Addressing Equity and Reaching the Underserved …...Addressing Equity and Reaching the Underserved and Unreached in India Dr. Karan Singh Sagar Dr. Sumant Mishra Dr. Gunjan Taneja

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

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

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