Addressing Equity and Reaching the Underserved and Unreached in India

Transcription

1 Addressing Equity and Reaching the Underserved and Unreached in India Dr. Karan Singh Sagar Dr. Sumant Mishra Dr. Gunjan Taneja 13 th World Congress on Public Health Addis Ababa, Ethiopia 26 th April 2012

2 Presentation overview Universal Immunization Programme in India MCHIP in India Situation analysis Jharkhand Improving equity: State initiatives MCHIP interventions in focus districts Assessing Outcome

3 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

4 The Jharkhand Story DLHS-2 ( ) DLHS-3 ( ) Jharkhand District state came into existence District on 15 th November 2000 Full immunization: 8.8% (NFHS II: ) BOKARO Wide inter district variations (DLHS II and III) CHATRA DLHS-2 ( ) DLHS-3 ( ) JAMTARA NA 38.6 LATEHAR NA 72.7 DEOGHAR DHANBAD DUMKA EAST SINGHBHUM GARHWA GIRIDIH GODDA GUMLA HAZARIBAG LOHARDAGA PAKUR PALAMAU RANCHI SAHEBGANJ SARAIKELA NA 69.3 SIMDEGA NA 61.2 WEST SINGBHUM JHARKHAND

5 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

6 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 6

7 MCHIP Geographical presence building on past experience Gonda Varanasi Banda Uttar Pradesh Deoghar Jamtara Jharkhand Immunization focus districts Integrated districts Simdega Chaibasa Giridih

8 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

9 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 9

10 Developing comprehensive microplans Deoghar : Sessions held vs planned (1600 / month) Microplanning key to improved coverage Month Sessions held % Use of microplanning tool to generate comprehensive Apr' RI microplans May' Jun' Jul' Aug' HSC microplan Sep' Oct' Nov' Monthly immunization calendar Dec' Jan'

11 RAPID Approach 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 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 10 of the 11 facilities are in good category after four rounds of RAPID. In the Deoghar Jasidih first round 54 only Good one facility 52 was Good in good 52 category. Good 58 Good Quality of service quality improved with each round Sarwan 47 Avg 53 Good 53 Good 58 Good Reflects in improved coverage Palojori 37 Avg 50 Avg 50 Avg 53 Good Karon 33 Avg 35 Avg 53 Good 58 Good Kundhit 24 Poor 41 Avg 50 Avg 60 Good Jamtara Narayanpur 26 Poor 39 Avg 48 Avg 55 Good Flow chart of RAPID process Nala 27 Poor 40 Avg 56 Good 50 Avg Jamtara 30 Avg 56 Good 58 Good 58 Good

12 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

13 Technical Assistance Injection safety corner: before and after Glimpses: Demonstration center and cross learning visit Cross learning visit

14 Media Coverage: Cross Learning Visit

15 Tracking Drop outs MCHIP ID Name of subcenter Name of village/hamlet Name of child/pregnant women Name of parent/husband Date of birth / LMP Vaccination due C Ghasko Ghasko Abhishek Hembram Kavita Murmu DPT (B1)OPV (B)JE MCHIP piloting the Tracking Every New Born (TEN) model on the lines of GOI Mother and Child Tracking System (MCTS) C Ghasko Ghasko Manju Soren Sonamuni Murmu DPT (B1)OPV (B)JE C Ghasko Ghasko Beronica Murmu Abraham Murmu DPT (B1)OPV (B)JE C Ghasko Ghasko Binod Hembram Paklu Murmu DPT (B1)OPV (B)JE C Ghasko Ghasko Devraj Murmu Chintamuni Hansda DPT (B1)OPV (B)JE C Ghasko Ghasko Ajay Kumar Savitri Devi MeaslesVit A-1DPT (B1)OPV (B)JE C Ghasko Ghasko Pushpa Marandi Amina Tudu DPT (B1)OPV (B)JE Drop outs identified C Ghasko Ghasko Rubyshal Murmu Dev Murmu MeaslesVit A-1DPT (B1)OPV (B)JE Includes tracking of pregnant women also C Ghasko Ghasko Sunita Soren Alamuni Hembram MeaslesVit A-1DPT (B1)OPV (B)JE Pregnant women: 221 Child beneficiaries: 601 C Ghasko Ghasko Usha Marandi Mahima Soren DPT (B1)OPV (B)JE Pilot initiative in 5 HSCs in Sarwan block in Deoghar, 2 blocks in Jamtara block CHC in Jamtara C Ghasko Ghasko Dinesh Kumar Kunti Devi DPT (B1)OPV (B)JE C Ghasko Ghasko Chandan Kumar Kunti Devi MeaslesVit A-1 C Ghasko Ghasko Neha Kumari Rajesh Pujhar MeaslesVit A-1 C Ghasko Makra Parwati Hembram Rasmuni Murmu JE Learnings to be applied Beneficiaries to strengthen immunized GOI MCTS C Ghasko Makra Suman Tudu Anupama Hembram MeaslesVit A-1DPT (B1)JE C Ghasko Makra Ritesh Marandi Chudki Soren DPT (B1)OPV (B)JE C Ghasko Makra Ajay Pahariya Anita Devi Vit A-1DPT (B1)OPV (B)JE OPV1 OPV3 DPT1 DPT3 Measles TT2 C Ghasko Makra Eleni Hansda Bablu Hansda Vit A-1DPT (B1)OPV (B)JE C Ghasko Makra Balika Kumari Sindhyawati Devi Vit A-1DPT (B1)OPV (B)JE C Ghasko Makra Kaushalya Kumari Mamta Devi Vit A-1DPT (B1)OPV (B)JE C Ghasko Makra Vipul Hembram Hiramati Murmu DPT (B1)OPV (B)JE C Ghasko Makra Shobha Kumari Akli Devi Vit A-1DPT (B1)OPV (B)JE C Ghasko Makra Sunita Tudu Gonay Tudu Vit A-1DPT (B1)OPV (B)JE C Ghasko Makra Vishal Hansda Kulmuni Hembram DPT (B1)OPV (B)JE C Ghasko Makra Suraj Marandi Dhanmuni Hembram DPT1OPV3MeaslesVit A-1DPT (B1)OPV (B)JE C Ghasko Makra Ganesh Tudu Srimati Soren DPT (B1)OPV (B)JE C Ghasko Makra Rubylal Hemram Muni Murmu DPT (B1)OPV (B)JE C Ghasko Makra Srijal Hembram Baharani Marandi Vit A-1

