Improving Vaccinator Performance
The Manoff Group manages and provides technical assistance to a joint IMMUNIZATIONbasics/BASICS program to improve child health status in East Timor. Since August 2007, the USAID/TAIS child health project has collaborated with the Expanded Progamme on Immunization (EPI) in East Timor to implement a multi-pronged strategy to improve vaccinators’ performance, particularly in vaccine handling, vaccine administration, and the recording and use of data.
A New Use of a Proven Method
The main strategy employed is a supportive supervision system based on the steps in Trials of Improved Practices (TIPs), a counseling-intensive formative research approach commonly used with mothers and families. As of August 2008, TAIS and MOH teams conducted one or more supportive supervision rounds to 53 of the 65 community health centers in Timor-Leste, and 5 of the 6 hospitals. Supervisors assessed skills and attitudes of vaccinators, gave feedback to vaccinators and facility heads, immediately taught certain skills, and, using a cornerstone of the TIPs approach, jointly made a plan with vaccinators for improving practices. Findings were shared at every level. The team categorized each district by coverage and dropout rates, stimulating discussions of causes and solutions at quarterly meetings of EPI officers from all 13 districts.
Steadily Rising Performance
After rising just after refresher training in 2007 and then falling for a few months, vaccinator scores have increased steadily: In a year, average scores rose from 48.6% of skills and attitudes well-performed to 73.6%—an increase of nearly 50%. This activity contributed to a rise in national immunization coverage from 49% in 2005 to 70% in 2007 and to a decrease in dropout rates from 9% to 7% during this time. Supportive supervision has not only improved vaccinator morale and performance, but also informed other support needs: Findings have led to the development and use of several job aids and reference materials, as well as special refresher training for hospital staff, whose performance scores were low.
Ensuring Lasting Results
The TIPs approach has been effective because it goes beyond identifying and improving knowledge and skills to capture perceptions and attitudes. It also structures supervision sessions in a series of steps designed to be supportive and positive. As sustainability is always a concern, partners are working to institutionalize the process, encouraging increased participation by national and district EPI staff. The MOH’s interest in replicating the approach for other health areas is promising, as the strategies employed in the supportive supervision system can be applied to a wide range of health contexts.