Table 1.

Summary of opportunities and constraints of enhancing immunization programme performance

Dimension	Opportunities	Constraints
Systems	Established systems encourage managers to consider processes and budget requirements needed to achieve targets RED planning, budgeting and tracking systems in place for immunization Established EPI statistics reporting system Performance review system identify problems and remedial actions Facilities planning norms encourage consistency in service resource allocation	MoH Action Planning Guides do not focus on immunization Performance review does not assess cost and efficiency issues No linkage of inputs to outputs or coverage indicators No consideration of immunization-related costs No flexibility in budget templates Incompleteness and inaccuracy of EPI reporting system Limited feedback on performance Limited systems for up-to-date staffing and staffing costs information Limited systems to increase knowledge of vaccine costs among local managers Limited responsiveness of systems for capital procurement
Structures	Authority to reallocate staff within and between services Can investigate instances of over- or under-staffing	Centralization of decision-making for immunization Limited control over key budget items and functions (i.e. human resources and vaccines) leads to passive approach by local managers
Strategies	Consistent prioritization of immunization in national health policy Supportive environment to improve efficiency of immunization programming within resource constraints Further research advocated to ensure effectiveness of newer policies
Style of leadership		Performance highly dependent on the quality of leadership provided by DMOs and their teams High turnover of strong managers
Staff capacity and skills	Managers able to interpret and generate cost and efficiency indicators Managers able to identify ways to reallocate scarce resources to enhance performance Extensive orientation, mentoring and supportive supervision of lower levels and experienced managers	High turnover of skilled managers Poor morale of staff Limited availability of experienced accounts staff Low capacity at sites farther from main centres Declining funding for supportive supervision and mentoring
Shared values	Staff commitment to EPI services Support for supportive supervision and mentoring	Divisions of perspectives on the value and function of staff incentives
Other factors		Unreliable disbursement of budgets

RED: Reaching Every District in Zambia with High Quality Routine Immunization Services.