"Reaching every district" (RED) is a strategy to achieve the goal of 80% immunization coverage in all districts and 90% nationally in the WHO member states. RED aims to fully immunize every infant with all vaccines included in the national immunization schedule of countries. In order to achieve this goal, the strategy focuses on building national capacity from district level upward to maximize access to all vaccines, old and new.

RED addresses common obstacles to increasing immunization coverage such as poor quality district planning, low quality and unreliable service, inadequate monitoring and supervision of health workers.

1. Re-establishing outreach services

In many countries a large proportion of the population only have access to immunization though outreach sessions. Outreach is any delivery strategy that requires health facility staff to leave their facility to deliver immunization. Ideally a minimum of four contacts per year are required to fully immunize an infant. For some communities, access can only be provided irregularly, and may require mobile teams to provide outreach, which will involve resources beyond the health facility and district level. Outreach sessions, especially mobile teams, present opportunities to provide other interventions along with immunization.

2. Supportive supervision

Supportive supervision implies providing on site training to health workers at the time of a supervisory visit, or at regular district meetings. To be supportive, supervisors should make regular schedules for visits, help to solve problems locally and follow up regularly with supply and resource issues. Supervisors will themselves need training to adapt their own approaches to supervision.

3. Linking services with communities

Involving the community with the planning and delivery of the service will encourage community ownership and improve attendance. Identifying community volunteers providing them with a role, such as follow up of defaulters, and holding regular meetings is an important step towards building a link with the community.

4. Monitoring and use of data for action

Monitoring and use of data for action implies not only the timely collection of data at district level, but the use of the data to solve problems. Some simple tools, including wall charts that display access and utilization need little training, but are very useful to take action according to monthly progress. Not only do districts collect coverage data, but also a large amount of other information, including logistics, supply, surveillance, all of which should be used to improve the immunization system. Some qualitative data may not be available in regular reports and may need to collected though supervisory visits.

5. Planning and management of resources

The district micro-plan is the key to the RED strategy. The micro-plan should be based upon a local situation analysis which involves every health facility and through them the community that they serve. At the national level, there is a responsibility to ensure the needed financial and human resources are available to the district, while the district must ensure the resources are efficiently used, through regular monitoring and adjusting the micro plan. Continuing to fund the RED strategy for more than the first year of implementation is vital for sustainability of coverage increase.

Partners

Many immunization partners such as the United Nations Children's Fund (UNICEF), the Centers for Disease Control and Prevention of the United States Department of Health and Human Services (CDC), Program for Appropriate Technology in Health (PATH), Immunization Basics and the United States Agency for International Development (USAID) have been involved in the development and implementation of the RED strategy. 

Countries implementing the RED strategy

Most countries in the WHO regions of Africa, Eastern Mediterranean, Europe, South-East Asia and the Western Pacific have adopted and have been implementing the RED strategy since 2002. RED priority countries are those with large population and a high number of unimmunized infants such as India, Indonesia, Nigeria, Ethiopia, Pakistan and China.

RED evaluation

The evaluation of the RED strategy in five countries2 in Africa in 2005 showed that the RED approach contributed significantly to strengthening immunization systems and improving the delivery of vaccines. In the five countries evaluated between 2002-2004, the total number of districts with DTP3 coverage over 80% increased from 70 to 197, while the number of districts with less than 50% coverage declined from 377 in 2002 to 222 in 2004. While it was not possible to conclude which RED components or which factors contributed most to increasing coverage, the common factor in all these countries was a focus in micro planning at the district level. Another RED evaluation in several countries in Africa is planned for 2007. 

Resources

The RED evaluation showed that the extra resources needed to implement the RED strategy are relatively modest. These extra resources are mainly used in micro planning activities, workshops, training and to cover other supervisory and monitoring costs. The success of the RED strategy will depend on the sustainability of these resources as well as its availability at the district level. 

WHO work on RED

WHO regional offices have been involved in several RED planning activities and implementing RED meetings and workshops. Within countries WHO and UNICEF staff are able to provide technical support in the development of the national EPI programme RED planning and implementation.