Expanded Program for Immunization (EPI) in Ethiopia was launched in 1980 and progress in increasing coverage for all antigens. EPI programme aims to protect vaccine preventable diseases, reduce disabilities and deaths among children and mothers. In order to achieve these, recently Ethiopia adhere 10 types of vaccines i.e. BCG, PENTA, PCV, ROTA, OPV, MEASELES, MEN A, Hib & hep B under immunization programs for <1 year children on routine & <5 year in SIAs, and also TT vaccine for pregnant women. These vaccines has high role on immunizing herd immunity in order to prevent polio virus, TB, hepatitis, Homophiles influenza type B, measles, meningitis and so on diseases that has a great effect on maternal and child morbidity and mortality.

In Ethiopia country the policy set to have received all basic vaccinations, a child must receive at least:

§ One dose of BCG vaccine, which protects against tuberculosis
§ Three doses of DPT-HepB-Hib, which protects against diphtheria, pertussis
(whooping cough), and tetanus

§ Three doses of PCV vaccine

§ Two doses of Rota vaccine

§ Three doses of polio vaccine

§ One dose of IPV vaccine
§ one dose of measles vaccine

Wolayita is a Zone in the Ethiopian Southern Nations, Nationalities and Peoples Region (SNNPR). The administrative center of Wolayita is Sodo town. The colored areas in the administrative map of the zone are the woredas included in the zone.

Health information of the zone

Total Population – 2,020,386 (2011 E.C or 2018/19 G.C i.e. this year)
Live birth (LB) – 69,905
Surviving Infant (SI) – 64,450
Number of Hosp – 7
Number of HC – 68
Number of HP – 352
Number of Urban kebeles – 62
Number of rural kebeles – 306
Number of identified inequitable gottes/Villages – 193

Although remarkable gains have been achieved in EPI program, still large number of around 700000 infats in Ethiopia anual cohort (3 million) remain unprotected against a nine vaccine preventable disease anually according to the 2016 WHO-UNICEF estimate of immunization coverage (WUENIC) report. Based on the 2016Ethiopian DHS, national coverage of pentavalent vaccine for 3 dose is only 53%, measles first dose is 54% with significant varriation among regions,HH wealth quantile, education level and residence.

The recent vaccination coverage of zonal administrative is somehow decreasing as you can see from below Penta 1, Penta 3 & Measles indicator. This is b/c first, when comparing to country DHS, the administrative coverage is too high than the surveyed. Second there existed unvaccinated children at ground is found hence it was believed that the admin report has to be verified at ground and there existed a false report hence through time the country has worked to avoid cooked report so that the amount is becoming decreasing.

DHS 2016 result: Close to two in every five children age 12-23 months (39%) received all basic vaccinations at some time, and 22% were vaccinated by the appropriate age. The percentage of children age 12-23 months who are fully vaccinated increased by 15% from 24% in 2011 to 39% in 2016.

As per the result separated by region, SNNPR has a fully vaccination coverage of 47% which is very much paradox with zonal administrative report.

SNNPR region, wolaita zone last 6 years vaccination admin report trend using Penta 1, Penta 3 & Measles coverage indicator.

The coverage has discrepancies across the woredas, health facilities and kebeles. Geographic set up, mountainous area and far distant households are the major problems in addressing the vaccination services equitably. In fact Wolaita zone is one of highly contributing zone for unvaccinated children withn the region and is also one of the selected Zone for the support of immunization Equity program and it has identified 193 inequitable villages. Hence it is studied and believed that, there existed persistent disparity among the population in vaccination service.

Equity distribution is pertinent in the zone for the past years and the DOR of penta 1 - Penta 3 and Penta 1 - Measles is describes as below graph for the year 2018/2011 EFY. 

 

The limitations or bottlenecks on data availability, quality, and use in my context is there exist limited governance policy in supporting the EPI program, logistic, and ownership of the whole system is somehow less.In recent days, political transformation and reform made is slow progression in every aspect of health system at lower level which also impacts the vaccination implementation activity to commence the outreach site and which in turn lead to have many unvaccinated children.
We have been using a population projection which is conducted in every 10 year till lower level and using of conversion factors given by central statistics Denominator problem issue exist in the system as well. I have witnessed this, when doing supportive supervision, doing SIAs like house to house polio campaign, which indicate the amount of existed under five children and comparing it with projection population using conversion in some kebeles are somehow has high differences.
The commitment of health professional and existence amount of human resource at all levels of the hierarchy is poor b/c of the political transformation in our country situation.
Data is collected at each level as per the schedule unless there are few interruption in timeliness of the report but verification and checking on the quality of data is expected to be conduct at all level starting from the ground, there also exist a performance review team /PRT/ committee at each level, who checks the completeness and quality of the report each month but this system is dysfunctional mostly b/c of the commitment of the professionals at lower level.

The tool that we are using for collection, reporting, and use of data in recent day is DHIS 2 but this data base has been recently introduced in the country and most HIT professionals are not well aware of the system. The country used to use E-HMIS method before but since the data system is upgraded recently and there existed unfamiliarity with the new DHIS database.

