Routine Immunization UIP-ANNEX

ANNEX 1
TEN NATIONAL RECOMMENDATIONS

1. The existing national level Inter Agency Coordination Committee (ICC) needs to a) increase its focus on routine immunization by specifically monitoring MYP implementation b) broaden its membership c) meet at least quarterly 2. Revitalize standard processes for active monitoring and supervision practices, for example through field visits, periodic reviews and reliable reports with a focus on district and sub district levels. The central / state monitoring teams should lead by example. 3. Central level should review, update and disseminate operational guidelines for use by all UIP staff that include simple key messages on: a) Devising and implementing routine immunization micro plans b) Simple aspects of injection safety c) Vaccine logistics (ordering, storage, wastage and use) d) Immunization schedule and practices e) Cold chain logistics standards f) Record keeping and using data for action g) Defaulter tracing 4. Ensure and monitor that funds are appropriately released in a timely way for operational costs, such as supervisors' mobility and locally appropriate vaccine delivery system to every immunization site (e.g. cycles, mobility support for ANMs, per diems for helpers, rickshaw fares etc.) by providing clear, updated guidelines that allows flexibility. 5. Ensure an uninterrupted supply of all vaccines to state level through a vaccine stock management system that includes annual forecasting (based on sessions planned - especially for BCG & measles) and wastage rates. To minimize the wastage and facilitate increased coverage 10 dose BCG vials should be procured. 6. Central level should provide the necessary policy, guidelines, training materials and supplies (auto-disable syringes (ADs) and disposal systems) for states to implement safe injection practices at all immunization sites. 7. Central level should review, update and disseminate training modules, simple tools and job aids for possible adaptation at state level. Central level should also ensure the states implement 'on the job' and pre servIndia Universal Immunization Programme Review 25
ice / basic training for public and private health workers. These should contain such elements as: a) Interpersonal skills training b) Data recording and reporting practices and use for action c) Micro-planning to increase coverage rates and reduce drop outs d) Immunization safety, with special focus on syringe and needle disposal e) Cold chain maintenance and vaccine logistics, with specific reference to inappropriate vaccine freezing f) Supportive supervision skills 8. Central level should provide technical support and resources for states to develop evidence based Social Mobilization Plan (including logo and branding). 9. In specific low performing states, a district / block based operations research scheme could be considered and scaled up if successful. This sustainable low cost scheme at district / block and village levels could be based on recommendations made during the review. This could comprise data use, tools, job aids for improved convergence of planning, monitoring, registration and follow-up of births / defaulters, delivery and quality of services. 10. All hard-to-reach and urban slum areas should be reached at least four times per year with routine immunization or catch ups (where appropriate). Other packages of healthcare (e.g. preventive health messages, antenatal care etc.) may also be delivered.
ANNEX 2
BIHAR REPORT
1. Summary
Immunization coverage in Bihar is abysmal with services in dire condition. Nevertheless, there are some bright spots. The team was impressed with how much is being achieved in spite of difficult work conditions. Many lower level staff are working hard and trying their best without much support. This report provides many practical and low-cost organizational, managerial and technical suggestions that after discussion, debate and implementation by State and District staff and their partners should improve routine immunization coverage and quality, by using the existing resources and infrastructure. Expanded vision and critical thinking are needed. The review team believes that at present the immunization program is too narrow. In a poor-performing state like Bihar with many competing priorities, the immunization program seems to be viewed from below as something of an external imposition. In a country as huge and diverse as India, with many administrative layers, the review team is convinced that authority and decision-making must become more decentralized and more flexible to bring about ownership at each successive level down the system. Rather than issuing instructions/orders that may de-motivate people and lead to passivity and fatalism, the program at central and state levels should encourage local problem-solving at district and block levels, so that customized approaches are identified and implemented to address local problems. At all levels, more focus is needed to concentrate on getting the program to work at the most peripheral level by strengthening the links between the ANMs and the communities they serve. With limited resources, the health sector must broaden its vision and partner with other programs that have enormous human resources already present in the communities. For example, the ICDS has a work force nationwide of nearly 600,000 communitybased AWWs who each cover 1000 population, conduct regular name-based head counts, and have a stated program objective of improving immunization coverage.
ty for utilizing existing funds at all levels. 2. Inter-sectoral Coordination: Engage PRI, ICDS, literacy workers and the private sector to tap their potential. 3. Improve cold chain and logistics management by providing sufficient additional funds at regular intervals for mobility of vaccine and logistics and running the cold chain (i.e., POL for vehicles and generators, icepacks (or ice from factories), 4. Develop and implement and supportive supervision [1] to monitor and train staff 5. Rationalize human resources, hire staff on contract (e.g., ANMs, MOs, drivers, etc.) to fill vacant posts
[1] monitoring to include regular review of performance and managerial data; training is needed at all levels, using modular learning materials and simple tools/job aids
2. Background
Bihar is located in the north of India. The neighbouring states of Jharkhand and Uttar Pradesh also have low coverage (<30%); but Bihar's coverage rate is less than half that of its neighbours. Demography (data from 2001 census): Total 2001 population was 82 998 509, making it the 3rd most populous state in India. The population growth was 28% since the 1991 census; the 11th highest growth rate of the 35 States and Union Territories; the 2nd highest of large States (>2.5 million population). Bihar population is 90% rural (72% for India). The overall gender imbalance is the 14th worst of the 35 States and Union Territories with 919 females for every 1000 males (933 per 1000 for India). Children aged under-five-years comprise 13% of the Bihar population (11% for India). Immunization: The Universal Immunization Programme (UIP) is a national programme established in 1985, built upon the Expanded Programme on Immunization (EPI) started in 1978. The UIP is delivered as part of the Reproductive and Child Health (RCH) programme. Private practitioners also deliver the UIP and offer additional vaccines. The UIP had its last comprehensive review in 1989, with more recent but less comprehensive reviews undertaken in 1999. The 2004 UIP review was undertaken in six States. Bihar was selected because it is a
India Universal Immunization Programme Review
The key recommendations to strengthen routine immunization in Bihar

1. Fund Flow: Provide clear guidelines and flexibili26
state with very low immunization coverage. State immunization performance: There is perceived political pressure for districts to report over 90% coverage, as this is one of the '20 points' for which each district is assessed. As a result reported coverage has become unreliable, especially in states with low coverage. For example, 2001/2 BCG coverage in Bihar was reported at 60% compared to evaluated coverage of 32%. Coverage performance is thus assessed through surveys. UNICEF conducted national cluster surveys covering most or all states every year from 1999 to 2002. Bihar's data shows awful perfromance with both extremely poor access and very high dropout. Estimated full immunization rate in Bihar was 13%, 13%, 10%, and 12% for 1999, 2000, 2001, and 2002, respectively. Dropout contributes to the problem, as shown by the BGC to measles dropout rate of 53%, 44%, 58%, and 65% for 1999, 2000, 2001, and 2002, respectively. However, access is the major problem as indicated by BCG coverage rate of 33%, 37%, 32%, and 39% for 1999, 2000, 2001, and 2002, respectively. In 2001, Bihar contributed 2.6 million unimmunized infants to the pool of susceptible children: the 2nd largest in India. [Estimate from 2001 coverage survey and 2001 census] Background for districts visited: Kishanganj District has a population of 1,406,657 with 52,609 children under 12 months of age. The district's birth and death rate are 37.4 and 9.2 per 1000, respectively. Most immunization sessions are held only within the block PHC and very few are held at sub centre level. Even at block level, some PHCs have not held a single immunization session in the past year. The present reported immunization coverage for fully immunized children is only 3.2% (calculated from coverage data provided by the district). Detailed antigen-wise coverage rates are given in the data analysis section. The dropout rate from BCG to measles is 64.5% and from DPT1 to DPT3 is 43.2%. A micro-plan for routine immunization was developed in 2003. Aurangabad District has a population of 2,055,084, according to the District statistician (computer) with 53,000 children less than 12 months of age. However, the target for less than 12 months last year available at State level was around 72,179. The birth rate is 36.0 per thousand. Most immunization is conducted through outreach, supplemented by sessions at the block PHC. The present reported immunization coverage for measles is 42% (calculated from the coverage data provided by the district and using the denominator of 72,000). The dropout rate from BCG to
measles is 45% and from DPT1 to DPT3 is 19%. A micro-plan for routine immunization was developed in 2003.
3. Method
The review provides qualitative and selective information on the immunization programme. It is not intended to be either quantitative or statistically representative. The aim was to identify strengths, weaknesses, and bottlenecks to develop practical strategies for improving routine immunization. The review also aimed to help prioritise implementation of the multiyear plan (MYP: the 2005-2010 strategic plan). The state review was undertaken following a protocol and questionnaires developed by the national UIP review team. Aurangabad and Kishanganj districts were each visited by one team, with the first team also visiting the State Headquarters. Details of the team members, their itinerary, and the main persons met can be seen in the full state report. More facilities were reviewed than in the protocol to get the requiste information. The Kishanganj team was also able to visit additional blocks (not on original list). Specific functions, such as delivery of vaccine and icepacks from the district to the block and early morning collection of vaccine by ANMs were also observed. The interviews were typically conducted with one member leading the discussion and the second member recording information and observations. To elicit common information from ANMs, a focus group discussion was held. More detailed observations and recommendations made by the teams can be seen in the full state report. These observations, the completed questionnaires, and discussions between team members generation of up to three each of successes, barriers, conclusions, and recommendations for: Strengthening routine immunization at every level (section 4) Eight technical areas of protocol, to aid prioritisation for the MYP (section 5) Further discussion led the team to agree on up to five key recommendations to strengthen routine immunization (presented in the summary); and the priority actions for the MYP (section 5). The teams prepared a state presentation summarising the findings and initial recommendations (Annex 4). National level discussion with the other teams, and subsequent synthesis were used to finalise the state report.
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4. Strengthening routine immunization