16 My village my home initiative OPV DPT Hep B DOB Birth wt BCG B B Community level tool for community health workers 19 Munna, S/O Hafiz Ansari Kg Munna, S/O Hemavati Marandi Kg Pictorial depiction of immunization status 17 Koyal, D/O Mamuni Badhyakar Kg Facilitates community involvement in planning and implementation of services 16 Ravindra, S/O Nirmal Murmu Kg Durga, D/O Surajmuni Tuddu Kg Rakesh, S/O Komli Murmu Kg Simple tool to identify drop outs and left outs 13 Pooja, D/O Ashunta Hembram Kg Biswajit, S/O Mahadevi Marandi Kg Initiated in 7 AWCs to be scaled up to 5 HSC areas Kalamkani, D/O Sonamuni from April Kg Kusum, D/O Sukhimuni Soren Kg Dev, S/O Juba Badhyakar Kg Hembram 8 Rajkishor, S/O Sitamuni Soren Kg Mealses Vit A 7 Munna, S/O Opu Mandal Kg Jotin, S/O Osima Murmu Kg Sunita, D/O Mangoli Murmu Kg Chabi, D/O Sonamuni Hembram Kg Radhika, D/O Surajmuni Hembram Kg Sabera, D/O Jaitun Bibi Kg Rahul, S/O Logori Hembram Kg

17 Improved coverage with birth dose 100% 90% 80% Newborns the newest cohort of unreached 70% Newborns often miss out on birth dose Advocacy 60% for administration of OPV 0 and BCG to Pre intervention phase newborns 50% delivered at health facilities in focus districts. Areas strengthened: 40% Issue of vaccines to the delivery room in proper cold chain 30% Post intervention phase on daily basis 20% Correct recording of vaccination done to the newborns. For 10% this purpose separate columns were added in the delivery registers. 0% Immunization cards issued to ensure tracking at outreach session sites. 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-12 BCG 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%

18 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

19 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)

20 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

21 CES results: Immunization status 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 14.2% 34.8% 51.0% Baseline 6.7% 27.1% 66.2% Midterm Fully Immunized Partially Immunized Unimmunized N=210 families (12-23 month children) Data source: MCHIP CES, 2010 & 2011, Jharkhand

22 Coverage of different antigens 100% 90% 80% 70% 60% 50% 40% 10% Improved coverage across all antigens: 30% Improved access (DPT 1 up from 81.0% to 88.6%) Improved 20% utilization (DPT1-DPT3 drop out rate decreased from 27.2% to 13.0%) 0% BCG OPV - 0 DPT - 1 OPV - 1 DPT - 2 OPV - 2 DPT - 3 OPV - 3 Measles Baseline 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% Baseline Midterm N=210 families (12-23 month children) Data source: MCHIP CES, 2010 & 2011, Jharkhand

23 Distances of session sites <5 minutes by walking, 41.3% 5-15 minutes by walking, 45.9% By Public Transport, 3.1% 1/2 to 1 hour by walking, 9.7% Improved access Session site <15 minutes from home Baseline survey 74% Midline survey 87% N=210 families (12-23 month children) Data source: MCHIP CES, 2010 & 2011, Jharkhand

24 % fully immunized in MCHIP districts (Jharkhand) Improvement in fully immunized status in MCHIP focus districts over a period of one year FIC Deoghar: 2010 (50%), 2011 (67%) 40-60% 60-80% % December 2010 December 2011 Data source: WHO-NPSP office, Jharkhand

25 Availability of due list at session site Jan' Feb Mar Apr' Ma Jun' Jul' Aug Sep Oct' Nov Dec Jan' Feb Mar Apr' Ma Jun' Jul' Aug Sep Oct' Nov Dec 10 '10 '10 10 y' '10 '10 10 '10 '10 11 '11 '11 11 y' '11 '11 11 '11 '11 Jharkhand MCHIP Focus District Availability of due lists better in the focus districts from April 2011, due lists ensure proper tracking and improved coverage

26 Progressive improvement in coverage MCHIP a partner by collaborating at the state level and in the focus districts

27 Thank you