addressing equity and reaching the underserved …...addressing equity and reaching the underserved...
TRANSCRIPT
Addressing Equity and Reaching the Underserved and Unreached in India
Dr. Karan Singh Sagar Dr. Sumant Mishra Dr. Gunjan Taneja
13th World Congress on Public Health Addis Ababa, Ethiopia
26th April 2012
Presentation overview
• Universal Immunization Programme in India • MCHIP in India • Situation analysis Jharkhand • Improving equity:
– State initiatives – MCHIP interventions in focus districts
• Assessing Outcome
UIP in India • One of the largest programs in the world • Annual cohort of:
– 29 million pregnant women – 26 million infants
• FIC in India stands at 61.0% (CES 2009) • DPT 1- DPT3 drop out rate: 13.4% (CES 2009) • Highest number (approximately 7.4 million) of
children who have not received DPT-3 in the world
• Wide inter-state and inter-district variation in coverage
The Jharkhand Story • Jharkhand state came into existence on 15th November 2000 • Full immunization: 8.8% (NFHS II:1998-99) • Wide inter district variations (DLHS II and III)
District DLHS-2 (2002-04)
DLHS-3 (2007-08)
BOKARO 29.7 56.4
CHATRA 15.3 45.4
DEOGHAR 9.2 35.7
DHANBAD 42.2 47.5
DUMKA 5.2 52.9
EAST SINGHBHUM 35.7 81.5
GARHWA 18.3 66.6
GIRIDIH 19.2 21.6
GODDA 6.3 28.4
GUMLA 20.7 68.6
HAZARIBAG 48.9 68.9
District DLHS-2 (2002-04)
DLHS-3 (2007-08)
JAMTARA NA 38.6
LATEHAR NA 72.7
LOHARDAGA 44.1 81.2
PAKUR 25.8 41.9
PALAMAU 22.4 53.4
RANCHI 44.3 74.3
SAHEBGANJ 7.7 33.6
SARAIKELA NA 69.3
SIMDEGA NA 61.2
WEST SINGBHUM 13.5 59.1
JHARKHAND 25.7 54.1
Key bottlenecks & challenges • Lack of awareness and community participation. • HR issues • Poor microplanning:
– Sessions not held as planned – HRA areas / mobile and migrant population not included – HR crunch / inadequate deployment of available staff
• Low utilization of services: high drop outs • Weak vaccine and logistics management • Lack of monitoring and supportive supervision • Poor waste management • Fear of AEFI, weak VPD and AEFI surveillance • Poor data quality
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Technical support: MCHIP’s role in India
USAID’s flagship programme for achieving MDGs 4&5
Provides technical assistance for RI strengthening to UIP and partners National Level Priority states of Jharkhand and UP Five poor performing districts:
• 2 in JHK: Deoghar and Jamtara • 3 in UP: Banda, Gonda and Varanasi
MCHIP – Geographical presence – building on past experience
Uttar Pradesh
Gonda
Varanasi
Banda
Deoghar
Jamtara
Jharkhand
Giridih Simdega
Chaibasa Immunization focus districts Integrated districts
Improving equity: reaching the unreached
• State initiatives: – Identification of high risk districts and blocks – Special catch up campaigns – Focused interventions for Primitive Tribe Groups – Planning for slums and underserved areas – Comprehensive microplans – Establishing the AVD mechanism – Institutionalizing program review meetings – Establishing and strengthening the state RI cell
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Key interventions
Developing comprehensive microplans Regular Appraisal of Program Implementation in District
(RAPID) approach Establishing demonstration sites for cross learning Tracking drop outs Institutionalization of newborn vaccination at health facilities Strengthening program reviews Using data for action
Developing comprehensive microplans
• Microplanning key to improved coverage • Use of microplanning tool to generate comprehensive
RI microplans
HSC microplan
Monthly immunization calendar
Deoghar : Sessions held vs planned (1600 / month)