The state review team identified up to three key successes, barriers, conclusions and recommendations for strengthening routine immunization, for each level. More detailed observations and recommendations, as well as some illustrative case studies can be seen in the full state report. Successes S T A T E
Coverage data available. Cold chain maintained. Health workers mostly motivated, despite constraints.
Barriers
Poor implementation: rigid system and poor management. Policies not clearly articulated. Lack of funds; available funds not used; salaries not paid; ANM travel allowance not paid.
Conclusions
Potential to better use existing resources; and more benefit from PPI. Poor quality of services;. No use of data at any level; inadequate supervision and monitoring.
Recommendations
Encourage local solutions for each level (and flexible fund release) to reach every child, and use AWW register to ensure no left outs or dropouts. Include routine immunization in an expanded State immunisation core group (e.g., PRI, ICDS, etc.). Develop an operational approach at block level to improve coverage [1]. Improve resource use through better planning and coordination (e.g., engaging Panchayat Samiti and others to focus on UIP) . Strengthen supervision; upgrade block officers at regular meetings [2]. Alternate ice pack freezing facility, running of gen set. Involve interested private sector practitioners in Government training programs.
D I S T R I C T
Micro-plan available Good system design; data are collected. Most ANM positions filled in one district.
Unfilled positions (one district); vaccine shortages in 2003/4; power cuts; delayed CC equipment repairs. Limited coordination. Programme costs not covered.
Change in management approach needed. Focus on inputs instead of outcomes. Potential to better use private practitioners.
U R B A N P H C
Private practitioners providing UIP vaccines. Private hospital provides high quality service, including injection safety. Regular staff meetings. Waste disposal good at some sites. Local innovation on staff rotation and vaccine collection at some sites. Microplans in place; registers mostly used; cards used. AWWs have namebased head counts. Demand exists; PRI can mobilise - if service reliable.
Private not reporting statistics and storing vaccines without temperature monitoring.
Sale of other vaccines can attract people for UIP vaccines.
Lack of coordination with DMC/ICDS. 30% sessions missed Cold chain equipment mostly non-functional (lack power/POL/maintenance). Lack/poor use of tools to identify & track infants. Failure to inform and mobilise community. Poor injection technique and recording practice.
Poor planning, implementation, and monitoring of services which are thus variably delivered and generally of poor quality.
Improve coverage [1]. Use meetings for planning, monitoring and training [2]. Health representative should attend monthly ICDS meeting Alternate ice pack freezing facility, running of gen set. ANM & AWW to coordinate registration & follow-up; use tally sheets for monthly reporting. Introduce ADs & fund vaccine logistics. Form team to mobilise community and advise session dates (use signboard) and arrival of ANM.
S C
ANMs need supportive supervision; materials (e.g., monitoring charts and registers) ; and resources to improve their service.
Notes: [1] Coverage improvement should be a sustainable, low resource and replicable operational approach to improve coverage block by block (i.e. working at the lowest administrative level). Efforts need to initially focus on only one or a few blocks to work out the best approach to implement in each area. The basic principle is that in RED strategy: to use data, community links, and supportive supervision to increase coverage supported by simple tools, job aids for planning, monitoring, registration and follow-up of births and drop outs (such as the cumulative monitoring graph for systematic feedback, the work plan to plan and monitor the number of sessions held). The network of SMO could help develop and monitor efforts, and to strengthen active system of monitoring, data analysis and use at each level of collection. [2] The regularly scheduled meetings should be used for training to upgrade skills; training needs to be skills-based using adult learning techniques and using simple modular learning materials and tools materials that can be taken away as job-aids to reinforce the skill/practice trained.
28 India Universal Immunization Programme Review
5. Priority areas for implementation of the multi year plan

The state review team identified up to three key successes, barriers, conclusions and recommendations on eight technical areas, detailed below. From these, the national team identified priority actions from a subset of the recommendations. With many potential priorities, the final list was limited to feasible actions most likely to have an impact in relation to the overall goal - protecting children from disease. Each priority action was linked, if possible, to one of the 20 objectives in the MYP. The objectives are numbered and given a short title here, with the full description and associated goal in the full state report. Implementing the priority action for that objective provides a focus for implementing the MYP.
Priority actions MYP objective
1. Provide support to help each district, block, PHC, and SC develop coverage improvement plan (CIP) (see section 4, footnote 1) 2. Develop and provide simple tools and job-aids to register newborns and track each child, and to monitor progress, and to validate coverage 3. Provide flexibility of funding and clear instructions for operational costs 4. Ensure that staff attend their duty station; recognise/reward good performance; use contracted staff to cover vacant positions. Develop supportive supervision to provide monitoring and on-the-job training, and use regular meetings as training opportunities using modular learning materials 5. Coordinate with other departments and entities in developing a social mobilization plan engage community resources and stimulate ownership.
1.1: regular sessions 6.3: coverage monitoring 1.1: regular sessions 3.1: adequate finance 1.2: adequate staffing 1.1: regular sessions 4.1: social mobilisation
In the table describing the eight technical areas, the abbreviation use is in square brackets: Service delivery & injection safety [DEL]; Surveillance & monitoring [S&M]; Vaccine distribution & logistics [LOG]; Programme management [MGT]; Cold chain management [CC]; Human resources [HR]; Training [TRN]; IEC and social mobilization [IEC] Successes D E L
AWWs present at immunization sessions. Immunization registers used at some sites. Awareness of injection safety; and practice in some areas.
Barriers
Operational guide lines not available. No plans to serve hard-toreach; plans not adequate; no flexibility/innovation. Unsafe injection (and disposal) common from lack of supplies. Denominators unknown or inaccurate; catchment areas not linked to Panchayat pop. Reported coverage data inflated; no tracking. VPD and AEFI not reported.
Conclusions
Huge unmet demand (and resentment) in community. Health workers cover UIP costs from own pocket some tomes. Male Health Workers positive for delivery; poor supervision . Lack of supervision, support, monitoring, analysis & feedback at all levels. Data not used for feedback at any level for planning and management.
Recommendations
Plan sessions rationally, and ensure that they are held as planned, at user-friendly sites. Provide ANMs needed supplies (incl. ADs) & funds to safely deliver UIP. Develop block level operational approach to improve coverage [see section 4 table footnote 1]. Provide simple tools for ANM to register and track [1]. Use CNA for setting targets & should be reviewed, followed at all levels Rationalise and make more effective use of meetings (to train, monitor & coordinate); DM meet quarterly to review performance.
S & M
Coverage data are collected and largely available for review. Immunization cards available and used. AWW Head count of target population.
Notes: [1] Register using AWW's name-based head counts; use standard register and other simple tools to track newborns and beneficiaries together with AWW; simplify and facilitate reporting; use cumulative monitoring graph at block level and above for monitoring and feedback. [2] Training should be through supportive supervision (on-the-job training). ANMs, Block officers, AWWs, MOs attend regular monthly/weekly meetings. These meeting are opportunities for training that should be used. Areas where training is the priority include injection safety; injection technique; record keeping, tracking; and micro planning.
India Universal Immunization Programme Review 29
Successes L O G
Sufficient, uninterrupted supply since April 04 Extra vaccine depot in 2 blocks aids ANM collection
Barriers
Supply interruptions for several months in 2003 No funds/driver to use available vehicles. Microplans not used to improve logistics.
Conclusions
PHC and SC staff would welcome any initiative for alternative vaccine delivery. Innovative use of available transport resources can overcome constraints. .
Recommendations
GOI provide funds for vaccines delivery to immunization site. Better use existing District and PHC resources for vaccine delivery. Ensure all antigen are available at all sessions & .Vaccinate all children attending the sessions. Increase managerial capacity, funding, and administrative flexibility that focuses on outcomes. Improve data quality and use for programme management. Improve effectiveness of meetings for training and monitoring; reduce unnecessary workload of staff; improve coordination for routine immunization. Provide sufficient POL and fund for maintenance of cold chain equipment and generators. Provide flexibility and clear guidelines to use of funds to maintain CC and procure ice.
M G T
State Cell created for UIP; State task force meetings held weekly (mainly for PPI). Good organization in some places; microplans in place. Data collected at each level. State cold chain room has good power supply. Inventory of equipment needing repair. CC infrastructure at district level; equipment mostly functioning; temp records kept. ANM rotation plan in one district. ANM positions mostly filled in one district. Staff mostly want to improve performance, despite tough working conditions. Most ANMs trained on UIP in one district last year, but still need reorientation training .
Lack of funding for few key area &; available funds for identified areas not used; delayed salary payment. Data inaccurate and not used for planning Rigidities prevent appropriate local solutions. Power cuts and generators non-operational (not funded/maintained). Delays in repairs; lack of trained staff for CC. Private sector CC - no temperature records.
Operational costs devolved but unfunded;Fund flow is a problem Missed opportunities for coordination with other sectors (incl. private). Too many meetings: interfere with service delivery. Innovative logistic solutions in some areas to overcome cold chain constraints. CC and logistic failures lead to immunization sessions not being held.
C C
H R
Many state and district level posts for UIP unfilled. In one district, half MO posts are vacant/ absconded. Shortage and unequal distribution of ANMs.
MO's absence means no supervision or motivation for staff. Inadequate staff for workload. Low morale: late payment and no feedback. Most ANMs need training on all aspects of UIP [2]. Previous trainings do not appear to have been sufficient.
Ensure MO attends duty regularly; fill vacant posts with contracted staff if required. Replenish staffing levels (Rationalize ANM work load & place additional AMN if required Recognize/reward good performance Develop training materials and simple tools/job aids and implement training [2]. Test feasibility/effectiveness of video to teach injection technique. Involve private practitioners in Govt training programs. Develop social mobilisation plan that engages community resources to inform and mobilise communities (incl. forming a community team for mobilisation); DM to use Panchayat Samiti and block convergence meetings for health issues. Block health representative should attend every monthly ICDS meeting. Better use current IEC resources, including immunization card.
T R N
No supervision at any level; training opportunity at regular meetings not used. Training on UIP only as part of RCH: not enough on UIP. Not using simple tools. Little attempt to engage community resources/ programmes; failure to inform community. No State plan exists for IEC for immunization. Screening & counselling is weak.
I E C
Demand for immunization exists. PRI eager to support and mobilise - if service reliable. AWWs are valuable resource for mobilisation and tracking.
Scope for further coordination with other departments (e.g., PRI, ICDS and Education) with potential to support UIP through existing schemes and personnel (e.g. Jan Siksha Abhiyan, Anganwadi, village Pradhan).
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ANNEX 3
JHARKHAND REPORT
1. Summary
Jharkhand is a State of contrasts. There are big cities and large tracts of beautiful countryside. So too in the immunization programme, there are notable successes, especially at the periphery, and serious failures. Infants are not being immunized and fail to be protected against life-threatening vaccine-preventable diseases, whose full extent is not known as they are not being reported. Even where immunization services are being offered, nearby areas have no access to services and overall, access to services may be poor. Failures of the cold chain may result in inactive vaccines being administered, and inadequate technique may result in adverse events following immunization (AEFIs), which are also not reported. There is a lack of standardized guidelines and registers, an incomplete micro-plan, inadequate monitoring, supervision, insufficient inter-sectoral collaboration, IEC and social mobilization. Cold Chain management, could be improved by provision of POL, preventive maintenance and the institution of a system of same day vaccine delivery to the periphery from the district and block PHC levels. Some improvement can be achieved in the short term through filling vacant positions on contract basis (if required), involving the private sector, including private practitioners and local NGOs. Training will be crucial, including the areas of quality service delivery, monitoring, supervision, vaccine forecasting, data management and analysis. Much of this training can be done as in-service training utilizing the existing monthly meetings. Main successes: 1. Political Commitment exists for the health programs, especially UIP and plans have already commenced for improvement of infrastructure and staff levels 2. There is collaboration with the private sector and NGOs for delivery of immunization services Main barriers: 1. Documentation is not in standardized formats and whatever data that is collected, is not analyzed or used for program planning / monitoring. In addition surveillance for VPDs & AEFIs is not being done 2. The quality of the cold chain is questionable due
to an erratic power supply, inadequate storage facilities at state level and an improper distribution system
The key recommendations to strengthen routine immunization in Jharkhand

