Characteristics of the health facilities
Forty-nine health centers were included in the study, 17 HC II (34.7%), 28 HCIII (57.1%), 3 HC IVs and 1 Regional referral hospital as shown in Table 1 below. Majority (40 or 81.6%) of health centers were government owned and the rest (18.4%) were private health facilities.
We found that 89.8% of the health centers had fridges for storage of vaccines. Most (87.8%) health centers reported to have experienced stock out of vaccines. All health centers had EPI focal persons. Immunization outreach schedules were present in 81.6% of health centers. Allowances for EPI had been paid in 77.6% of health centers. Support supervision had been conducted at least once in the previous six months in 89.8% of the health centers.
The characteristics are of the health facilities are broken down by distance of less than 25km or more and are shown in details in table 1 below. Facilities in Buhaguzi were much further away from the headquarters compared to other health sub districts. Health facilities that were closer compared to those that were further away did not differ in the rest of the characteristics such as presence of an EPI fridge, vaccine stock-out, payment of allowances, and having support supervision visits.
Table 1: Characteristics of health centers in Hoima District
Characteristic
|
Frequency (%)
|
p value
|
Total
|
=<25Km from District Head quarters
|
>25Km from District Head quarters
|
|
Health Sub District
|
Bugahya
Buhaguzi
Hoima Municipality
|
16 (32.7)
23 (46.9)
10 (20.4)
|
10 (37.0)
7 (26.0)
10 (37.0)
|
6 (27.3)
16 (72.7)
0 (0.0)
|
<0.001
|
Level of Health Centre
|
Regional Referral
Health center IV
Health center III
Health center II
|
1 ( 2.1)
3 ( 6.1)
28 (57.1)
17 (34.7)
|
1 (3.7)
3 (11.1)
12 (44.4)
11 (40.7)
|
0 (0.0)
0(0.0)
16 (72.7)
6 (27.3)
|
0.11
|
Presence of EPI fridge
|
No
Yes
|
5 (10.2)
44 (89.8)
|
3 (11.1)
24 (88.9)
|
2 (9.1)
20 (90.9)
|
0.99
|
EPI Fridge maintenance
|
No
Yes
|
10 (20.4)
39 (79.6)
|
3 (11.1)
24 (88.9)
|
7 (31.8)
15 (68.2)
|
0.09
|
Stock out of Vaccines
|
No
Yes
|
6 (12.2)
43 (87.8)
|
4 (14.8)
23 (85.2)
|
2 (9.1)
20 (90.9)
|
0.68
|
Stock out of Gas for EPI fridge
|
No
Yes
N/A*
|
21 (42.8)
9 (18.4)
19 (38.8)
|
14 (51.9)
4 (14.8)
9 (33.3)
|
7 (31.8)
5 (22.7)
10 (45.5)
|
0.48
|
Presence of EPI outreach schedule
|
No
Yes
|
9 (18.4)
40 (81.6)
|
5 (18.5)
22 (81.5)
|
4 (18.2)
18 (81.8)
|
0.99
|
Received funding for EPI activities
|
No
Yes
|
5 (10.2)
44 (89.8)
|
1 (3.7)
26 (97.3)
|
4 (18.2)
18 (81.8)
|
0.16
|
EPI allowances paid timely
|
No
Yes
|
11 (22.4)
38 (77.6)
|
4 (14.8)
23 (85.2)
|
7 (31.8)
15 (68.2)
|
0.18
|
Presence of Community mobilizer
|
No
Yes
|
1 ( 2.0)
48 (98.0)
|
1 (3.7)
26 (97.3)
|
0 (0.0)
22 (100)
|
1.0
|
Facility has means of transport
|
No
Yes
|
34 (69.4)
15 (30.6)
|
22 (81.5)
5 (18.5)
|
12 (54.5)
10 (45.5)
|
0.06
|
EPI performance discussed in staff meetings
|
No
Yes
|
10 (20.4)
39 (79.6)
|
7 (25.9)
20 (74.1)
|
3 (13.6)
19 (86.4)
|
0.48
|
Attend EPI performance review meeting
|
No
Yes
|
25 (51.0)
24 (49.0)
|
13 (48.1)
24 (51.9)
|
12 (54.5)
10 (45.5)
|
0.18
|
Have support supervision
|
No
Yes
|
5 (10.2)
44 (89.8)
|
1 (3.7)
26 (96.3)
|
4 (18.2)
18 (81.8)
|
0.16
|
* Health centers do not have gas fridge
Demographic characteristics of respondents/health center in-charges
We interviewed one health worker per health facility included in the study and the demographics are shown in Table 2 below. Almost 50% of them were aged 30 years or less. Only 6 health workers with a degree headed a health facility and at least 60% of the health facilities were headed by diploma holders. Majority (n=38 or 77.5%) were trained in EPI. Also majority of these health workers were male.