The components of DHIS for EPI activities are:

• all vaccine given performance (Penta 1,3, OPV1,3, PCV 1,3, Rota 1,2, IPV, MCV 1)
• Wastage rate (Dose opened/dose given/Dose Damaged/ Dose expired
• DOR are included in DHIS 2

Since EPI equity now a days is hghly priority number 1 issue in Ethiopia and is majorly the theme of this project, equity activity with in the zone when looked in SWOT Analysis seemed as below

STRENGTH: Equity focus micro plannnng were developed as per the standard equity matrix were developed from lower level.

: zone level training has been given to all district, heath facility and health extension worker level.

: Oppening of additional 97 outreach sites to access those unvaccinated children in HTR area

; prioritizing of SDD fridges to those inequitabley identified kebele

; utilizing of communiy base health insurance and safty net program as a tool for srengthening immunization equity program.

WEAKNESS: commitment problem on health professional at lower level

; less awareness regarding of EPI equity focus activities by PHCU professionals

; scarcity of transportation problem on lower level for support

OPPORTUNITY: Presence of Health Extension worker in thecommunity

; presence of high amount of stakeholders thatsupport EPI activity within he zone

THREAT: there exist an electricity interruption problem which affect the coldchain system for delivering of pottent vaccine in different districts of the zone.

I want to give focus mainly on incomplete/inaccurate or false data recording & reporting practices.

As you can see from fishbone analysis, the major reasons for having false, incomplete and inacurate reports are:

1) Giving high focus only for performed numbers - the higher officials at every step are reviewing only performed coverage and appreciating the facility woreda, or zone who scorred higher coverage and the reverse for lower coverage. which intern leads the profesionals at lower level to give false report inorder to be applaused and acknowledged.

2) Data is used only for report not for taking actions at lower level - the report generated at lower level from Health extension workers /HEWs/ is not analysed and use it for action instead they just submite it for report consumption.

3) Poor monitoring system of the HEWs on doing their day to day activity - in recent days, the mechanism of monitoring the HEWs depends on the individual commitment at health center level and above otherwise its upto the HEWs moral of doing the day to day activity which led the over all system at stake hence the data generated at ground is then affected and not amenable if they couldnt commence their daya to day deliverables properly.

4) Poor PRT committee which either not meet or review the data in poor awareness - Performance review team as i tried to mention above is expected also to clean, analyse, findout any false seeming data by triangulating but in few areas and situation it is seem to be not done well which lead to have a bunch of misleading report at higher level.

5) Poor database, computer & Health knowledge from HIT focal at lower level - the HIT focals assigned for data analysis are mostly out of health professional which need a detail briefe on the system but at HF level and district level which the data is generated and could be solved easly, this professions just insert any number at database which can create wrong/false report. Say for example if the HEW placed 1 in "amount of Ebola suspected case found" by mistake or even by unknowing knowledge of her, the HIT profesional will insert this number with out realising it and send it to higher level which intern lead to other situation. hence existence of unawarred HIT professional and unfamiliare of HIT focal with DHIS do be the reason for passing wrong/false report

6) Data tool presenting for HEWs is in English which the HEWs don’t understand - i have witnessed during supervisions and checking of data quality at health post (data generating base), there exist health extension workers who dont understand few indicators in their reporting format b/c its written in english, they may interprete it also in different way hence they just put numbers willingly just for not bieng accused latter for not reporting hence the data tools (reporting, tally sheet, registries...) are given in English & their level of english language understanding some how are not that much.

My recommendation for better data quality and overcoming of incomplete/inaccurate or false data is:

1. A system that needs to address the quality of the service in parallel needs to be established so that having a good performed amount of number is good but confirming this performance is measurable at ground and its quality would make it better. Hence if 100% fully vaccinated children is reported monthly from HEWs, Rapid convenience surveys, house to house checks if there existed, triangulating the report with amount of vaccine used or amount of session conducted in that area would identify whether the report is amenable or not therefore a routine system that can assure the quality of the health system delivery would made the system fulfilled.
2. The HEWs at health post (Lower level of PHCU in Ethiopia & data generated facility) needs to be supported well in regading of their knowledge, skill & practice of immunizaionb/c the HEWs say in one kebele are trained level 1/2/3 girls on community health which are not even Nurses at rural areas and are expected to conduct whole health service deliveries holistically for the community which is high work load so that they may not fully conducted as per the expected TOR. The other issue is if only one HEW existed in the HP the service to address the whole kebele will be too hard which in turn do affect the expected activity from being done and will lead to be reported undone activity/cooked report.
3. Capacitating HEWs, HP from the HC & district and HIT professionals on data use for action, analysis, and interpretation. Capacitating on all health indicator meaning from DHIS and on reporting tools routinely would benefit the system to have create an understanding of the DHIS reporting and data quality.
4. Conducting of review meetings on regularly on reported/performance data at each level to let see what quality problems are being found so that the HEWs will be sensitive on undone reporting and will have also clearance/wake up call for next reports.
5. Setting a way or developing a system that monitor performance review team has regularly meet before passing the reports to higher level & this PRT committee at all level may have identify any cooked, incomplete/inaccurate or false data if existed.
6. It would also be better if the data tools at lower level, specially at HP level for HEWs to have an understandable tool as per their Native language and they can know what the reporting format is exactly asking so that they can put the performance what they have only conducted.

Here is a proposed action plan in order to adress the problem of data problem:
 

N.B - Since the summerized activity plan below in table form is not that much visible i have attached it above in excel sheet.