1. Establish a comprehensive task force for inter-sector/inter-agency collaboration 2. Conduct a budgetary audit and review the system for payment of staff salaries 3. Conduct an intensive training program in all aspects of immunization 4. Focus on reorganizing the infrastructure/staffing based on population distribution 5. Improve the quality of the cold chain by replacing condemned equipment, having a long-term plan for replacement, expanding the storage capacity, ensuring a steady power supply, a needs-based distribution system and provision of technical staff for maintenance and repairs
2. Background
Jharkhand is one of the most recently created states in India. It was established in the year 2000 and comprises the southern districts of the erstwhile state of Bihar. About 20 per cent of the state is forest-land with wild life such as tigers, deer, and elephants. Summer commences in mid-March and winter in November. The rainy season lasts from Mid-June to the end of September. The majority of the state's population is village or tribal people who do mainly cultivation. There is a deficiency in food grains, due to periods of floods and droughts resulting in intermittent famines and scarcity. There is a deep traditional and religious culture with the majority of religious ceremonies occurring during September and October. These months are also the busiest time for the farmers. Hindi is the main language spoken but each district has its own dialect. The main mode of communication is by word of mouth and folklore as the literacy rate is relatively low. While most people have access to a radio, the radio station is out of Bihar. Though there is power generation, there is a problem with power distribution. In Jharkhand, block PHCs are called PHCs. What are called PHCs in other states are called additional PHCs in Jharkhand. CHCs are called referral hospitals in Jharkhand.
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Demography (data from 2001 census) - need confirmed The total 2001 population was 26 945 829, making it the 13th most populous state in India. The population growth was 23% since the 1991 census; the 18th highest growth rate of the 35 States and Union Territories; the 7th highest of large States (>2.5 million population). Jharkhand population is 78% rural (72% for India). The overall gender imbalance is the 21st worst of the 35 States and Union Territories with 941 females for every 1000 males (933 per 1000 for India). Overall literacy rate is 54% (65% for India), with substantial female educational disadvantage as shown by a male to female literacy rate ratio of 1.7 (1.4 for India). Children aged under-five-years comprise 12% of the Jharkhand population (11% for India). Immunization: The Universal Immunization Programme (UIP) is a national programme established in 1985, built upon the Expanded Programme on Immunization (EPI) started in 1978. The UIP is delivered as part of the Reproductive and Child Health (RCH) programme. Private practitioners also deliver the UIP and offer additional vaccines. The UIP had its last comprehensive review in 1989, with more recent but less comprehensive reviews undertaken in 1999. The 2004 UIP review was undertaken in six States. Jharkhand was selected because it is a newly created state with low immunization coverage and weak infrastructure serving a tribal and rural population. State immunization performance: There is administrative pressure for districts to over report coverage, as this is one of the '20 points' for which each district is assessed. As a result, reported coverage has become unreliable, especially in states with low coverage. Coverage performance is thus assessed through surveys. UNICEF conducted national cluster surveys covering most or all states every year from 1998 to 2002. The surveys included Jharkand in 2001 and 2002 and show poor access and high dropout. Estimated full immunization rate in Jharkhand was 24%, and 23% for 2001 and 2002, respectively. Dropout is an important contributor to low coverage, as shown by the BGC to measles dropout rate of 37%, and 47% for 2001 and 2002, respectively. However, access is the major contributor to low coverage as indicated by BCG coverage rate of 43%, and 56% for 2001 and 2002, respectively. In 2001, Jharkhand contributed 0.7 million unimmunized infants to the pool of susceptible children: the 9th largest in India. [Estimate from 2001 coverage sur32
vey, 2001 census assuming 3.5% of the population are infants] Background of districts visited: Godda district is located in the northeast part of the state. The total population of the district for 2004 is 1,130,835, based on the last census done in 2001. The population is distributed into 3.2% infants under 1 year (36,386), 16.1% children under 5 years of age (181,930) and 3.6% pregnant women (40,890). The sex ratio is 926 females per 1000 males but in the age group 0-6 years it is 995: 1000. The population density is 496 per sq. km. Of a total 422,604 workers, 33.2% are cultivators and 47.8% are agricultural labourers. 34.3% are females. The total literacy rate is 43.73% (males 58.17% and females 28.0%). East Singhbhum district is located in the southeast part of the state. The total population of the district for 2001 is 1,978,671 based on the last census done in 2001. The population is distributed into 3.2% infants under 1 year (63,317), 16.1% children under 5 years of age (3,18,566) and 3.6% pregnant women (71,232). The sex ratio is 931 females per 1000 males. The population density is 496 per sq. km. Of a total 422,604 workers, 33.2% are cultivators and 47.8% are agricultural labourers. 34.3% are females. The total literacy rate is 78.03% (males 80.08 % and females 75.98%). Out of the total populations, 54.96 % is urban & and 45.03 % is rural. Godda district is divided into 8 blocks with Godda block being the only urban block. There is no municipal committee or municipal corporation in the urban area. With the exception of 2 blocks, the population is more or less evenly distributed among the other 5 blocks. Godda district has one district hospital, 3 referral hospitals and 2 private hospitals. There are 7 Block PHCs, 9 additional PHCs and 147 functional sub-centres out of 195. Each block PHC covers a population of more than 50,000. Immunization services are provided in all of these facilities. A few Paediatricians and general practitioners also provide limited immunization services on demand. East Singhbhum district is divided into 9 blocks with Jamshedpur being the only urban area. There is no municipal committee, however TATA has an urban development and coordination committee, which takes care of many urban areas along with other local companies. With the exception of Jamshedpur urban area, the population is more or less evenly distributed among the other 9 blocks. East Singhbhum district has one district hospital, one referral hospital and one private hospital run by TATA, and MGM medical college run by Govt. There are 9 Block PHCs, 16 additional PHCs and 244 functional sub-centres, 830 Anganwadis. Each block PHC
covers a population of more than 75,000. Apart from the above, TATA run 30 urban outreach sites for delivering
3. Method
The review provides qualitative and selective information on the immunization programme. It is not intended to be either quantitative or statistically representative. The aim was to identify strengths, weaknesses, and bottlenecks to develop practical strategies for improving routine immunization. The review also aimed to help prioritise implementation of the multiyear plan (MYP: the 2005-2010 strategic plan). The state review was undertaken following a protocol and questionnaires developed by the national UIP review team. Godda and East Singhbhum districts were each visited by one team, with the first team also visiting the State Headquarters. Details of the team memebers their itinerary, and the main persons met can be seen in the detailed state report. In Jharkand, the blocks were selected randomly from a stratified list of tribal and non-tribal areas. Some of the key observations made by the teams are detailed in the state specific report. These obser-
vations, the completed questionnaires, and discussions between team members generated up to three each of successes, barriers, conclusions, and recommendations for: Strengthening routine immunization at every level (section 4) Eight technical areas of protocol, to aid prioritisation for the MYP (section 5) Further discussion led the team to agree on up to five key recommendations to strengthen routine immunization (presented in the summary); and the priority actions for the MYP (section 5). The teams prepared a state presentation summarising the findings and initial recommendations that can be seen in the state specific report. National level discussion with the other teams, and subsequent synthesis were used to finalise the state report. There are important limitations with the method based on selective visits from two very different districts. The districts varied greatly with respect to reported coverage, involvement of NGOs and private sector, and the distribution of AWWs. While preparing state- and national-level recommendations, there was limited ability to communicate the differences between these districts and how they reflect Jharkhand state.

The state review team identified up to three key successes, barriers, conclusions and recommendations for strengthening routine immunization, for each level. More observations and recommendations can be seen in the state specific report. Successes S T A T E
Health Secretary support; recent multi-intervention catch-up round. Reporting system in place State is using contractors for vacant MO positions.
Barriers
Vacant posts Quality of services poor Fear to report problems. Late pay of salary; no travel/contingencies. Poor State infrastructure, health facility power unreliable.
Conclusions
Poor performance, but potential "new start" for the state. Cold chain poorly maintained - some vaccines frozen Vaccine logistics weak some stock outs at state level Unsafe injection common. Morale is low and work conditions are poor. Staff don't have skills needed to improve service delivery. District microplan doesn't include all needed components.
Recommendations
Establish and strengthen the state immunization cell to implement key actions [1]. Improve coverage data accuracy and disease reporting - use data for programme management.
D I S T R I C T
District micro plans generally in place; private & NGOs delivering UIP. Reports comprehensive and timely; good compilation of data. IEC materials in use.
No in-service training since 1998; lack supervision/ monitoring. Inadequate record-keeping for follow-up. Cold chain break downs are not attended promptly and weak power back up .
Use leadership e.g. Civil Surgeon to highlight administrative commitment to UIP by visiting and monitoring every PHC annually. Use monthly meeting opportunities for training. Raise morale: pay salaries (and back-pay) and allowances; and reward good performance.
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Successes U R B A N
Private practitioners (PPs) delivering UIP as well as other vaccines. Training to PPs on cold chain by NPSP.
Barriers
PPs have deficiencies in knowledge and practice ; no follow-up; and poor injection safety/technique. Poor urban catchment definition - missed children
Conclusions
PPs' contribution to UIP is positive and further encouraged. Lack of facilities for urban population. Urban health centre catchments not well defined
Recommendations
Map and demarcate urban catchments; providers (private, NGOs, etc) should coordinate efforts to implement outreach sessions Expand TATA activities to other blocks; use TATA management skills training for government facilities. Maintain PHCs so that they are functioning and hygienic Implement supportive supervision for monitoring and training. Expanded catch-up campaigns to remedy previous low coverage for all antigens. Train ANMs with continuous in-service training in all aspects of immunization. Involve local community; train local women to be ANM; use PRI to monitor service locally; develop a single community building for both AWW and ANM. Supply standardized records and registers.
P H C
Regular sessions. Vaccine supply mostly good, but some stock outs IEC messages on walls; AWWs active in social mobilisation. Good coordination with AWWs; delivery with other interventions. Filling staff gaps using ANMs on contract. Adequate injection supplies (incl. ADs) and sterilization.
Lack of SC buildings (or non-functional); lack of water and power; no fuel for generator. Staffing level poor. Waste disposal poor. ANM often do not live on site; tribal language barrier. Missed opportunities when vaccine not available. Record keeping is improper and not standardized.
PHCs provide services under severe constraints would be even worse coverage, if not for dedication of some staff.
S C
Areas of good performance, including where AWW supporting ANM. Making ANM pick up vaccines limits their ability to deliver services.
Notes: [1] Key actions include: improve flow and accountability for salaries and operational costs; reward good performance to motivate staff ; establish a multi-agency taskforce to coordinate, increase priority for, and monitor UIP; plan for better allocation of services according to population and need; improve vaccine logistics, including direct delivery to immunization site; engage community, including a wider range of partners, to help mobilise community as well as to deliver services; replace aged cold chain; and improve quality with on-the-job training supplemented by interactive training/sharing experiences at regular meetings. Training is needed at all levels especially on safe injection practices, cold chain, data analysis and monitoring; medical officers need training on vaccine logistics and forecasting; all supervisors need training in supportive supervision that comprises monitoring and onthe-job training.
5.Priority areas for implementation of the multi year plan

