Partnering with immunization staff for capacity building: The START project

For public health capacity building and training programs to achieve success, effective partnerships are key.

Partners must agree on whether a weakness in the health system is a training issue or not. If so, then they must agree on the skill and knowledge gaps among staff to be trained, on who should be trained, on the training methods and materials to be used, and on how to measure the impact of the training. Anyone who has helped develop a training agenda knows it sometimes requires the negotiation skills of senior diplomats.

One of the common ways a capacity building program can fail is to ignore the training participants as being partners.  

Adult learning theory notes that adults use a hands-on, problem-solving approach to learning; that they are accustomed to being active; and that they have many life and work experiences which they bring to a training class. However, too often public health training is conducted in crowded workshops, with hours of lectures and information giving as the primary teaching methods. This way, the trainees are viewed less as partners in the learning process and more as passive recipients of facts.    

A new U.S. Centers for Disease Control and Prevention project is trying a different approach.  The Strengthening Technical Assistance for Routine Immunization Training project — better known as START — seeks to improve immunization program planning, monitoring and service delivery among district and health facility staff. START consultants mentor district immunization staff, and together with the district staff, conduct on-the-job trainings at selected underperforming health centers within their districts for five months or longer. The consultants visit both their assigned districts and the selected health centers multiple times each to help ensure knowledge and skills are not only learned but applied. When working with district staff, consultants facilitate discussion about a topic, ask for their ideas, provide guidance, and, with the staff, develop a list of tasks to work on to improve performance. At the health centers, where immunization services are delivered, START consultants and the district officers train staff together using a hands-on approach: demonstrating a skill, such as how to complete and interpret a monitoring chart; getting staff to practice using their health center’s data; providing feedback; and discussing use of the chart during the next visit.

Three teams of START consultants have worked in 54 districts in Uganda since July 2013, and they have reported that they think using adult learning principles is an effective approach.

One consultant noted that a health center staff person said, “I’ve attended three workshops on developing an immunization microplans, but never understood how to do it until I worked with you.”

District immunization partners have also responded positively to these learning methods and the nonhierarchical approach. One officer described the START consultant as “being on the same team with us, not an expert who drops in to tell us what we are doing wrong.”

George Momanyi, a public health nurse from Kenya who has worked as a START consultant in Uganda, noted that he explicitly acknowledged his role as a partner when he first met immunization staff in his assigned districts. “I reassure workers that I am there to work with them as a colleague to support them to improve their routine immunization performance,” he said.

A three-month follow-up evaluation of the pilot START team in Uganda suggests that the approach of multiple mentoring and on-the-job training visits with immunization staff may be working, at least in the short term. District participants reported an increased use of routine immunization data for program planning, as well as an improvement in vaccine forecasting and program monitoring.

Likewise, among a sample of health center staff trained by START consultants, 87 percent reported improvements in how they conduct both fixed site and outreach vaccination sessions. An ex-post evaluation of the pilot team is scheduled for 2015 to assess the longer-term impact of the training approach.

START has expanded to Ethiopia in September 2014, where a team of 10 consultants would work for 12 months, and plans are underway to work in additional countries in 2015. CDC is funded for the START project with a grant from the Bill & Melinda Gates Foundation through 2018.

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