Rationale for Effective Practices Every element of this proposal is grounded in our vi-

sion of health equity and health system strengthening. Drawing on the “nutcracker approach” as designed by the Commission of Social Determinants of Health chaired by Sir M. Marmot [92-93] we prioritize, first and foremost, the target population and their needs, expectations, perceptions, and contributions. The core rationale of this master plan includes, in order of im- portance:

1. Inclusion of target population needs and expec- tations in all phases: design, implementation, and evaluation

2. A contextual framework that rationalizes health- seeking behavior and decision making through the context of complex, underlying beliefs and practic- es of marginalized and impoverished populations, medical systems and public health services

3. Plausible approaches that are available and effec- tive for directing benefits towards the poor

programs, waste scare resources, or weaken frag- ile systems as has been seen with PEPFAR in Sub- Saharan Africa [105]. Instead, this initiative aims to strengthening health systems (in the six building blocks WHO framework of action for strengthening health systems) [98], but most importantly at the community-level [106]

5. A progressive policy development approach [93], which simply includes the adoption of the principle of “health equity in all policies”

6. The empowerment of social groups to promote their political and social rights [92-93]

7. The principle that resources in international devel- opment agendas and health projects in particular should trickle down rather than up [35]

4.4.1 Map of Opportunities to Maximize

the Impact of the Immunization Inter-

ventions of the MHI

This map of opportunities was developed to identify potential strategies to reach target populations of this initiative (Table 5). This map complements other infor- mation presented as effective (see sections: Theory of Change and Recommended Regional Interventions). The color code shows the urgency with which the im- munization group considers the recommendation. (Highly Suggested, Should Consider, Consider when available or developed).

Areas of Opportunity Strategies to reach target _populations Monitoring and Evaluation _Indicators Validity of Immunization Coverage

Levels

Lot quality sampling assessment base- line and subsequent assessments Serologic analysis of a sample of patients to validate coverage levels (tetanus or hepatitis B)

Rapid monitoring assessment supervision and evaluation

Percentage of validity assessments performed/assessments planned Percentage of concordance between reported rates and those identified dur- ing the assessment

Coverage level by specific biologic agent and with full vaccine schedule Increase effective coverage

Reaching 95% coverage rate per biological

Prevent missed opportunities and unmet needs by:

- Community-based educational campaigns to reach the most socially excluded populations with culturally appropriate messages regarding the benefit of vaccination

- Supplementary outreach campaigns that take services out into communi- ties through mobile camps usually accompanied by energetic information campaigns regarding the benefits of vaccination

Integrated rapid-impact package of intervention with other health-related interventions (maternal, nutrition, vector-borne diseases) (see probable indicators on table 7).

Public-private partnerships to develop social marketing strategies

Capacity-building at all levels with a focus at the community level and then at every level of the national immuni- zation program

Unify information systems at the country level (Use mobile technology and internet-based systems to assist in vaccination-registry or a unified regional vaccination registry) For permanent health-centers need more hours of operation (weekends, holidays, and evenings)

Number and % of municipalities distributing culturally appropriate materials

Number of persons reached with edu- cational materials, talks or workshops Percentage of community-based work- shops conducted versus those planned Percentage of people reached by edu- cation activities / community popula- tion

Change in the coverage rate from baseline to intervals

Verified effective vaccine coverage rate in target population

An alternative proxy measure has been suggested by the COFVAL, correlating 1) the data on mortality and morbidity with 2) the data on raw coverage for each disease-vaccine by federal, state/ provincial and local level.

Effective vaccine use, contrast: a) the number of doses bought (at national, district, municipal level) b) coverage for a specific disease Percentage of health centers with extended service hours (among those for which this was a problem in the community).

Areas of Opportunity Strategies to reach target _populations Monitoring and Evaluation _Indicators

Information Systems Unify information systems at the

country level (Use mobile technology and internet-based systems to assist in vaccination-registry or a unified regional vaccination registry – nominal census data) Capacity building at all levels

Number of children/% of children in registry from target population Number of municipalities/% of mu- nicipalities using mobile technology to collect data/register children Number of municipalities/% of municipalities using internet based systems to assist in vaccine registry or regional vaccination registry Number of health works/% of health workers that have been trained to use mobile technology and/or internet- based systems of vaccine registry

Monitoring and Evaluation of Nation- al Immunization Programs

Epidemiologic Surveillance

Capacity building of personnel at the community level for monitoring vac- cine uptake/demand of vaccine Supervision of cold-chain activities Community needs assessment Use a performance improvement and process evaluation approach to diagnose and systematically improve services, starting at the facility level by the community

Providing community-health workers with information on how to use data for monitoring and evaluation, how to engage community leaders, and how to better manage vaccine stocks Improved detection by laboratory- based surveillance

Creation or strengthening of a regional network of surveillance (epidemiologic and laboratory-based)

Percentage of active vaccine at the different locations (national, regional, local, and community level

Number/Rate of illness due to VPDs in target population

Number/Rate of deaths due to VPDs in target population

Change in the burden of VPD in target population

Change in the differences between the burden of VPDs in target popula- tions and national averages

Number of lab tests for VPDs com- pleted for target population

Areas of Opportunity Strategies to reach target _populations Monitoring and Evaluation _Indicators Operational Activities of the National

Immunization Program - Cold-Chain

- Human Resources

Increased number of supervisors and increased training of supervisors Use a performance improvement and process evaluation approach to diagnose and systematically improve services, starting at the facility level by the community

Number of staff trained at all levels Percentage of workshops at all levels including community-based con- ducted versus those planned

Percentage of supervisions conducted at all levels including community- based conducted versus those planned

Knowledge Management **Web-based Library as part of the

Mesoamerican Public Health Institute as a site for exchanging information on guidelines’, norms, technical proce- dures, publications, effective practices.

Number of virtual websites Number of publications in peer- reviewed journals

Number of contributions to national or regional guidelines

Number of effective practices shared by countries through the use of virtual information networks

Introduction of New Vaccines Introduction of vaccines that may have

a higher impact on decreasing the bur- den of disease in children under 5: -Rotavirus

-Conjugate pneumococcal heptavalent Use seed money and search for other sources of sustainability to introduce these vaccines through PAHO, local governments, and GAVI (Honduras and Nicaragua)

Percentage of countries that in- troduce rotavirus (monovalent or pentavalent)

Percentage of countries that in- troduce conjugate pneumococcal heptavalent vaccine

** There is an existent web-based library platform established by the Virtual Mesoamerican Public Health Institute where countries can build upon their interventions and activities