Strengthening Vaccination Systems – how it STARTs

George Momanyi, a public health nurse from Kenya, has twice served as a consultant with CDC’s Strengthening Technical Assistance for Routine Immunization Training (START) project in Uganda.  START, funded through a grant from the Bill & Melinda Gates Foundation, provides mentoring and on-the-job training to district-level immunization officers and service providers in areas with high numbers of unimmunized children. START consultants make regular visits to district health officers and service providers, delivering training and reinforcing the application of practical job skills.  START’s objective is to build the capacity of program staff and thereby strengthen the overall immunization system. 

As a START consultant, George worked in eastern Uganda from July-December 2013, and in northern Uganda from February-June 2014. As he was ending his service on the 2nd START team in June, he sent us this blog about his experience.

Getting Started

I came into the START project having worked in the Expanded Program on Immunization (EPI) in Kenya for more than 10 years and also after having served as a Stop Transmission of Polio (STOP) volunteer in Ethiopia in 2009.  With this background, I had quite some experience, but still was open to learning more from the Ugandan setting.  There were two important factors that enabled the START team’s success before deploying to the field.  The first was the pre-service training we received in Kampala, and the second was a meeting with all the Health Officers from the districts where our team would work to introduce the project and discuss how we would be working together.  In this way the health officers could see this would be a collaboration with them, and not a short-term project imposed on them from the outside.

After initial training of the district EPI officers, I accompanied them to the health centers, where vaccination services are delivered, to provide on-the-job training to the staff there.  It was not always easy for the district officer to offer training to the health center staff at the beginning, so I did initial health center trainings while the district officer observed, so he could become more familiar with the topics and training methods.  On the follow-up visits the district officer and I trained the health center staff together, increasing the officer’s confidence in doing this on his own in the future.

Many times, I sat together with the health center workers and led them through the group exercises.  I engaged health workers while building on what they already knew on the topic before introducing any new concepts.  One of my key mentoring approaches was to understand the workers’ knowledge and skill gaps and to focus on those during our time together.  In order to help slow-moving health centers, I often shared pictures of good practices seen in other facilities as a way to encourage them that it was possible to do even better.

In order to win their confidence and establish a positive relationship, I often reassured health workers that I was there not as a supervisor but rather as a colleague to support them to improve routine immunization performance.  In that way, the staff were always free to interact with me and even open up to me with details they had not told to their supervisors. One EPI staff person told me, “I admire the way you handle our staff, and they are able to give you details they would rarely mention to us.” While supporting the districts, I used every available opportunity to mentor the teams.  Health workers could call me to seek clarification or even request that I revisit their health facilities at any time, and I always made time for them.

Working in the field

As a START volunteer, I came across many challenges but managed to cope.  Many of these were related to routine immunization service delivery.  I often took time to help health workers understand how their own practice had a bearing on overall system performance – that their actions could contribute to the system either performing well or poorly.  Therefore I worked with the teams to try to accurately identify the reasons for problems, and then explore solutions.  Before providing my own suggestions, I always sought ideas from both the district or health center teams about the issues and what they thought they could do on their part.  Where appropriate, I engaged the district health officers for their support.  Some of the common issues encountered included were these:

• Getting quality time, especially with the key district EPI officers, was a challenge, because of competing activities
• EPI data at the facilities was not always available
• Shortage of data collection forms
• Health center staff absenteeism  

And there were factors outside the health system like poor road networks, especially as a result of rain. At times we had to spend long hours driving and pulling our vehicle out of the mud, which delayed movement to facilities. Despite this, my spirit grew each day, as a new challenge meant developing newer coping strategies, and this is what kept me moving.  Building a good working relationship with the district teams and my drivers was especially helpful.

Challenging roads during rainy seasons

Reflections on my work on the two START teams

Working in Uganda has been a great achievement and a big learning experience for me. Working as a START consultant requires a lot of patience, flexibility and consistency in everything you do. You need to build and gain the confidence of the district teams and staff at the health centers from the outset, and respond to their inquiries promptly.  The START experience exposes one to working closely with the district and health center teams, and one learns what works well and what doesn’t.  The bottom line to me has been to effect some positive change in terms of the teams working consistently towards achieving agreed-upon deliverables and sustaining these interventions, which I call the “START effect.”

There are times when things went well and other times when nothing seemed to move.  I felt low whenever the teams were slow to implement new techniques.  However, I never showed my frustration to them. Rather, I encouraged them by sharing best practices I seen elsewhere, and used these times as opportunities to share such feedback to the district health officers who I felt had responsibility over their own staff and could hold them accountable.  The most encouraging aspects of working in START were meeting teams who appeared enthusiastic about START and revisiting them to see the wonderful progress they made.  I came across very brilliant health workers who were doing great, and I often made reference of the good work they were doing and even shared their work with others as encouragement.

Despite the challenging situations, some comments from the health workers I interacted with kept my spirits high:

“As a medical doctor I did not know what to supervise in routine immunization, but now I am more skilled in supervision of RI activities” – Medical Superintendent – Bukwo General Hospital

“These training materials have been very nice and useful for my job” William – DranyaHealth Center

“The micro-planning process has helped us build a better understanding of our performance, and we will move ahead to develop a micro-plan for FY 2014/15” Alfred – YumbeHealth Center

While providing feedback to the Koboko District Health Team, the regional officials reported, “There is a big difference in health facilities already supported by the START trainings compared to the other facilities not yet trained.”

I feel I’ve learned a great deal being on the two START teams.  I gained the ability to interact fairly with people I’m working with.  For future jobs I am better prepared to embrace listening, patience, and courtesy.  My communication skills are stronger too, because I’ve had to mentor and train health workers in a new country.  Working as a START consultant has also increased my intellectual capacity by gaining more expertise about EPI service delivery and its underlying principles.  I can confidently reflect on the differences between where I found health centers at the beginning and the improvements I observed by the end of my mission!  While the impact of START may not be felt immediately, it has enormous potential.  Continued collaborations and support at all levels should continue.  It is my sincere hope that the districts supported by the first two START teams in Uganda will endeavor to sustain the initiatives we began in order to achieve the “START Effect.”

START is funded through 2016 by a grant from the Bill & Melinda Gates Foundation. The next START teams will be in Uganda and Ethiopia during the second half of 2014.

Processes improved after mentorship interventions:

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