The state review team identified up to three key successes, barriers, conclusions and recommendations on eight technical areas, detailed below. From these, the national team identified priority actions from a subset of the recommendations. With many potential priorities, the final list was limited to feasible actions most likely to have an impact in relation to the overall goal - protecting children from disease. Each priority action was linked, if possible, to one of the 20 objectives in the MYP objective. The objectives are numbered and given a short title here, with the full description and associated goal in the state specific report. Implementing the priority action for that objective provides a focus for implementing the MYP.
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Priority actions
MYP objective
1. Train staff through supportive supervision and use of regular meetings 2. Provide standard forms and training to improve coverage, disease, and AEFI monitoring; use data for programme management 3. Develop leadership and political commitment for UIP 4. Replace aged cold chain and improve management 5. Employ/contract adequate staff; pay regularly and give back-pay; rationalise distribution of staff
1.1: regular sessions 6.1 to 6.3: Disease, AEFI and coverage surveillance 4.2: advocacy 1.3: cold chain 1.2: adequate staffing
In the table below describing the eight technical areas, the abbreviation used is in square brackets: Service delivery & injection safety [DEL]; Surveillance & monitoring [S&M]; Vaccine distribution & logistics [LOG]; Programme management [MGT]; Cold chain management [CC]; Human resources [HR]; Training [TRN]; IEC and social mobilization [IEC] Successes D E L
Microplans include details of sites, datesand staff for sessions. ICDS, private, and NGOs participation. Adequate equipment for sterilization; ADs used in some sites. Monthly reporting in place; some documentation. Reporting timely. Polio S&M system provides example for RI. System in place to obtain and distribute vaccines and supplies. Vaccine supply usually adequate. Designated staff manage stock at district and block PHC levels. One district has regular DIO and supervisory system. Yearly action plan. Social mapping done in one district to identify homes with infants.
Barriers
Poor infrastructure; buildings in poor condition or absent; In the hard-to-reach tribal areas, some language barriers are an issue. Not all vaccines available at each session causing missed opportunities. Non-standard forms; no report/record of AEFIs and VPDs. Indicators not known or discussed by staff. No use/analysis of coverage or wastage data; inaccurate data Poor stock management leads to increasing costs and some stock-outs; no wastage monitoring. Inadequate storage facilities increasingtime & travel to get vaccine. Incomplete stock recording. No accessible & standard guidelines to implement UIP; inadequate financial and administrative support. Lack supervision & monitoring; no written feedback. Inadequate coordination.
Conclusions
Access limited by poor infrastructure and ANM staffing levels and distribution. Unsafe injection (incl. disposal) common.
Recommendations
Employ more ANMs, rationalise distribution and supervise them - provide all vaccines at each session. Build new centres; refurbish existing ones. Re-train ANMs in safe injection and disposal; provide needle cutters. Train staff on data analysis and monitoring. Provide standard forms (cards, registers and monitoring charts); train staff to use; review at monthly meetings. Establish VPD and AEFI surveillance (incl. private). Expand non cold chain storage facilities at district, block, and PHC level. Train staff in vaccine needs assessment and stock recording and management (provide standard registers and guidelines). Explore same day delivery of vaccines to immunization sites. Implement standardized MYP, operational guidelines, and reporting system. Develop and implement supportive supervision. Increase coordination with other departments, private sector and NGOs.
S & M
Poor data quality and data analysis skills make programme monitoring nonexistent. Programme effectiveness cannot be assessed without AEFI and VPD surveillance. Inadequate forecasting and incomplete stock recording. Vaccine collection by ANMs and PHCs is time and resource intensive.
L O G
M G T
Programme management is of poor quality because, poor planning and little accountability.
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Successes C C
District and block PHCs have functional ILRs and freezers. PHCs and SCs have adequate vaccine carriers and ice packs. Some temperature monitoring charts kept.
Barriers
Power cuts and no POL for generators prevent use of available equipment. Some vaccines spend at least 36-48 hours in vaccine carrier before use at PHC and SC. No cold chain mechanic, spare parts, or guidelines to maintain and repair. Vacancies exist for all categories of workers. Irregular salaries lead to low morale, motivation, and retention. ANM non-resident at SC interruption of service.
Conclusions
Poor cold chain maintenance and improper vaccine storage leads to extra work, potentially damaged vaccines, and vaccine wastage (frozen vials, destroyed labels).
Recommendations
Address deficiencies in staffing, guidelines (incl. temp charts), and equipment replacement/repair. Provide generators and adequate POL for power back-up. Deliver vaccines to outreach sessions on same day, where possible. Fill vacancies and increase staff (especially cold chain mechanics) in keeping with population growth. Raise staff morale by giving back pay, timely payment of salaries and recognizing good performance. Wherever possible, select local women to assist the UIP. Assess in-service training needs/methods and develop plan to train all staff (incl. private) in all aspects of UIP. Ensure full participation of staff to attend in-service training Use monthly meetings for training and accreditation. Provide readily accessible training resources at all levels. Establish district level IEC unit to develop plans that address any local language barriers and community resistance; engage community; expand AWWs to all areas. Provide adequate supplies of local IEC materials Use all available media for delivering IEC. Develop immunization logo and paint it on walls of all imm. sites.
H R
ANMs evenly distributed in one district. Contracted MOs and ANMs to fill vacancies. AWWs, local resource persons and volunteers provide support to ANMs. All staff at posts had some immunization training. Training officer is in place in one district. Training modules are available at district level.
Service delivery improved with contracted workers, but still many vacancies still exist. Morale and effectiveness of staff is limited by the absence of regular salary.
T R N
No training plan in place at state or district levels. Frequent transfer of trained Medical Officers leads to poor management of the UIPFailure to use monthly meetings for training.
Need for continuous inservice training at all levels in all aspects of UIP. Training has been limited and ineffective (without evaluation, accreditation, continuing education, and skills development).
I E C
AWWs and volunteers provide home visits and miking for some RI issues in public places. IEC messages on some walls. Some printed material used (e.g., immunization cards and brochures in local language).
No IEC or social mobilization plan available. Limited strategies and use media; inadequate IEC materials. Language barriers between ANMs and local tribes in some areas.
Limited IEC and social mobilization limits demand for immunization. Community not engaged/aware of UIP;
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ANNEX 4
MADHYA PRADESH REPORT
1. Summary
Practices vary widely with no standards of supervision and monitoring. Operational Guidelines for Pulse Polio Immunization (PPI) have facilitated uniform implementation. Operational guidelines are similarly needed for routine immunization. The Government of India should develop the guidelines that should cover all aspects of the programme, with a special focus on use of data to manage the programme, and for supervision and monitoring to ensure that coverage data is validated. Reporting mechanisms for various components of the programme, such as immunization sessions held, number and percent of children vaccinated, supervision visits conducted, from ANMs to the blocks, from blocks to the district, from districts to the States and from States to the Govt. of India, are also not in place. This leads to inadequate monitoring of the program at each level, lack of appropriate supervision, and poor immunization delivery.
The key recommendations to strengthen routine immunization in Madhya Pradesh

1. Establish a state taskforce to review performance, every quarter. Processes and indicators for review to be specified in the operational guidelines (recommended above) and should include field visits to at least two randomly selected districts every quarter 2. Central level to develop operational guidelines covering all aspects of the immunization programme; ensures that states implement the existing and new guidelines, including for disease reporting. 3. Implement monitoring and supervision at all levels on delivery of sessions and coverage data (including tracking individuals) with a focus on ensuring the accuracy of reports, and on monitoring the percent of planned sessions held. 4. Provide in-service continuous training to ANMs, medical officers, and those involved in the cold chain to improve the quality of services 5. Decrease administrative pressure for high reported coverage, and ensure that coverage is validated through regular monitoring and analysis.
2. Background
Madhya Pradesh is in North Central India and is one of the largest states in terms of geographic area. The
state has a total of 45 districts and 313 blocks. Basic health indicators in Madhya Pradesh have been low putting it among the Empowered Action Group (EAG) states. Some areas are hard-to-reach, including areas cut-off during rainy season leading to areas with poor service delivery. Demography (data from 2001 census) verify Total 2001 population was 60 348 023, making it the 7th most populous state in India. The population growth was 24% since the 1991 census; the 17th highest growth rate of the 35 States and Union Territories; the 6th highest of large States (>2.5 million population). Madhya Pradesh population is 73% rural (72% for India). The overall gender imbalance is the 13th worst of the 35 States and Union Territories with 919 females for every 1000 males (933 per 1000 for India). Overall literacy rate is 64% (65% for India), with substantial female educational disadvantage as shown by a male to female literacy rate ratio of 1.5 (1.4 for India). Children aged under-five-years comprise 12% of the Madhya Pradesh population (11% for India). Immunization The Universal Immunization Programme (UIP) is a national programme established in 1985, built upon the Expanded Programme on Immunization (EPI) started in 1978. The UIP is delivered as part of the Reproductive and Child Health (RCH) programme. Private practitioners also deliver the UIP and offer additional vaccines. The UIP had its last comprehensive review in 1989, with more recent but less comprehensive reviews undertaken in 1999. The 2004 UIP review was undertaken in six states. Madhya Pradesh was selected because it is a large state reflective of EAG chararcteristics. State immunization performance There is perceived political pressure for districts to report over 90% coverage, as this is one of the '20 points' for which each district is assessed. As a result reported coverage has become unreliable, especially in states with low coverage. For example, 2001/2 BCG coverage in Madhya Pradesh was reported at 85% compared to evaluated coverage of 78%. Coverage performance is thus assessed through surveys. UNICEF conducted national cluster surveys covering most or all states every year from 1999 to 2002. Estimated full immunization rate in Madhya Pradesh was 48%, 30%, 50%, and 67% for 1999, 2000, 2001, and 2002, respectively. Dropout is an important contributor to low coverage, as shown by
37
the BGC to measles dropout rate of 23%, 31%, 26%, and 15% for 1999, 2000, 2001, and 2002, respectively. However, access is the major contributor to low coverage as indicated by BCG coverage rate of 71%, 69%, 78%, and 95% for 1999, 2000, 2001, and 2002, respectively. The coverage survey data show moderately poor access and dropout, with marked improvement of both in the 2002 survey. In 2001, Madhya Pradesh contributed 1.1 million unimmunized infants to the pool of susceptible children: the 6th largest in India. [Estimate from 2001 coverage survey and 2001 census]
3. Method
The review provides qualitative and selective information on the immunization programme. It is not intended to be either quantitative or statistically representative. The aim was to identify strengths, weaknesses, and bottlenecks to develop practical strategies for improving routine immunization. The review also aimed to help prioritise implementation of the multiyear plan (MYP: the 2005-2010 strategic plan).
The state review was undertaken following a protocol and questionnaires developed by the national UIP review team. Guna and Seoni districts were each visited by one team, with the first team also visiting the State Headquarters. The state specific report details the team members, their itinerary, and the main persons met. Some of the key observations made by the teams are detailed in the state specific report. These observations, the completed questionnaires, and discussions between team members generated up to three each of successes, barriers, conclusions, and recommendations for: Strengthening routine immunization at every level (section 4) Eight technical areas of protocol, to aid prioritisation for the MYP (section 5) Further discussion led the team to agree on up to five key recommendations to strengthen routine immunization; and the priority actions for the MYP (section 5). The teams prepared a state presentation summarising the findings and initial recommendations that can be seen in detail in the state specific report. National level discussion with the other teams, and subsequent synthesis were used to finalise the state report.