Month Sessions held % Apr'11 1552 97.00 May'11 1548 96.75 Jun'11 1550 96.88 Jul'11 1349 84.31
Aug'11 1353 84.56 Sep'11 1548 96.75 Oct'11 1541 96.31 Nov'11 1556 97.25 Dec'11 1587 99.19 Jan'12 1521 95.06
RAPID Approach
Flow chart of RAPID process
Round 1
(Feb 2010) Round 2
(Nov 2010) Round 3
(April 2011) Round 4
(Nov 2011)
District PHC Points Grade Points Grade Points Grade Points Grade
Deoghar
Mohanpur 25 Poor 43 Avg 55 Good 59 Good
Sarath 47 Avg 41 Avg 53 Good 55 Good
Madhupur 36 Avg 41 Avg 50 Avg 55 Good
Jasidih 54 Good 52 Good 52 Good 58 Good
Sarwan 47 Avg 53 Good 53 Good 58 Good
Palojori 37 Avg 50 Avg 50 Avg 53 Good
Karon 33 Avg 35 Avg 53 Good 58 Good
Jamtara
Kundhit 24 Poor 41 Avg 50 Avg 60 Good
Narayanpur 26 Poor 39 Avg 48 Avg 55 Good
Nala 27 Poor 40 Avg 56 Good 50 Avg
Jamtara 30 Avg 56 Good 58 Good 58 Good
10 of the 11 facilities are in good category after four rounds of RAPID. In the
first round only one facility was in good category. Quality of service quality improved with each round
Reflects in improved coverage
Process of development of Demo Sites
Situation analysis of all
facilities ; Composite
scores for each facility through a
matrix and RAPID
Demonstration site identified
Handholding and Mentoring at
site
Readiness assessment
checklist Demonstration site developed
on four key thematic areas
Cross learning of health
functionaries from other
facilities
Thematic areas: Programme Management, Cold Chain and Vaccine Management, Recording & Reporting, Injection Safety
Technical Assistance
Injection safety corner: before and after
Cross learning visit
Glimpses: Demonstration
center and cross learning visit
Media Coverage: Cross Learning Visit
Tracking Drop outs
• MCHIP piloting the Tracking Every New Born (TEN) model on the lines of GOI Mother and Child Tracking System (MCTS)
• Includes tracking of pregnant women also • Pilot initiative in 5 HSCs in Sarwan block in Deoghar, 2
blocks in Jamtara block CHC in Jamtara • Learnings to be applied to strengthen GOI MCTS
MCHIP ID Name of subcenter Name of village/hamlet Name of child/pregnant women Name of parent/husband Date of birth /
LMP Vaccination due
C0710002 Ghasko Ghasko Abhishek Hembram Kavita Murmu 26-06-10 DPT (B1)OPV (B)JE C0710003 Ghasko Ghasko Manju Soren Sonamuni Murmu 05-06-10 DPT (B1)OPV (B)JE C0910004 Ghasko Ghasko Beronica Murmu Abraham Murmu 12-08-10 DPT (B1)OPV (B)JE C0710007 Ghasko Ghasko Binod Hembram Paklu Murmu 10-05-10 DPT (B1)OPV (B)JE C0910008 Ghasko Ghasko Devraj Murmu Chintamuni Hansda 28-07-10 DPT (B1)OPV (B)JE C1110011 Ghasko Ghasko Ajay Kumar Savitri Devi 16-10-10 MeaslesVit A-1DPT (B1)OPV (B)JE C1010012 Ghasko Ghasko Pushpa Marandi Amina Tudu 16-09-10 DPT (B1)OPV (B)JE C1110014 Ghasko Ghasko Rubyshal Murmu Dev Murmu 02-11-10 MeaslesVit A-1DPT (B1)OPV (B)JE C1210016 Ghasko Ghasko Sunita Soren Alamuni Hembram 13-11-10 MeaslesVit A-1DPT (B1)OPV (B)JE C0910017 Ghasko Ghasko Usha Marandi Mahima Soren 28-08-10 DPT (B1)OPV (B)JE C1010018 Ghasko Ghasko Dinesh Kumar Kunti Devi 30-09-10 DPT (B1)OPV (B)JE C0411019 Ghasko Ghasko Chandan Kumar Kunti Devi 25-03-11 MeaslesVit A-1 C0311020 Ghasko Ghasko Neha Kumari Rajesh Pujhar 03-02-11 MeaslesVit A-1 C0410021 Ghasko Makra Parwati Hembram Rasmuni Murmu 05-04-10 JE C0610025 Ghasko Makra Suman Tudu Anupama Hembram 22-05-10 MeaslesVit A-1DPT (B1)JE C1110026 Ghasko Makra Ritesh Marandi Chudki Soren 31-08-10 DPT (B1)OPV (B)JE C1010027 Ghasko Makra Ajay Pahariya Anita Devi 20-09-10 Vit A-1DPT (B1)OPV (B)JE C1110029 Ghasko Makra Eleni Hansda Bablu Hansda 01-11-10 Vit A-1DPT (B1)OPV (B)JE C0910030 Ghasko Makra Balika Kumari Sindhyawati Devi 21-07-10 Vit A-1DPT (B1)OPV (B)JE C1110033 Ghasko Makra Kaushalya Kumari Mamta Devi 26-10-10 Vit A-1DPT (B1)OPV (B)JE C0910034 Ghasko Makra Vipul Hembram Hiramati Murmu 27-08-10 DPT (B1)OPV (B)JE C1110035 Ghasko Makra Shobha Kumari Akli Devi 19-10-10 Vit A-1DPT (B1)OPV (B)JE C1010036 Ghasko Makra Sunita Tudu Gonay Tudu 01-10-10 Vit A-1DPT (B1)OPV (B)JE C0610037 Ghasko Makra Vishal Hansda Kulmuni Hembram 22-05-10 DPT (B1)OPV (B)JE