Table 2: Demographic characteristics of health facility in-charges
Characteristic
|
Frequency (%)
|
Age
|
≤30years
>30years
|
23 (46.9)
26 (54.1)
|
Years of experience
|
≤5years
>5years
|
25 (51.0)
24 (49.0)
|
Gender
|
Male
Female
|
27 (55.1)
22 (44.9)
|
Title position
|
Medical doctor
Clinical Officer
Nursing Officer
Enrolled Nurse or Midwife
Others
|
3 ( 6.1)
24 (48.9)
7 (14.3)
13 (26.6)
2 (4.1)
|
Level of Education
|
Certificate
Diploma
Bachelors or Masters
|
13 (26.5)
30 (61.2)
6 (12.3)
|
Marital Status
|
Single
Married
Divorced
|
10 (20.4)
38 (77.5)
1 ( 2.1)
|
Trained in EPI
|
No
Yes
|
11 (22.5)
38 (77.5)
|
Performance and distribution of health facilities in Hoima district
Thirteen or 26.5% of the health facilities scored in the highest RED category and 11 scored in the lowest as shown in Table 3 below. Over, at least 55% of the health facilities were rated as having poor immunization performance. The distribution of health facilities by their immunization performance is shown in Figure 1 below in the map of Hoima. The map shows the clustering of health facilities with poor performance around or near the district headquarters, and those with good performance away from the headquarters.
Table 3: Performance of Health centers in Hoima district.
Characteristic
|
Frequency (%)
|
WHO RED Category
|
1
2
3
4
|
13 (26.5)
9 (18.4)
16 (32.7)
11 (22.4)
|
Immunization performance
|
Good
Poor
|
22 (44.9)
27 (55.1)
|
Bivariate analysis of factors associated with immunization performance
Several factors related to vaccine delivery were not significant and included presence of an EPI fridge at the health facility, history of stock out of vaccines or gas for EPI fridge, presence of EPI outreach schedule, having received funding for EPI activities and paid allowances. Discussion of EPI performance at staff meetings, attendance of EPI performance review meetings, community mobilization and having means of transport for vaccination outreaches were not related to immunization program performance.
Having a community mobilizer, discussion of EPI performance in staff meetings, having at least 75% staffing level at the health facility and having conducted at least 20 outreaches in the last 6 months or conducting at least 75% of all planned outreaches for immunization were all unrelated to program performance.
There was no significant difference in the performance by the level of the health facility or ownership type and the results are shown in Table 4 below. However, facilities located in the Municipality or the more urban part of the district were more likely to perform poorly compared to those located distally such as Buhaguzi (p=0.026). Although majority of the health facilities reported they received support supervision, we observed that facilities that received no support supervision were more likely to report good performance.
The facilities that were located within 25km of the district headquarters were more likely to perform poorly compared to those that were located much further away (p=0.023 using Fisher’s exact test). At least 70% (n=19) of the health facilities within 25km performed poorly compared to only 36.4% (n=8) of those more than 25km from the district headquarters.