The state review team identified up to three key successes, barriers, conclusions and recommendations for strengthening routine immunization, for each level. Successes S T A T E
Quarterly bulletin is good initiative - but data not analysed.
Barriers
Cold chain at state lying at headquarters without distribution plan Poor cold chain maintenace at State level (WIC especially) Reporting timeliness and completeness from districts not ensured; no analysis of these reports.
Conclusions
RI operational guidelines are needed. Private sector is not delivering immunization.
Recommendations
Establish State Task Force to review performance. Develop and implement operational guidelines for RI. Improve monitoring and supervision at all levels; implement on-the-job training for ANMs though supportive supervision.
D I S T R I C T
Sufficient cold chain space, but sub-optimal management. Micro plans in place - but do not include numbers, sites and some basic details. Sessions planned for every Tuesday and Friday - but no monitoring of sessions held.
Planned sessions not being held (estimated 25% from vaccine register; but sessions also not held even after vaccines collected). Practically no monitoring and supervision; failure to use regular meetings. Vaccine and logistics stock-outs common. BCG only delivered at district hospital, not outeach sessions (urban areas)
Knowledge, skills and practice need to improve Inappropriate denominators, with failure to use CNA approach to estimate infants. Fear of wastage, especially for BCG, leads to missed opportunities.
Implement monitoring and supervision of sessions held and to validate reported . Increase coordination with ICDS and other departments. Improve logistics to ensure adequate supply. Provide in-service continuous training to UIP staff
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Successes P H C / S C
Adequate staffing, with most posts filled, in one district. .
Barriers
Some PHCs do not have cold chain equipment in spite of having sufficient supplies at district / block Poor injection technique and disposal practice. No coordination with AWW (in one district).
Conclusions
Vaccine ordering, distribution, and stock-keeping practices can be improved, and need to ensure matched diluents for BCG and measles. Health staff often deputed to other duties on session days by block and health administration leading to cancelling of sessions Supervisory visits from district level not adequate
Recommendations
Monthly meetings should be used as an opportunity for inservice continuous training for all UIP staff Adminstration should ensure that UIP staff are not engaged for other activities on session days District / block officials should ensure supervisory visits take place on session days

The state review team identified up to three key successes, barriers, conclusions and recommendations on eight technical areas, detailed below. From these (and the complete set of observations and recommendations are detailed in the state specific report), the national team identified priority actions from a subset of the recommendations. With many potential priorities, the final list was limited to feasible actions most likely to have an impact in relation to the overall goal - protecting children from disease. Each priority action was linked, if possible, to one of the 20 objective in the MYP. The objectives are numbered and given a short title here, with the full description and associated goal detailed in the state specific report. Implementing the priority action for that objective provides a focus for implementing the MYP.
Multi-year plan priority actions MYP objective
1. Train staff through supportive supervision and use of regular meetings 2. Provide adequate supply of ADs; 3. Improve accuracy of reported data through regular monitoring and analysis; remove pressure to over-report 4. Improve logistics with close monitoring at all levels 5. Engage community and develop IEC resources
1.1: regular sessions 1.5: safe injection 6.3: coverage monitoring 6.3: coverage monitoring 4.1: social mobilisation
Service delivery & injection safety

Successes
Infrastructure for delivery exists Few staff vacancies Microplans available at PHC/SC, but incomplete
Barriers
Poor service quality Inadequate social mobilisation
Conclusions
Training, monitoring, and supervision needed at all levels Weak distribution logistics
Recommendations
Establish supportive supervision to provide monitoring and on-the-job training. Immunization sessions should be monitored with random selection of 10% of sessions UIP progress should be monitored by joint ICDS and health administrations
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Surveillance & monitoring

Successes
Data available Registers filled
Barriers
Over-reporting coverage Not reporting disease No reporting of AEFI Poor timeliness of reports
Conclusions
Data not used for action Priorities not identified Neglect of hard to reach areas
Recommendations
Validate coverage is validated through regular monitoring and analysis Implement simple monitoring tools Ensure reporting of VPD and AEFI as per communicated guidelines
Vaccine distribution logistics

Successes
Adequate plan for vaccine distribution
Barriers
Erratic supply of vaccines and injection supplies Wastage concerns interfering with coverage Vaccines not supplied with adequate / proper diluents
Conclusions
Recommendations
Improve logistics with close monitoring at all levels Consider 5-dose vial for BCG
Programme management
Successes
Few staff vacancies People aware of UIP policies Health workers committed to UIP
Barriers
Fund flow distribution from district to block for supervision / POL problematic. Supervision and programme monitoring poor
Conclusions
Supervision and monitoring practices need improved Fund flow mechansism need streamlined
Recommendations
Set up UIP taskforce at state level Set up immunization core group in each of districts to regularly monitor program and make field visits.
Cold chain management

Successes
Available power supply with back up gens Generally adequate
Barriers
Sub-optimal management (eg. Temperature monitoring weak in some places) Cold chain stuck at block level
Conclusions
Overall satisfactory
Recommendations
Improve management as part of overall training efforts Improve cold chain maintenance response time
Human resources
Successes
Generally adequate
Barriers
Promotion opportunities few for ANMs ANMs and Mos not staying in place of posting
Conclusions
Recommendations
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Training
Successes
MLM trainings taken place for district level officials
Barriers
No recent in-service continuous training at all levels Cold chain handlers not received training
Conclusions
Need high quality training that can be performed at meetings or supervisory visits
Recommendations
Implement supportive supervision to provide on-the-job training
IEC and social mobilization

Successes
Interpersonal communication effectively used by ANMs and AWWs
Barriers
Limited use of IEC materials; limited social mobilisation
Conclusions
Other programmes using IEC materials should use immunization materials
Recommendations
Engage community and develop IEC resources
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ANNEX 5
ORISSA REPORT
1. Summary
1.1 Successes
Strong links between immunization system and ICDS AWW, and PRIs. Initiative has been taken by State Government for involvement of PRIs Most LHVs and ANM posts filled Fixed day, fixed site strategies are being implemented Annual action plans in place; coverage improvement plans in place (team approach, campaign, NGO & PRI support) Cold chain system established at most levels according to GoI standards AD syringe in use since 2001 in BDCS district
increased by reducing dropout, as well as improving access. Vaccine and supplies logistics need improvement to ensure that inadequate supply of vaccine and/or injection does not interfere with service delivery.
The key recommendations to strengthen routine immunization in Orissa

1. Appoint a dedicated State Immunization Officer (with no additional charges) to coordinate activities of a State Immunization Taskforce and district activities. [1] 2. Ensure adequate staff (fill all sanctioned ANM, LHV and male health worker posts) who are motivated (pay ANMs and contractual staff on time) with adequate working environment (build or rent subcentre buildings, or repair/maintain, as appropriate), and supplies (including monitoring , such as registers, vaccine cards, monitoring and surveillance forms) and mobility allowances (review system) 3. Develop and implement a state immunization training plan. [2] 4. Develop a state injection safety policy (with special emphasis on bio-medical waste disposal), disseminate it widely, and monitor its implementation through state injection safety committees. 5. Improve social mobilisation by developing adequate IEC materials and appropriate methods for each community, and that every immunization site has a signboard to display, at minimum, the time and date of the next session Notes: [1] Activities will include coordination of the implementation and accurate monitoring of coverage improvement plans at State, district and block levels that include: Identifying and reaching underserved populations Prioritizing areas based on coverage and drop out rates Using analyzed data for action at all levels Developing and implementing a supportive style of supervision, with regular supervisory visits Increased community involvement in session planning and use of ICDS, PRI and civil society to reduce drop out rates, increase demand, and help deliver other preventive health messages (such as breast feeding practices, diarrhoeal treatments etc.) [2] Training should include on-the-job training delivered through regular supervisory visits using a supIndia Universal Immunization Programme Review
1.2
Barriers
Micro-planning to reach remote areas on a routine basis is inadequate Vaccine delivery system is erratic, ad hoc due to insufficient mobility allowance and shortage of male health workers. Injection practices as well as waste disposal practices are often hazardous. Inadequate supportive supervisory visits Poor use of data for action; poor data feedback at all levels; criteria for calculating targets varies, causing confusion in planning VPD / AEFI surveillance is weak Lack of syringes Few IEC materials available
1.3
Conclusions
The number of infants fully immunized in the state appears to be decreasing from 1998 - 2002; the proportion of districts achieving over 80% DTP3 coverage has also decreased. Involvement of key government officials (e.g. Principal Secretary H/FW, District Collector) as well as collaboration between PRI and ICDS has contributed to recent successes in immunization in several districts of Orissa. Routine, regular access to remote areas appeared to be a problem in the districts visited. But relatively high and stable BCG coverage suggest that coverage can be
42
portive style of supervision, supplemented by training during the regular meetings at state, district, and block level for the different staff. Training needs to include the following components: Interpersonal skills so that every immunization contact delivers four key messages to reduce drop out rates: i) importance of immunization, ii) normal effects post immunization, iii) timing and place of child's next immunization, iv) preventive behavioural health messages including breast feeding and nutrition Data recording and reporting practices and use for action Micro-planning to increase coverage rates and reduce drop outs Immunization safety aspects - with special focus on injection technique and waste disposal Cold chain maintenance and vaccine logistics, with specific reference to preventing freezing of freezesensitive vaccines (TT, DT, DTP and hepatitis B)
2. Background
Orissa is a medimum-size state in the eastern part of India. Approximately 30% of the area is difficult to reach to due geographical barriers. Overall 22% of the population is tribal; 17% is member of a scheduled caste. Per capita income is Rs. 5648 per annum. There are 30 districts 314 blocks, 2 Municipal Corporations, 30 Municipalities and 68 NACs in Orissa; and 138 large and small towns. Demography (data from 2001 census) Total 2001 population was 36 804 660, making it the 11th most populous state in India. The population growth was 16% since the 1991 census; the 5th lowest growth rate of the 35 States and Union Territories. Orissa population is 85% rural (72% for India). The overall gender imbalance is the 28th worst of the 35 States and Union Territories with 972 females for every 1000 males (933 per 1000 for India). Overall literacy rate is 63% (65% for India), with substantial female educational disadvantage as shown by a male to female literacy rate ratio of 1.5 (1.4 for India). Children aged under-five-years comprise 10% of the Orissa population (11% for India) Immunization The Universal Immunization Programme (UIP) is a national programme established in 1985, built upon the Expanded Programme on Immunization (EPI) started in 1978. The UIP is delivered as part of the Reproductive and Child Health (RCH) programme. Private practitioners also deliver the UIP and offer additional vaccines. The UIP had its last comprehensive review in 1989, with more recent but less comprehensive reviews
undertaken in 1999. The 2004 UIP review was undertaken in six States. Orissa was selected because of its tribal populations and weak infrastructure. State immunization performance There is political pressure for districts to report over 90% coverage, as this is one of the '20 points' for which each district is assessed. As a result reported coverage has become unreliable, especially in states with low coverage. For example, 2001/2 BCG coverage in Orissa was reported at 112% compared to evaluated coverage of 84%. Coverage performance is thus assessed through surveys. UNICEF conducted national cluster surveys covering most or all states every year from 1999 to 2002, which included Orissa for each year except in 2002. Of the six states in the UIP review, Orissa had the best coverage for the three years 1999 to 2001. The coverage surveys show relatively good access, but with increasing dropout leading to poor coverage in Orissa, with full immunization rate of 73%, 46%, and 53% for 1999, 2000, and 2001, respectively. Dropout is shown by the BGC to measles dropout rate of 10%, 29%, and 26%, for 1999, 2000, and 2001, respectively. Access is relatively good, as indicated by BCG coverage rate of 85%, 83%, and 84%, for 1999, 2000, and 2001, respectively. In 2001, Orissa contributed 0.6 million unimmunized infants to the pool of susceptible children: the 10th largest in India. [Estimate from 2001 coverage survey and 2001 census]
3. Method
The review provides qualitative and selective information on the immunization programme. It is not intended to be either quantitative or statistically representative. The aim was to identify strengths, weaknesses, and bottlenecks to develop practical strategies for improving routine immunization. The review is also to help prioritise implementation of the multiyear plan (MYP: the 2005-2010 strategic plan). The state review was undertaken following a protocol and questionnaires developed by the national UIP review team. Keonjhar and Baragarh districts were each visited by one team, with the first team also visiting the State Headquarters. Team members, their itinerary, and the main persons met can be seen in the state specific report. Specific functions, such as delivery to the block of vaccine and icepacks from the district and early morning collection of vaccine by ANMs were also observed. The interviews were typically conducted with one member leading the discussion and the second member recording information and observations. To elicit common information from ANMs, a focus group discussion was held.
43
Detailed observations, the completed questionnaires, and discussions between team members generation of up to three each of successes, barriers, conclusions, and recommendations for: Strengthening routine immunization at every level (section 4) Eight technical areas of protocol, to aid prioritisation for the MYP (section 5)Further discussion led the
team to agree on up to five key recommendations to strengthen routine immunization (presented in the summary); and the priority actions for the MYP (section 5). The teams prepared a state presentation summarising the findings and initial recommendations that can be seen in the state specific report. National level discussion with the other teams, and subsequent synthesis were used finalise the state report.

