This document summarizes a mixed methods comparative case study approach to understanding what drives routine immunization system performance in Africa. The study examined countries in Africa that had improved DPT3 immunization coverage at the district level to identify factors contributing to increased performance. Through interviews, focus groups, and data analysis at the district, facility, and community levels, the study identified four direct drivers of improved routine immunization coverage: a cadre of community-centered health workers, immunization services tailored to community needs, strengthened health system and community partnerships, and regular review of program and health worker performance.

1. What Drives Routine Immunization System Performance in Africa? A mixed methods comparative case study approach The Africa Routine Immunization System Essentials Project (ARISE)
Anne LaFond, JSI
Panel on Case-based Evaluation Approaches, Washington DC,
November 2014

2. 2
Context
History of investment in national immunization programs in Africa.
Why does coverage improve in some settings and not in others?
The Complexity: Many variables associated with high levels of immunization coverage but little understanding of the dynamics of coverage improvement.

3. 3
Methods
•Mixed methods, multiple case studies
•Case selection: Countries with DPT3 coverage improvement
•Nested case: Three districts per country with recent DPT3 coverage improvement and one district with steady or unchanged coverage
Robert K. Yin 1984, p 23

4. 4
Design & Data Collection
Focus on district level and the dynamics of change
Mixed methods: Coverage trend analysis and verification; RI Situation Analysis (service readiness); Open-ended, semi structured key informant interviews district, facility, community levels; FGD; field observation.
Iterative field level analysis by district
Grounded theory building
Interdisciplinary team: Routine immunization expert, researchers, country program
Cross district case consistency
Close collaboration with technical and country experts
Country level validation (stakeholder workshop)

5. Theory building

6. Addressing challenges
•Quality and availability of coverage data to select cases
•Consistent approach across country cases
•Intensive fieldwork stage with iterative analysis and theory building

7. Four Direct Drivers of RI Performance Improvement
Cadre of Community Centered Health Workers
Immunization Services Tailored to Community Needs
Health System and Community Partnership
Regular Review of Program and Health Worker Performance
Improved Service Delivery
Increased Acceptance and Use
Improved Immunization Coverage

9. information
For more information, please contact:
Anne_LaFond@jsi.com
thank you
Funded by
the Bill and Melinda Gates Foundation
Implemented by
Anne LaFond, Natasha Kanagat, Jenny Sequeira, Robert Steinglass, Rebecca Fields (JSI). Judith Justice (Ehtiopia), Cheikh Niang, (Cameroon) and Ann Larson (Ghana)
In collaboration with
Sangeeta Mookherji, George Washington University SPH