A qualitative study of the development and utilization of health facility-based immunization microplans in Uganda

BACKGROUND: In 2006, Uganda adopted the Reaching Every District strategy with the goal of attaining at least 80% coverage for routine immunizations in every district. The development and utilization of health facility/district immunization microplans is the key to the strategy. A number of reports have shown suboptimal development and use of microplans in Uganda. This study explores factors associated with suboptimal development and use of microplans in two districts in Uganda to pinpoint challenges encountered during the microplanning process. METHODS: A qualitative study was conducted comparing two districts: Kapchorwa, with low immunization coverage, and Luwero with high immunization coverage. Data were collected through multilevel observation of health facilities, planning sessions and planning meetings; records review of microplans, micromaps and meeting minutes; 57 interviews with health workers at the ministry level and lower-level health facility workers. Data were analysed using NVivo 8 qualitative text analysis software. Transcripts were coded, and memos and display matrices were developed to examine the process of developing and utilizing microplans, including experiences of health workers (implementers). RESULTS: Three key findings emerged from this study. First, there are significant knowledge gaps with regard to the microplanning process among health workers at all levels (community and district health facility and nationally). Limited knowledge about communities and programme catchment areas greatly hinders the planning process by limiting the ability to identify hard-to-reach areas and to prioritize areas according to need. Secondly, the microplanning tool is bulky and complex. Finally, microplanning is being implemented in the context of already overtasked health personnel who have to conduct several other activities as part of their daily routines. CONCLUSIONS: In order to achieve quality improvement as outlined in the Reaching Every District campaign, the microplanning process should be revised. Health workers’ misunderstanding and limited knowledge about the microplanning process, especially at peripheral health facilities, coupled with the complex, bulky nature of the microplanning tool, reduces the effectiveness of microplanning in improving routine immunization in Uganda. This study reveals the need to reduce the complexity of the tool and to identify ways to train and support workers in the use of the revised tool, including support in incorporating the microplanning process into their busy schedules.