The state review team identified up to three key successes, barriers, conclusions and recommendations for strengthening routine immunization at each level. Successes S T A T E
D I S T R I C T
State immunization taskforce recently formed - meeting quarterly. State level annual action plan - but doesn't reach underserved Infrastructure and plan in place. Special immunization camps in one district. PRI and ICDS actively supportive of immunization activities. Urban centres fully staffed, with outreach and strong community links in some areas. Cold chain adequate and in place Private sector contributing and starting additional UIP initiatives. Cold chain and logistics adequate : no stock outs despite stock outs at district level AWW, PRI chairman and NGO role in social mobilisation. Team approach for hard to reach areas
Barriers
No senior staff member solely for immunization. Weak coordination between training institutefamily welfare; privatepublic sectors and in urban areas. Vaccine stock outs; delivery strained by vacant staff positions. Almost no social mobilisation or IEC materials. Low quality data and poor planning. Inaccurate denominator; lack of standard forms (to report and to track). Mobile population makes tracking harder. Chaotic sessions in unhygienic environments and no IEC materials. Hazardous injection safety practices Poor work setting [5]. Numerator and denominator inaccuracies for coverage data; incomplete microplans. PHC is weakest link for UIP; with little MO involvement.
Conclusions
Strong commitment to improve coverage. Comprehensive coverage data, but inaccurate & not used for planning or monitoring. Inadequate coverage improvement plan. Monitoring data not used; denominators unclear. Action plan repeats last year's activities and does not address coverage improvement for the coming year. No efforts to reach underserved. Weak monitoring; data not used for planning. Potential for greater private sector and NGO involvement.
Recommendations
Develop, implement, and monitor state CIP [1]. Dedicated state immunization officer to: coordinate taskforce activities, with focus on CIP development and monitoring. DIO to develop, implement, and monitor district CIP [1]. Constitute a district immunization core group , incl. ICDS, PRI and NGOs, to coordinate and support CIP. Train district level staff on priority areas [2]. Develop CIP [1] appropriate for mobile populations & slums. Train UHC & private staff on priority areas [3]. Provide UHCs & private sector with registers and reporting forms and IEC materials [4]. Develop and implement CIPs [1] for block to support it. Develop alternative system to deliver vaccine to PHCs and ANMs. Review mobility allowance for supervisory POL.
U R B A N
P H C
Poor social mobilisation; practically no IEC materials; no posting of session times. Weak supervision aggravating poor reporting, compiling, and use of immunization data.
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Successes S C
Coordinate with AWW, ICDS, MSS, and PRI. Most planned sessions held. ANMs resident in SCs and effectively delivering services; sometimes pay own transport costs.
Barriers
Poor work setting [5]; minimal training; onerous reporting requirements Dropouts high with no tracking; missed opportunities Confusion over denominators
Conclusions
ANMs have poor work conditions& support. Resources wasted to record & report inaccurate data that is not used. Poor social mobilisation; few IEC resources used.
Recommendations
State review and improve work conditions (incl. reporting) for ANM. Train AWWs & ANMs [3]. Provide every immunization site with IEC materials [4]; and adequate vaccines and injection equipment for each session.
Notes: [1] Coverage improvement plan (CIP) to describe activities needed, building to any existing plans, to reach every child. CIP is ongoing process that includes: (a) identifying underserved populations; (b) prioritizing areas based on coverage and drop-out rates; (c) using analyzed data for action at all levels; (d) increased frequency and quality of supervision with supportive style of supervision; (e) increased community involvement in session planning and use of ICDS, PRI and civil society to reduce drop out rates and increase demand; (f) integration of immunization with other health interventions (such as education on breast feeding practices etc, nutritional supplementation, deworming, bed nets) [2] Priority training topics at district and state level include learning: additional skills for developing, implementing and monitoring the CIP building on micro planning skills and using data for programme management; supportive style of supervision to provide on-the-job training and monitoring; and safe injection practices (with emphasis on waste disposal) [3] Priority training topics at service delivery level include learning: use of data for planning, use of patient contacts as opportunities to promote immunization and for other key giving preventive health messages; and immunization safety, with a focus on injection technique and waste disposal. [4] IEC materials need to be developed that use appropriate messages and methods for promoting participation in programme. All immunization sites should have a signboard showing immunization site, timing and immunization schedule, as well as appropriate promotional material for routine immunization. [5] Working conditions are poor causing poor morale. Problems include level of salary and delayed salary payments; no feedback on performance or reports; inadequate mobility allowance for supervision visits which are of low quality. For ANMs the subcentre building is a particular problem with half of sub-centres with no building (and not enough rental funds given to rent one) and the remainder in a poor state of repair.

