From 2003 to 2010, MVN-A programs in Kenya, Mali, Uganda and Zambia trained more than 1,000 Expanded Program on Immunization (EPI) health workers across all four countries. Trainees in each country have demonstrated significant improvement in perceived ability, competence, knowledge and skills in most targeted areas of EPI management. In addition, MVN-A graduates have returned to their home medical facilities to cascade their expertise and knowledge to fellow health workers.

In all four countries, "training of trainers" sessions conducted by Ministry of Health and WHO EPI personnel enhanced the national training capacity of the MVN-A programs. A cadre of local MVN-A trainers is now available to sustain these efforts in each country, supported by the Ministry of Health and other national stakeholders.

Interim course evaluations to date demonstrate that MVN-A training is useful to participants. Response to training and changes in knowledge and practice were measured using various techniques including pre- and post-tests of knowledge and retention, and daily course evaluations on content, facilitation and participation.

• In Uganda, the pre-test average score was 62 percent and post-test average score was 74 percent. Similar average score improvements were found in Kenya.
• In Zambia, six-month post-assessments showed significant improvements over baseline in participants' perceived confidence in all areas except the WHO Reach Every District (RED) strategy; as a result, the MVN-A collaborators in Zambia revised their EPI training curricula accordingly.
• In Mali, interim assessments informed the need to provide quarterly supportive supervision to reach peripheral health centers, after which the MVN-A program implemented focused supportive supervision visits on a single theme and directly observed actual immunization practices by EPI health workers.
• In Zambia, low- and high-performing districts were paired to promote ongoing support via peer mentoring.

The MVN-A programs have also found that, while cascade training appears to be an efficient way to reach several management levels, it requires extensive "training of trainers" and targeted follow-up to effectively reach EPI health workers at peripheral levels. Supervisory training can enhance the distribution of information to peripheral health centers. But to maintain high immunization coverage, the MVN-A training programs have concluded there is a need to significantly improve supportive supervision practices in each country and make public resources available to conduct more frequent, focused training of mid-level EPI managers to support evolving national immunization priorities.