Table 4: Bivariate analysis of health center type and geographical location with immunization program performance
Characteristic
|
Total (n=49)
|
Good performance n=22 (%)
|
Poor performance n=27 (%)
|
p value*
|
Level of health facility
|
HC II
HC III
HC IV or higher
|
17
28
4
|
7 (41.2)
13 (46.4)
2 (50.0)
|
10 (58.8)
15 (53.6)
2 (50.0)
|
0.91
|
Ownership
|
Government
Private
|
40
9
|
17 (42.5)
5 (55.6)
|
23 (57.5)
4 (44.4)
|
0.71
|
Support supervision
|
No
Yes
|
5
44
|
5 (100.0)
17 (38.6)
|
0 (0.0)
27 (61.4)
|
0.009
|
Health Sub District
|
Bugahya
Buhaguzi
Municipality
|
16
23
10
|
4 (25.0)
15 (65.2)
3 (30.0)
|
12 (75.0)
8 (34.8)
7 (70.0)
|
0.026
|
Distance from District Headquarters
|
< 25KM
>25KM
|
27
22
|
8 (29.6)
14 (63.6)
|
19 (70.4)
8 (36.4)
|
0.023
|
*Using Fishers exact test
Results of key informant interviews
We interviewed four key informants involved in immunization at the district and health sub-district. Overall three reasons were provided to explain the performance of the immunization program namely 1) health worker attitude 2) outreach site selection and 3) community mobilization as shown in Table 5 below.
Table 5: Reasons to explain immunization performance from key informant interviews
Reason
|
Explanation
|
Health workers’ attitude
|
Less time committed to immunization activities
Residence near health facility
|
Outreach site selection
|
Convenient selection of outreach sites
|
Community mobilization
|
Outreaches conducted in the morning hours when clients are still in the gardens
Less support for community mobilization
Village health teams (VHTs) don’t reach all households with information on immunization dates
Dates and time for outreaches not well known
|
Health worker attitude
The key informants indicated that the health facilities located closer to the district headquarters might put up a poor performance because the health workers there reside in the town, away from their work stations and are more likely to commit less time to immunization activities like outreaches compared to their more rural counterparts. They mentioned that health workers in the rural areas reside close to the health facilities unlike their urban counterparts. The KIs mentioned that the urban health workers also tend to leave their work stations earlier to travel to town for other competing priorities as illustrated by one of the respondents:
Outreach site selection
The RED strategy requires that health centers conduct immunization outreaches to communities in hard-to-reach areas or villages located more than 5 km from the health center. KIs indicated that, health centers in the urban and peri-urban areas tended to select immunization outreach sites closer to the health center for their convenience.
“Health workers in urban areas select outreach sites that they can easily access and many of them are located less than 5 km from their station, so they don’t delay to return.” KI, Hoima
“Health workers in urban areas go for immunization outreaches early morning and leave early when mothers are still in their gardens because they [health workers] want to return early to their families in town. But health workers in the rural areas commit more time from late morning [un]till evening for immunization outreaches.” KI, Hoima district
Community mobilization
All the key informants indicated that rural areas seem to have better mechanisms for community mobilization compared to their urban counterparts through grass root mechanisms.
“The rural areas have implementing partners who support them in mobilizing communities using loud speakers and other local public address systems. In addition, these village women seem to have stronger interpersonal relationships and communication which they use to remind each other to attend immunization days”. KI, Hoima district
“Health centres in rural areas rely on VHTs to mobilize communities for immunization. I have visited many households in urban and peri-urban areas and mothers reported no visits from VHTs. I have interacted with mothers in these areas and they usually know the location of the immunization outreach sites in their locations but usually don’t know the exact dates and time when health workers go there.” KI, Hoima district
Outreach site selection
The RED strategy requires that health centers conduct immunization outreaches to communities in hard-to-reach areas or villages located more than 5 km from the health center. KIs indicated that, health centers in the urban and peri-urban areas tended to select immunization outreach sites closer to the health center for their convenience.
“Health workers in urban areas select outreach sites that they can easily access and many of them are located less than 5 km from their station, so they don’t delay to return.” KI, Hoima
Community mobilization
All the key informants indicated that rural areas seem to have better mechanisms for community mobilization compared to their urban counterparts through grass root mechanisms.
“The rural areas have implementing partners who support them in mobilizing communities using loud speakers and other local public address systems. In addition, these village women seem to have stronger interpersonal relationships and communication which they use to remind each other to attend immunization days”. KI, Hoima district
“Health centres in rural areas rely on VHTs to mobilize communities for immunization. I have visited many households in urban and peri-urban areas and mothers reported no visits from VHTs. I have interacted with mothers in these areas and they usually know the location of the immunization outreach sites in their locations but usually don’t know the exact dates and time when health workers go there.” KI, Hoima district