some people
cannot be reached in any other way.

Countries commonly use a combination of approaches to

reach those eligible for immunization, as communities in many countries have varied access to
immunization services. Periodic Intensification of Routine Immunization (PIRI) is an approach
with activities similar to that of a campaign, but has the objective of improving routine immunization
coverage. 

School-Based Vaccination

With the availability of newer

vaccines that extend beyond the first year of life (e.g., human papillomavirus) and a new emphasis
on booster doses of routine vaccines for older children (e.g., second dose of measles vaccine) there
is an increased interest in designing strategies for immunizing in schools.

When establishing immunization programs in schools, integration with existing platforms for
youth/adolescent health education is essential, as is strong engagement with community members,
religious leaders, and other key partners in the communities.  

School-based vaccination presents new challenges for reaching eligible targets. One challenge will
be reaching girls in countries where school attendance is low. Therefore, outreach strategies will
need to be designed to reach girls who are accessible through the school system.

Source: JSI for Gavi 2016

Supplemental Immunization Activities

 

Catch-up campaigns are special efforts to fill gaps in routine vaccination coverage. For example,
measles catch-up campaigns are sometimes conducted to improve measles immunization coverage.

Follow-up campaigns are held after catch-up campaigns to reach children in a narrower age range.

Measles catch-up and follow-up strategies provide a "second opportunity" because all children in
the target population are included, regardless of immunization status. Some countries have started
introducing a second dose of measles into the routine schedule; this is replacing some of these
follow-up campaigns.

Increasingly, these campaigns are being used to introduce other health interventions, such as
bednets, vitamin A, and de-worming. However, because these events are time- and resource-
intensive and irregularly spaced, they should NOT replace routine immunization services.
With routine immunization, services are usually offered on a daily, weekly, or monthly schedule
through a combination of fixed and outreach services. By contrast, the frequency of campaigns is
intermittent and depends upon the epidemiology of the particular disease. Services are expanded for
a temporary period to include not only fixed and outreach, but also door-to-door services and many
extra vaccination posts.

Did you know?

A critical difference between supplemental immunization activities and routine immunization is the way
doses are recorded. For routine services, doses are recorded by age category on tally sheets and also on
the child health card; they are then captured in estimates of coverage in children under one.  By contrast,
in campaigns, the doses are considered supplementary and are usually captured on campaign-specific
tally sheets but not on the child health card. This is done because vaccinations provided during SIAs are
considered supplemental and not part of the routine system. 

Highlight
Campaign strategies provide a second opportunity for those who were missed previously or who were
vaccinated but failed to develop immunity.

Reaching Every District (RED)

In 2001, the Reaching Every District (RED) approach was launched as an approach to
strengthen routine immunization services.

Developed by WHO and UNICEF and supported by USAID, RED is a strategy that focuses on
decentralized capacity-building to address common obstacles to increasing immunization coverage,
with an emphasis on planning and monitoring.
 The RED approach works to strengthen immunization, particularly within decentralized health
systems. It comprises five operational components:

1. Reaching the target population

2. Supportive supervision
3. Community links with service delivery
4. Monitoring and use of data for action
5. Planning and management of resources
The RED approach, focused at the district level, has been a valuable strategy for improving
immunization coverage. 

However, there are still segments of the population who continue to be missed with immunizations,
who remain unreached, or do not utilize services regularly. To address these inequities, greater
community focus and engagement is needed. This means putting more resources towards reaching
all populations and identify and mapping “marginalized” communities with plans to reach them with
routine services.

See WHO's RED strategy(link is external)(link will open new window) for more information. 

Session 5: Managing and Handling

Vaccines and Related Supplies
 WHO states that successful immunization programs are built on functional, end-to-end supply chain
and logistics systems. A well-functioning supply chain ensures effective forecasting, stock
management, vaccine storage, and handling; rigorous temperature control of vaccines throughout
the supply chain; and maintenance of adequate information systems for logistics management.

The ultimate goal is to ensure the uninterrupted availability of quality vaccines from
manufacturer to service-delivery levels, so that opportunities to vaccinate are not
missed because vaccines are unavailable. This requires a system to achieve the six rights of
supply-chain management:

1. Right product
2. Right quantity
3. Right condition
4. Right place
5. Right time
6. Right cost
This session highlights the integrated system of equipment, people, policies, and procedures to
properly manage and handle vaccines. 

Source: WHO