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The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunization system performance.
It is important to emphasize that while the WHO and UNICEF estimates are informed by data from national authorities and may not differ from official government reported data, they constitute an independent technical assessment by WHO and UNICEF of the national routine immunization system performance.
Finally, we believe that applying an assets-based lens to programme design, as applied in this study, allows the identification of varied local and successful pathways to coverage improvement and should be considered in future studies and routine assessments of district-level immunization system performance.
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They are also the primary source used by national authorities to fill in the WHO/UNICEF joint reporting forms (JRF) on vaccine-preventable diseases, a major source of information on global coverage and immunization systems performance (WHO 2006).
A robust routine immunization system functioning within the health system is required to achieve and sustain our ambitious goals.
The case studies also set out to understand which elements of the health and immunization system underpinned the performance drivers.
Child survival and immunization success is also influenced by the health system performance which had been experiencing low financing since 1980s; when Tanzania adopted Strategic Adjustment Program (SAP) and later, National Economic Survival Programmes (NESP) to foster economic development[ 5].
Figure 6 depicts a comprehensive pathway to improving RI coverage that includes all six performance improvement drivers, their interaction with key health and immunization system elements, and with each other.
Using a conceptual framework defined in the preparatory phase of our study, we found 56 potential performance drivers and categorized them as context, health system or immunization system factors.
We began exploring the drivers of improved RI system performance with an extensive literature review to understand key factors associated with high immunization coverage levels (JSI Research & Training Inc. 2012a).
While this PBI system does not employ measures of health outcomes, we suggest that measures such as sanitation coverage, identification of patients with chronic disease or malnutrition, and the use of immunizations, family planning, antenatal care, and cervical cancer screening services, nonetheless represent key measures of health system performance.
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