The state review team identified up to three key successes, barriers, conclusions and recommendations on eight technical areas, detailed below. From these (and the complete set of observations and recommendations, detailed in the state specific report), the national team identified priority actions from a subset of the recommendations. With many potential priorities, the final list was limited to feasible actions most likely to have an impact in relation to the overall goal - protecting children from disease. Each priority action was linked, if possible, to one of the 20 objective in the MYP. The objectives are numbered and given a short title here, with the full description and associated goal detailed in the state specific report. Implementing the priority action for that objective provides a focus for implementing the MYP.
1. Provide support to help each district, block, PHC, and SC develop coverage improvement plan (CIP) 2. Develop and provide simple tools and job-aids to register and track each child, and to monitor progress, and to validate coverage 3. Develop and implement state immunization safety and waste disposal policy 4. Improve vaccine stock management using guidelines to specify standard processes for ordering and maintaining stock levels 5. Develop state social mobilisation plan to engage community resources and ownership
1.1: regular sessions 6.3: Coverage monitoring 1.5: safe injection 1.4: logistics 4.1: social mobilisation
45
In the table below describing the eight technical areas, the abbreviation used is in square brackets: Service delivery & injection safety [DEL]; Surveillance & monitoring [S&M]; Vaccine distribution & logistics [LOG]; Programme management [MGT]; Cold chain management [CC]; Human resources [HR]; Training [TRN]; IEC and social mobilization [IEC] Successes
D E L
Use team/camp approach for hard to reach. AD syringes used in BCDs since 2001; all staff received injection safety training in 2003. Adequate injection technique.
Barriers
Hazardous waste disposal: lack clear state policy/guidelines. SCs in poor state of repair; if any building . Not following immunization schedule.
Conclusions
Waste disposal potentially harming workers and communities, especially in urban. Supervision mobility allowance needs review. Inadequate supervision with minimal on the job training.
Recommendations
Develop state immunization safety and waste disposal policy; form state and district committees to implement policy. Improve process for developing and reviewing microplans; include special camps for hard-to-reach. Develop supervisory practices to provide on-the-job training, supplemented by UIP field guide for ANM on service delivery, incl. injection safety. ANM reporting needs review to reduce burden; all data should be analysed and used by each level. Provide simple tools and training to follow-up dropouts; estimate denominator; and analyse data. Correct and reprint ICDS immunization registers where BCG has three columns Improve vaccine stock management, with guidelines on buffer stocks and ordering. Provide BCG syringes for all sites. Ensure vaccines are transported in plastic bags to keep dry for label . Provide support for LHVs and other sector supervisors to conduct supervisory visits to immunization sessions . Standardize target setting. Communicate targets to subcentre level.
S & M
Timeliness and completeness of reporting system; regular meetings. Some SC records well maintained. Good card retention by parents, if cards available.
Data only compiled and analysis is weak/non-existent; data not used; common reporting errors. ANMs maintain many registers - but not used; few imm. registers. Imm. card counterfoils not consistently used; no system to track dropouts. Vaccine stock outs; inadequate DTP in 2004. Inadequate syringes and needles. No diluent syringes supplied or used . Where AD syringe used, no BCG AD. Irregular supervisory visits to immunisation sessions. Target setting is not taking into account CNA results. ANMs unsure of targets.
VPD surveillance is weak. Coverage reporting is good, but requires excessive ANM time and data not used. Unclear guidance on denominator estimations contribute to confusion and poor planning. Poor vaccine stock management. Vaccine wastage concerns (especially BCG) causing missed opportunities; but wastage not monitored.
L O G
Stock record keeping is maintained at all levels. ANMs are concerned with vaccine wastage. Good supply system to PHCs . Strong support from District Collector and other important government administrators. Planned session schedules. SDMO, ADMO, MO are doing medical supervisory visits. State level cold chain well managed. Temperature monitoring common. Available equipment is in good condition; good power supply.
M G T
C C
Poor awareness of freeze risk. Back up power systems. Some PHCs not monitoring temps.
Cold chain is in relatively good shape.
Use baskets for storing vaccines to prevent freezing; train on freeze risk. Develop appropriate backup power, including support for generator/voltage stabilizer. Increase number of vaccine storage points.
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Successes H R
Highly competent LHVs. Involvement of MPHW (males) in assisting with immunization activities. All health workers attended RCH training in 2002. LHV provides on the job training. Immunization messages transmitted during sectoral meetings. AWW and ICDS provide house to house mobilization and for mobilizing community. Traditional birth attendants / 'drum beaters' help with mobilization in areas where AWW is not posted. In some areas, SHG, MMS, and Village Health Guide involved in mobilizing community.
Barriers
No Human Resource development plan. Many vacant positions Salaries not paid on time; staff not paid for several months Training materials out of date; no training since 2002 and a request for yearly updates.
Conclusions
Staff have low morale from lack of pay and no feedback or recognition for good work.
Recommendations
Create Human Resource development plan; fill vacant posts; recruit local women for ANM training. Pay salaries on time. Motivate health workers by recognising achievements. Develop and implement state immunization training plan [1], with refresher training every two years. Provide ANM operational guidelines
T R N
Knowledge and skills deficient for cold chain, injection safety, microplans, supervision.
I E C
Limited IEC materials used, except for PPI. No specific leaflets / posters available for routine immunization at PHC level. ANM / AWW not informing mothers of dates for next visits - leading to increased drop out rates; notification of immunization sessions was done adhoc.
Social mobilisation is inadequate and not using all potential resources.
Provide signboards and other IEC at sub-centre level. Improve communication of schedule of immunization sessions to the public, based upon micro-planning. Routinely advise mothers about the side-effects of vaccination and when the next immunisation is due.
Notes: [1] Priority training needs are: Interpersonal communication skills; Data recording and reporting practices and use for action; Micro-planning to increase coverage rates; Immunization safety aspects - with special focus on syringe and needles disposal; Conducting supervisory visits
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ANNEX 6
RAJASTHAN REPORT
1. Summary
There is an excellent system and basic infrastructure for delivery of immunizations in Rajasthan. However, the quality of services can be improved. Improving coverage is the first priority. Social mobilisation (including strengthening links with the community) and safe injection (including disposal) are also priorities. Every village must be served by an ANM ideally at least monthly (and at a minimum four times per year), so that every child can be reached and fully immunized by the age of 12 months. Routinely reported coverage data is not accurate, and is not believed or used at any level. Coverage data must be accurate and used to guide the programme. There is also a need to develop, implement, and monitor the use of, simple tools to improve coverage (e.g., maps, session plans, work plans, monitoring charts) and to properly implement the service delivery register that provides a good tool for tracking dropouts. The most effective way to improve data use at all levels of the programme is likely to be through supportive supervision that comprises monitoring and on-the-job training. The geographical coverage by the ANMs is not consistent across the State - population range is wide, geographical area covered is not a criterion, and cumulative numbers are less than required. The deployment and utilization of ANMs needs to be rationalized. Mobile teams may be needed to access remote areas at least four times in a year with a package of health interventions that includes routine immunization. Large sections, often the illiterate and backward communities, are unaware of need for immunization to protect their children. On the other hand awareness and acceptance of Polio vaccine is excellent. Building on lessons learnt on community mobilization for Polio, a massive communication campaign, consisting both mass media and interpersonal communication, is a critical recommendation. Injection safety is of serious concern. Auto-disable syringes (ADs) along with practical disposal systems must be implemented as soon as possible. On-the-job training for injection safety (including on immunization technique) is needed, and should be delivered through supportive supervision.
that the population comes to service delivery sites. 2. In some areas, the priority will be to establish regular and reliable services; this will be facilitated by more equitable and efficient workforce distribution. 3. In all areas, the quality of service delivery needs to be improved through on-the-job training, especially the use of data for programme management. 4. The government must provide adequate safe injection supplies, including disposal mechanism, and training to ensure injection safety. Actions needed at each level to implement the recommendations NATIONAL 1. Develop a Social Mobilisation Plan and provide adequate resources for States to implement, using the lessons learnt from polio including pre- and post-testing. 2. Review and refine RCH reporting forms and processes to minimise burden and maximise 'information for action' from the data. 3. Develop guidelines, simple tools, and job-aids to help a. Districts, Primary Health Centres, and Sub-centres to improve coverage; b. States develop a cadre of people trained in supportive supervision; and c. supervisors to validate routinely reported coverage. 4. Provide policy and directive for states to implement safe injection practices together with the required materials (ADs and disposal system). STATE 1. Revitalise the IEC department to develop effective social mobilisation strategies and resources. 2. Develop a system of supportive supervision (that comprises of monitoring and on-the-job training) to reach all PHCs and ANMs and includes validation, analysis, and use of coverage data. 3. Develop a policy on a package of services for hardto-reach areas, including delivery of supplies to ANMs using appropriate transportation system. DISTRICTS 1. Appoint dedicated District Immunization Officer (with no other commitments) whose role is to ensure that every PHC and SC develop maps, session plans, and work plans to define and reach their target population (using the lessons learnt from polio) to cover the entire the population.
The key recommendations to strengthen routine immunization in Rajasthan

1. The first priority is effective social mobilisation so
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2. Monitor the implementation of the work plan through analysis of validated coverage data and service delivery and improve performance through supportive supervision. 3. Use existing monthly meetings so that ICDS, PRI, and health functionaries are functionally linked at all levels. PHCs 1. Develop maps, session plans, and work plans to define and reach their target population ideally monthly, and at least four times per year in remote areas; urban PHCs need special strategies to define their population 2. Monitor the implementation of the work plans and use coverage data to improve performance. 3. Use existing PHC meetings to functionally link ICDS, PRI, and health functionaries.
2. Background
Rajasthan is a large and populous State in North West India, bordering Pakistan. Most of the population lives in the wetter eastern side of the State, with the western side being largely desert. There are 32 districts in Rajasthan. The block PHC is no longer used, as sub-divisions (usually composed of two blocks) are now the lowest administrative unit, with each sector PHC reporting to the sub-division. Demography (data from 2001 census) Total 2001 population was 56 507 188, making it the 8th most populous state in India. The population growth was 28% since the 1991 census; the 12th highest growth rate of the 35 States and Union Territories; the 3rd highest of large States (>2.5 million population). Rajasthan population is 77% rural (72% for India). The overall gender imbalance is the 16th worst of the 35 States and Union Territories with 921 females for every 1000 males (933 per 1000 for India). Overall literacy rate is 60% (65% for India), with substantial female educational disadvantage as shown by a male to female literacy rate ratio of 1.7 (1.4 for India). Children aged under-five-years comprise 13% of the Rajasthan population (11% for India). Immunization The Universal Immunization Programme (UIP) is a national programme established in 1985, built upon the Expanded Programme on Immunization (EPI) started in 1978. The UIP is delivered as part of the Reproductive and Child Health (RCH) programme. Private practitioners also deliver the UIP and offer additional vaccines. The UIP had its last comprehensive review in 1989, with more recent but less comprehensive reviews
undertaken in 1999. The 2004 UIP review was undertaken in six states. Rajasthan was selected because it is a diverse state with rural populations. State immunization performance There is political pressure for districts to report over 90% coverage, as this is one of the '20 points' for which each district is assessed. As a result reported coverage has become unreliable, especially in states with low coverage. For example, 2001/2 BCG coverage in Rajasthan was reported at 105% compared to evaluated coverage of 55%. Coverage performance is thus assessed through surveys. UNICEF conducted national cluster surveys covering most or all states every year from 1999 to 2002. The Rajasthan survey data show very poor access and high dropout, both of which are increasing. Estimated full immunization rate in Rajasthan was 35%, 24%, 30%, and 17% for 1999, 2000, 2001, and 2002, respectively. Dropout is an important and increasing contributor to low coverage, as shown by the BGC to measles dropout rate of 22%, 35%, 37%, and 50% for 1999, 2000, 2001, and 2002, respectively. However, access is the major contributor to low coverage as indicated by BCG coverage rate of 61%, 51%, 55%, and 49% for 1999, 2000, 2001, and 2002, respectively. In 2001, Rajasthan contributed 1.4 million unimmunized infants to the pool of susceptible children: the 4th largest in India. [Estimate from 2001 coverage survey and 2001 census]
3. Method
The review provides qualitative and selective information on the immunization programme. It is not intended to be either quantitative or statistically representative. The aim was to identify strengths, weaknesses, and bottlenecks to develop practical strategies for improving routine immunization. The review also aimed to help prioritise implementation of the multi-year plan (MYP: the 2005-2010 strategic plan). The state review was undertaken following a protocol and questionnaires developed by the national UIP review team. Ajmer and Jaisalmer districts were each visited by one team, with the first team also visiting the State Headquarters. Team members, their itinerary, and the main persons met are detailed in the state specific report. The UIP review protocol was to review the block PHC, and then select one PHC in that block. However, Rajasthan no longer has block PHCs, so the method was modified to visit two sector PHCs in the former block area that had been selected. Additional areas were visited to that required by the protocol for
49
observation of immunization sessions. However, only a very limited number or actual immunizations could be observed. Some of the key observations made by the teams are detailed in the state specific report. These observations, the completed questionnaires, and discussions between team members generation of up to three each of successes, barriers, conclusions, and recommendations for: Strengthening routine immunization at every level (section 4)
Eight technical areas of protocol, to aid prioritisation for the MYP (section 5) Further discussion led the team to agree on up to five key recommendations to strengthen routine immunization (presented in the summary); and the priority actions for the MYP (section 5). The teams prepared a state presentation summarising the findings and initial recommendations that can be seen in the state specific report. National level discussion with the other teams, and subsequent synthesis were used finalise the state report.

