Applying quality improvement tools to the Reaching Every District strategy: a mixed-methods examination of a systems strengthening approach to building the capacity of immunization managers and service providers in Ethiopia

The Reaching Every District (RED) strategy, implemented in Ethiopia for over 15 years, has helped to improve immunization performance. However, recent demographic and health survey data indicate wide variations in immunization coverage. To address these disparities, quality improvement (QI) tools and methods were applied in phases to the RED strategy between 2011 and 2018 and were ultimately scaled to 103 districts in Ethiopia. Quantitative and qualitative data were collected from 2015-2018 to examine RED-QI uptake, practices, sustainability, and effects on Ethiopia´s routine immunization (RI) system. Qualitative interviews examined how RED-QI practices were carried out in each district, and quantitative data from a sample of health facilities provided information on the effects of RED-QI on the RI system. The RED-QI intervention increased the capacity of immunization managers and health workers to plan, implement, and monitor immunization activities, achieving expanded reach and enhancing the quality of services. RED-QI strengthened health workers´ capacity to identify and target communities for immunization, including in hard-to-reach areas. Improved planning resulted in expanded reach and greater equity in services. Immunization staff experienced enhanced capacity to plan immunization services, design approaches to address local challenges, reach target populations, and use data to monitor program performance. While challenges were noted with certain QI tools, assessments indicate that the RED-QI approach can be used in diverse contexts to strengthen RI.