Karachi: Routine immunization rates have been falling in Sindh from 37 per cent in 2006-07 to 29 per cent in 2012-13. This is one of the reasons behind polio endemicity and is leading to outbreaks of deadly preventable childhood diseases such as measles. Other diseases covered by routine immunization are hepatitis B, pneumococcal infections, diphtheria, tetanus, and pertussis.
What is wrong with routine immunization and how can it be improved?
A pilot project in District Tando Muhammad Khan (TMK) implemented by Aga Khan University and supported by Global Alliance for Vaccines and Immunizations assessed the barriers and strengthened government Expanded Programme on Immunization (EPI) services through game changers. The result was a jump in routine immunization from 15-19 per cent surveyed for different vaccines–to 49-84 per cent as reported by independent monitoring.
According to the project lead for this component Dr Shehla Zaidi, Associate Professor, Women and Child Health Division, Aga Khan University, the main bottlenecks were low accountability of routine immunization, children often getting missed for vaccination at health facilities, insufficient visits to villages by vaccinators, and little efforts at routine immunization awareness even by the health workforce on ground.
Above all, the vaccination reporting is unverified, the numbers reported by government’s EPI are much higher than that by the national Pakistan Demographic and Health Surveys, showing the gap in performance accountability
So the project used strategies that can be sustained by the government, involve little cos and do not involve additional manpower.
The breakthrough came by focusing on performance accountability of vaccination, monitored independently through a smart phone android application. Named Teeko, the app was designed with the Aga Khan Development Network e-Health Resource Centre in Karachi.
It monitors the number of children being immunized, vaccinators’ movement, vaccine stock available at union council with real data instantly available for checking at district and provincial level. And the district took action by suspending low performing vaccinators and publically appreciating well performing ones.
Fuel support for visiting villages was provided to vaccinators based on immunization performance provided to vaccinators– and a detailed district micro-plan developed
A team approach to vaccination was brought in bringing the Department of Health staff and People’s Primary Healthcare Initiative staff together as a single team to reduce children missed for vaccination. Single window system was put in place at basic health units and rural health centers so that every child who comes in is screened for vaccination status, at colorful child friendly EPI rooms.
All frontline health staff from doctors to dispensers to lady health workers were trained to actively counsel and refer children for immunization. The team also plans together for monthly achievement of union council targets.
Communication to community was improved through one time, sustainable measures. Demand generation messages were sent to all mobile phone users for children registration, and local FM radio broadcasted jingles.
The innovations were designed in close collaboration with Sindh EPI, implemented through the district government and with input from UN agencies.
“At the same time, we had a high number of vaccinations reported that didn’t match the actual disease outbreak numbers. As the three month roll-out results show, there is instant online reporting of children under one-year-old vaccinated against targets, static and outreach performance, as well as details of underperforming and over-performing union councils,” she added.
District officials and legislators have welcomed the new planning and monitoring systems and are aware of the efforts that have been invested in the project.
“A major challenge for the district administration will be to sustain the progress we have made after the project is over,” said Agha Abdul Raheem, Deputy Commissioner, TMK.
“The real-time performance monitoring has been the major driver and can be taken over by EPI Sindh at very little additional cost and incorporated in its upcoming expanded EPI support,” said Dr Zaidi.