LETTERS
Reaching Every District (RED) approach: a way to improve immunization performance
Jos VandelaerI,1; Julian BilousII; Deo NshimirimanaIII
IHealth Section, Programme Division, UNICEF, New York, NY, United States of America
IIDepartment of Immunization and Biologicals, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
IIIRegional Office for Africa (AFRO), World Health Organization, Brazzaville, Republic of the Congo
In their paper, Victora et al.1 show that "child survival interventions are inequitably distributed within low- and middle-income countries". Areas of greatest need were not prioritized, and expansion of these health programmes in more difficult areas has tended to be delayed or postponed. In response, we wish to share some results and propose a way forward based upon experiences with immunization programmes.
Immunization programmes around the world have recognized and strived to reduce inequity for many years. While Universal Child Immunization (UCI) of 80% coverage was achieved in 1990, this merely emphasized the need to balance the inequalities within and between countries. Accordingly, several approaches were adopted. The "high risk approach" was designed in the mid-1990s to reach women in underserved areas with tetanus toxoid immunization using a campaign-style approach.2 District level microplanning has been the cornerstone of the polio eradication and measles elimination initiatives, to maximize the delivery of vaccines to all districts, especially underserved populations. District-level coverage and disease surveillance data are now routinely collected in most countries, with reporting of selected indicators to the global level since 2000.
In 2002, the Reaching Every District (RED) approach was developed and introduced by WHO, the United Nations Children's Fund (UNICEF) and other partners in the GAVI Alliance to improve immunization systems in areas with low coverage. Far from being a programme, or separate initiative, the approach outlines five operational components that are specifically aimed at improving coverage in every district:
- re-establishment of regular outreach services;
- supportive supervision: on-site training;
- community links with service delivery;
- monitoring and use of data for action;
- better planning and management of human and financial resources.3
The RED approach encourages countries to use coverage data to make an analysis of the distribution of unimmunized infants, and thereby prioritize districts with poor access and utilization of immunization, while districts are encouraged to make microplans to identify local problems and adopt corrective solutions.
Since 2003, 53 developing countries have started implementing RED to various degrees, mostly in Africa and south and south-east Asia.4 All 53 countries belong to the groups of lower income and lower-middle income countries, as per World Bank classification. In 2005, an evaluation of 5 countries in Africa that had implemented RED found that, in 4 of the 5 countries, immunization coverage had increased since the implementation of RED, and that the proportion of districts with DTP3 (three-dose diphtheria, tetanus and pertussis vaccine) coverage above 80% had more than doubled.5 The number of unimmunized children in these 5 countries was reduced from 3 million in 2002 to 1.9 million in 2004. Interestingly, the report notes that outreach services, one of the five components of RED, were often used to deliver other interventions beyond immunization, such as Vitamin A, antihelminthic drugs or insecticide-treated bed nets. This indicates that implementation of RED components may start to have an impact beyond immunization services alone.
An analysis of coverage data supports the findings of the evaluation in Africa. It shows that in the 53 countries that started to implement RED between 2003 and 2005, DTP3 coverage (as estimated by WHO and UNICEF) increased between 2002 and 2005 in 34 (64%) countries, and decreased in only 7 (13%).6
Although these data need to be interpreted with caution, since RED implementation has not been nationwide in many countries, they seem to indicate that where RED is implemented, it can help to reduce gaps in immunization coverage. We agree with the suggestion of Victora et al. regarding the need for information systems and training. Most of the 53 countries we refer to have functional immunization information, logistics and supply systems and have implemented district training, often using funds from the GAVI Alliance. Furthermore WHO, UNICEF and other partners at country and regional level have been closely involved in guiding countries adopting the RED approach to reach the unreached. We believe that the RED approach of district microplanning based upon local data using simple operational components and supported by supply and logistics has the potential for the successful delivery of other child health interventions, especially during outreach. 
References
1. Victora CG, Huicho L, Amaral JJ, Armstrong-Schellenberg J, Manzi F, Mason E et al. Are health interventions implemented where they are most needed? District uptake of the Integrated Management of Childhood Illness strategy in Brazil, Peru and the United Republic of Tanzania. Bull World Health Organ 2006;84:792-801. PMID:17128359 doi:10.2471/BLT.06.030502
2. Anonymous. The high-risk approach: the WHO-recommended strategy to accelerate elimination of neonatal tetanus. Wkly Epidemiol Rec 1996;71:33-9. PMID:8851826
3. Global Immunization Vision and Strategy 2006-2015. Geneva: WHO and UNICEF; 2005.
4. Global Polio Eradication Initiative: 2005 annual report. Geneva: WHO, Rotary International, CDC, UNICEF; 2006 (WHO/Polio/06.02).
5. Report of evaluation of Reaching Every District approach in five countries. Brazzaville: WHO Regional Office for Africa, 2005 [unpublished document].
6. WHO vaccine-preventable diseases: monitoring system: 2006 global summary. Geneva: WHO; 2006 (WHO/IVB/2006). Available from: http://www.who.int/immunization_monitoring/data/en/
1 Correspondence to Jos Vandelaer (e-mail: vandelaerj@who.int).