C1010038 Ghasko Makra Suraj Marandi Dhanmuni Hembram 04-09-10 DPT1OPV3MeaslesVit A-1DPT (B1)OPV
(B)JE C1210039 Ghasko Makra Ganesh Tudu Srimati Soren 29-11-10 DPT (B1)OPV (B)JE C1110040 Ghasko Makra Rubylal Hemram Muni Murmu 12-10-10 DPT (B1)OPV (B)JE C0211043 Ghasko Makra Srijal Hembram Baharani Marandi 10-01-11 Vit A-1
Drop outs identified Pregnant women: 221 Child beneficiaries: 601
Beneficiaries immunized
OPV1 OPV3 DPT1 DPT3 Measles TT2
21 43 38 47 42 45
My village my home initiative
• Community level tool for community health workers • Pictorial depiction of immunization status • Facilitates community involvement in planning and
implementation of services • Simple tool to identify drop outs and left outs • Initiated in 7 AWCs to be scaled up to 5 HSC areas
from April 2012
DOB Birth wt BCG
OPV DPT Hep B
Mealses Vit A
1 2 3 B 1 2 3 B 1 2 3
19 Munna, S/O Hafiz Ansari 29-12-11 3 Kg 30-12-11
18 Munna, S/O Hemavati Marandi 20-12-11 3 Kg 21-12-11 01-03-12 01-03-12
17 Koyal, D/O Mamuni Badhyakar 03-12-11 2.5 Kg 04-12-11 01-03-12 01-03-12
16 Ravindra, S/O Nirmal Murmu 21-10-11 3.5 Kg 22-10-11 02-02-12 02-02-12 02-02-12
15 Durga, D/O Surajmuni Tuddu 04-10-11 2 Kg 12-10-11 01-12-11 02-02-12 01-12-11 02-02-12
14 Rakesh, S/O Komli Murmu 06-09-11 2.5 Kg 02-10-11 01-12-11 05-01-12 02-02-12 03-11-11 01-12-11 01-03-12
13 Pooja, D/O Ashunta Hembram 18-08-11 2.5 Kg 01-09-11 01-12-11 02-02-12 12-10-11 01-12-11 02-02-12
12 Biswajit, S/O Mahadevi Marandi 07-08-11 2.5 Kg 12-10-11 01-12-11 05-01-12 02-02-12 12-10-11 01-12-11 05-01-12
11 Kusum, D/O Sukhimuni Soren 07-07-11 3 Kg 07-07-11 01-12-11 02-02-12 01-09-11 03-11-11 01-12-11
10 Dev, S/O Juba Badhyakar 11-05-11 3.5 Kg 02-06-11 07-07-11 03-01-12 02-02-12 07-07-11 04-08-11 01-09-11
9 Kalamkani, D/O Sonamuni Hembram 11-05-11 3 Kg 02-06-11 07-07-11 05-01-12 02-02-12 07-07-11 04-08-11 01-09-11
8 Rajkishor, S/O Sitamuni Soren 03-05-11 2.5 Kg 02-06-11 07-07-11 02-02-12 07-07-11 04-08-11 05-01-12
7 Munna, S/O Opu Mandal 26-04-11 3 Kg 05-05-11 07-07-11 05-01-12 02-02-12 07-07-11 04-08-11 01-09-11
6 Jotin, S/O Osima Murmu 14-04-11 2.8 Kg 05-05-11 07-07-11 05-01-12 02-02-12 07-07-11 04-08-11 01-09-11 02-02-12 02-02-12
5 Sunita, D/O Mangoli Murmu 24-04-11 3 Kg 05-05-11 07-07-11 01-12-11 02-02-12 07-07-11 12-10-11 01-12-11 02-02-12 02-02-12
4 Chabi, D/O Sonamuni Hembram 28-03-11 3 Kg 28-03-11 07-07-11 05-01-12 02-02-12 07-07-11 01-09-11 03-11-11 01-03-12 01-03-12
3 Radhika, D/O Surajmuni Hembram 10-03-11 2.5 Kg 05-05-11 05-05-11 02-06-11 05-01-12 05-05-11 02-06-11 01-09-11
2 Sabera, D/O Jaitun Bibi 22-02-11 2.5 Kg 07-04-11 05-05-11 02-06-11 05-01-12 05-05-11 02-06-11 04-08-11 01-12-11 01-12-11
1 Rahul, S/O Logori Hembram 09-01-11 2.6 Kg 10-01-11 03-02-11 07-04-11 05-05-11 03-02-11 07-04-11 05-05-11 03-11-11 03-11-11
Improved coverage with birth dose
• Newborns the newest cohort of unreached • Newborns often miss out on birth dose • Advocacy for administration of OPV 0 and BCG to
newborns delivered at health facilities in focus districts. Areas strengthened: – Issue of vaccines to the delivery room in proper cold chain
on daily basis – Correct recording of vaccination done to the newborns. For
this purpose separate columns were added in the delivery registers.
– Immunization cards issued to ensure tracking at outreach session sites.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12
Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12BCG to newborn 28.9% 19.2% 31.9% 28.0% 31.4% 33.1% 47.5% 47.2% 60.6% 59.7% 72.1% 76.8% 88.8%OPV '0' to newborn 35.9% 18.2% 31.9% 28.0% 31.4% 33.1% 55.8% 66.2% 60.0% 63.3% 74.1% 73.0% 85.9%
Pre intervention phase
Post intervention phase
Strengthen program review
• RI cell institutionalized in the focus districts – Platform for discussing and implementing RI
related activities in the districts • Review meetings at the block level
Identify gaps in the program and suggest appropriate action points
Using data for action
• Reported data analyzed to identify poor performing blocks and sub centers
• Use of self monitoring tools advocated
Coverage monitoring chart (estimate DPT 1- DPT 3 drop out rate)
Assessing Outcome • MCHIP conducted Coverage Evaluation Surveys
– Baseline: Feb 2010 – Midline: Sept 2011 – Standard WHO 30x7 cluster methodology
• RI monitoring data – Data generated through monitoring of RI session sites – House to house monitoring
• Ranking of districts – On basis of select parameters
CES results: Immunization status
51.0%66.2%
34.8%
27.1%
14.2% 6.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Midterm
Fully Immunized Partially Immunized Unimmunized
N=210 families (12-23 month children)
Data source: MCHIP CES, 2010 & 2011, Jharkhand
Coverage of different antigens
BCG OPV - 0 DPT - 1 OPV - 1 DPT - 2 OPV - 2 DPT - 3 OPV - 3 MeaslesBaseline 82.4% 32.4% 81.0% 80.5% 69.5% 70.0% 59.0% 59.5% 56.7%Midterm 91.0% 41.0% 88.6% 89.5% 83.8% 84.3% 77.1% 77.6% 69.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Midterm
N=210 families (12-23 month children)
Data source: MCHIP CES, 2010 & 2011, Jharkhand
Improved coverage across all antigens: Improved access (DPT 1 up from 81.0% to 88.6%)
Improved utilization (DPT1-DPT3 drop out rate decreased from 27.2% to 13.0%)
Distances of session sites
<5 minutes by walking, 41.3%
5-15 minutes by walking, 45.9%
1/2 to 1 hour by walking, 9.7%
By Public Transport, 3.1%
Data source: MCHIP CES, 2010 & 2011, Jharkhand
N=210 families (12-23 month children)
Improved access Session site <15 minutes from
home Baseline survey 74% Midline survey 87%
% fully immunized in MCHIP districts (Jharkhand)
December 2010 December 2011
Data source: WHO-NPSP office, Jharkhand
40-60% 60-80% 80-100%
Improvement in fully immunized status in
MCHIP focus districts over a period of one year FIC Deoghar: 2010 (50%), 2011 (67%)
Jan'10
Feb'10
Mar'10
Apr'10
May'10
Jun'10
Jul'10
Aug'10
Sep'10
Oct'10
Nov'10
Dec'10
Jan'11
Feb'11
Mar'11
Apr'11
May'11
Jun'11
Jul'11
Aug'11
Sep'11
Oct'11
Nov'11
Dec'11
Jharkhand 58.050.848.460.264.057.657.864.050.158.964.158.360.859.364.670.272.371.962.263.066.456.766.862.8MCHIP Focus District 86.053.689.091.481.145.465.280.131.375.040.039.383.352.943.581.389.084.287.382.574.674.577.276.4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Availability of due list at session site
Availability of due lists better in the focus districts from April 2011, due lists ensure proper tracking and improved coverage
•Progressive improvement in coverage •MCHIP a partner by collaborating at the state level and in the focus districts
Thank you