The state review team identified up to three key successes, barriers, conclusions and recommendations for strengthening routine immunization at each level. Successes S T A T E
D I S T R I C T
No polio since 2003. Reporting complete, timely& comprehensive. ANM positions filled (98%); 1200 extra planned -state funds. Good infrastructure and resources, given constraints. Cold chain & logistics Data compilation & reporting. Meticulous reporting. Cold chain. Private physicians' participation [5]. Structure in place & mostly delivering service. Well kept records and register, BUT variable and falsification seen. Some AWW coordination. Records and immunization register well kept (but much variability). Comply with onerous reporting; many had maps or plans. ANMs valued by their community
Barriers
Reported data not used coverage not credible, but no response [1]. Social mobilisation [2].
Conclusions
Immunization programme requires more managerial inputs. Cold chain & vaccine logistics are sub-optimal.
Recommendations
Increase priority for immunization through CIP [3]. Implement supportive supervision [4] to improve service and data quality.
Managerial capacity and commitment. Lack of supervisory staff and resources. Funds availability & disbursement
The system has the potential to deliver high coverage, but is failing to do so because of managerial and motivational failure.
As for State, plus: Appoint DIO and provide DIO with resources for tasks.
U R B A N P H C
Registers not used or incorrectly filled; no followup of dropouts. Injection safety. Level and distribution of workload. Inadequate knowledge and skills; monitoring; and training. Social mobilisation mostly limited to AWW. Microplans not adequate/implemented. Unequal distribution of villages and workload; inadequate transport. Lack of social mobilisation lead to extra workload for house visits or children missing out.
Variable quality of services in different setting most urban centres poor quality; hospitals and private practitioners good. Priorities are to improve: Coverage (including quality of reported data); Social mobilisation; and Safe injection (including disposal). ANMs are vital [7]. ANMs appear keen to improve the quality of their work, and need appropriate resources and training to do so.
Establish a system to allocate responsibility for a defined catchment population that includes temporary as well as permanent residents. Implement on-the-job training for ANM and LHV on priority issues [6].
S C
Training for ANMs [6]. Deliver vaccines directly to ANMs, where appropriate. (Distribution may be more efficient through vaccine depots other than the SCs and PHCs).
Notes: [1] Comprehensive data covering a wide rand of areas is routinely reported. But, nobody at any level is paying any attention to contents of these detailed reports, including coverage data; there is no feedback on content, except to require over 90% coverage (for dis
50 India Universal Immunization Programme Review
trict collector's '20 points'). Routinely reported coverage data is unreliable - but is being signed off at every level. [2] Social mobilisation is a problem at every level (and corresponding lack of advocacy). There is no or very limited material promoting immunization at every level. PPI may have aggravated the problem by leading to a perception that a child is fully immunized after having the polio drops, as well as the expectation for immunization at home. As a result the population is not aware of the need for routine immunization, and is too easily put off by the common local reactions to DTP vaccine. This is further aggravated by the lack of followup for drop-outs [3] The state, and every level, needs to demonstrate commitment to routine immunization. Immunization performance reflects the government's commitment to safeguard its citizens' health and well-being. Demonstration of commitment should be through a coverage improvement plan (CIP) for each level. The CIP describes activities needed, building to any existing plans, to reach more children using existing resources. The CIP describes an ongoing process that is data driven, and requires accurate and reliable coverage data to focus interventions and monitor their impact. There is a need for simple tools to help each level to monitor, analyse, and improve district and PHC coverage data. Supportive supervision for training and developing community links for social mobilisation are key elements needed for coverage improvement. [4] Supportive supervision describes an approach to supervision practice that is intended to provide training as well as monitoring. The on-the-job training provided by a supervisor skilled in supportive supervision. This style of supervision requires the ability to review the health worker's practice; praising all aspects that are appropriately performed and pointing out what areas need to be improved, and how to improve them. It requires follow-up to see if the deficient areas of practice have been improved. [5] The private physicians visited were knowledgeable about, and committed to, immunization. Although there is opportunity to strengthen the interaction between the private physicians and the UIP, the private sector can only have limited impact on the overall programme. [6] Training needs to through on-the-job training by supervisors trained and skilled in supportive supervision, supplemented by training and sharing of experiences/successes at existing regular meetings. There needs to be a focus for the training to cover a priority range of issues (e.g. thigh injection; AD use and disposal; using registers to track dropouts; developing work plans based on maps and session plans; using monitoring charts) [7] ANMs are the key health workers for the UIP, they provide the foundation and practically all the outputs of the programme. They are an invaluable resource for immunization as well as all other aspects of primary health care.

The state review team identified up to three key successes, barriers, conclusions and recommendations on eight technical areas, detailed below. From these and the complete set of observations and recommendations, detailed in the state specific report, the national team identified priority actions from a subset of the recommendations. With many potential priorities, the final list was limited to feasible actions most likely to have an impact in relation to the overall goal - protecting children from disease. Each priority action was linked, if possible, to one of the 20 objective in the MYP. The objectives are numbered and given a short title here, with the full description and associated goal in Annex 5. Implementing the priority action for that objective provides a focus for implementing the MYP.
1. Develop effective social mobilisation methods, materials, and partnerships to build community demand for UIP 2. Ensure that all areas have a regular service; improve quality of service through supportive supervision that provides monitoring and on-the-job training 3. Provide adequate supply of ADs and disposal systems; training on safe injection and disposal
4.1: social mobilisation 1.1: regular sessions 1.5: safe injection
In the table describing the eight technical areas, the abbreviation use is in square brackets: Service delivery & injection safety [DEL]; Surveillance & monitoring [S&M]; Vaccine distribution & logistics [LOG]; Programme management [MGT]; Cold chain management [CC]; Human resources [HR]; Training [TRN]; IEC and social mobilization [IEC]. Additional observations are provided in Annex 3.
51
Successes D E L
Excellent infrastructure. Major injection safety issues relatively rare. Some efforts to converge between ICDS & health functionaries. Timely, comprehensive reporting system.
Barriers
Lack of skills, including injection. Shortage of safe injection materials and disposal method. Serving remote, sparse populations. Coverage data overreporting; lack of understanding of value of reliable data. Practically no disease monitoring. BCG and Measles often short but not stopping services. Safe injection supplies not adequately provided. No full time DIO in both districts visited. Low priority & insufficient resources, esp. for operational costs. Poor implementation.
Conclusions
Poor social mobilisation causes extra work to reach beneficiary. Potential harm to individual, health worker, and community from injection practices. Data not used to guide decisions. Data not used at any level; no feedback on reports or corrective action.
Recommendations
Increase coordination between ICDS, Health, and PRI to improve awareness. On-the-job training to improve quality, including safe injection. Mobility support for hard to reach areas. Improve data quality and change management culture by using data for programme management. Supportive supervision should include validation of reported coverage data at every level. Improve vaccine stock management, including providing delivery directly to ANMs, where possible. Provide adequate safe injection supplies, incl. for disposal. Appoint dedicated, experienced mangers and provide resources needed for management. Use coverage data for mgt. Engage other departments (e.g., Patwari/Gramsevak) to monitor and support UIP. Improve monitoring, management and maintenance of cold chain equipment in deficient areas. Ensure equitable distribution of new ANMs. Improve management and monitoring of ANMs. Identify training needs and methods. Improve service quality through supportive supervision that provides 'on-the-job training'.
S & M
L O G
Vaccine usually available at all levels; no interruption of immunization due to vaccine shortage. Organization occurring between ICDS and the Health Department using monthly meetings.
Vaccine distribution infrastructure working.
M G T
Programme is poorly managed and appears demoralised.
C C
Cold chain appears to Temperature recording be a success. variable. (Excess of equipment Voltage stabilizer guidesupply). line not followed. Human resources, probably adequate for UIP given restraints. (State to provide 1,200 additional ANMs). Training institute in every district provides on-going classroombased training. . ICDS and Health Department convergence is happening. Some IEC is available. Some ANMs have higher workload than others. No DIO in place.
Cold chain generally functioning well.
H R
Main issues are management, monitoring, and training of staff.
T R N I E C
Inadequate amount and quality of training. No 'on-the-job training'. Low community awareness, aggravated by PPI. State level IEC bureau lacks resources, activities, and modern practice. Social mobilization is integral to the success of routine immunization and is deficient.
Old as well as new strategies are needed: locally appropriate & community driven, based on a community analysis.
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ANNEX 7
UTTAR PRADESH REPORT
1. Summary
All the infrastructural elements for delivery of routine immunization are in place in Uttar Pradesh. But, the system is failing to reach most children, largely, because of a lack of: 1) political and bureaucratic commitment 2) community ownership of the immunization programme 3) demand caused by irregular delivery of services and quality issues. The Government of Uttar Pradesh is urged to consider the tremendous health benefits of immunization for the 5.4 million infants born in this state each year and to make improvement of vaccine coverage a state health priority. After prioritization, gains in coverage will be achieved largely through management, training, and community partnership efforts and will not require large inputs of scarce human or financial resources.
The key recommendations to strengthen routine immunization in UP

1. Train all field staff (immediately) on current UIP policies, guidelines, and skills - with special emphasis on micro planning, injection safety, waste disposal, record maintenance and reporting. 2. Strengthen monitoring and supervision at all levels. 3. Involve other departments (ICDS, Railway, Education, PRIs) and partners (NGOs, private sector, medical colleges) more actively to communicate messages and provide services. 4. Develop a vaccine management system where vaccine requirements are based on accurate target population (from community level surveys) and working cold chain storage capacity.
2. Background
Uttar Pradesh is the largest state in India. Therefore, its performance in preventing communicable diseases, including for immunization delivery, has a huge impact on overall disease transmission in India. Demography (data from 2001 census) Total 2001 population was 166 197 921, making it the most populous state in India. The population growth was 26% since the 1991 census; the 16th highest growth rate of the 35 States and Union Territories; the 5th highest of large States (>2.5 million population).
Uttar Pradesh population is 79% rural (72% for India). The overall gender imbalance is the 9th worst of the 35 States and Union Territories with 898 females for every 1000 males (933 per 1000 for India). Overall literacy rate is 56% (65% for India), with substantial female educational disadvantage as shown by a male to female literacy rate ratio of 1.6 (1.4 for India). Children aged under-five-years comprise 12% of the Uttar Pradesh population (11% for India). Immunization The Universal Immunization Programme (UIP) is a national programme established in 1985, built upon the Expanded Programme on Immunization (EPI) started in 1978. The UIP is delivered as part of the Reproductive and Child Health (RCH) programme. Private practitioners also deliver the UIP vaccines and offer additional vaccines. The UIP had its last comprehensive review in 1989, with more recent but less comprehensive reviews undertaken in 1999. The 2004 UIP review was undertaken in six states. Uttar Pradesh was selected because it is a large state with low immunization coverage and large immunity gap. State immunization performance The structure and management of the immunization system is in place but not functioning efficiently. There are plans for conducting immunization sessions on two days a week throughout the state but only about 30% of the planned sessions are being held. Reported coverage is unreliable: 2001/2 BCG coverage in Uttar Pradesh was reported at 112% compared to evaluated coverage of 43%; reported DTP3 coverage is > 80% for the last few years, the NFHS II district coverage evaluation survey found a range from 29% in Badaun to 83% in Lucknow, with district average of 55% for the state. Coverage performance is thus assessed through surveys. UNICEF conducted national cluster surveys covering most or all states every year from 1999 to 2002. Estimated full immunization rate in Uttar Pradesh has been about 20% for the past three years. The main reason for low coverage is poor access (with less than half receiving BCG in the past three years), but about one third of children who start immunization do not complete the series. In 2001, Uttar Pradesh contributed 4.7 million unimmunized infants to the pool of susceptible children: the largest in India. [Estimate from 2001 coverage survey and 2001 census]
53
3. Method
The review provides qualitative and selective information on the immunization programme. It is not intended to be either quantitative or statistically representative. The aim was to identify strengths, weaknesses, and bottlenecks to develop practical strategies for improving routine immunization. The review also aimed to help prioritise implementation of the multiyear plan (MYP: the 2005-2010 strategic plan). The state review was undertaken following a protocol and questionnaires developed by the national UIP review team. Sitapur, and Meerut, and Gorakhpur districts were each visited by one team, with the first team also visiting the State Headquarters. The three teams covered Western, Central and Eastern parts of the state. Emphasis was given to visit remote sub-centres, where possible. In addition to the usual sites in the protocol, the teams also visited other government agencies (e.g. Railway Hospitals, ICDS Department, District Statistical Officer) and some NGOs. To elicit common information from ANMs, a focus group discussion was held to capture their opin-
ion on issues like alternate vaccine delivery methods. Due to the holidays and Pulse Polio activities the teams it was difficult for the teams to see an adequate number of sessions at the sub center and outreach sites. Some of the key observations made by the teams are detailed in the state specific report. These observations, the completed questionnaires, and discussions between team members led to the agreement of up to three each of successes, barriers, conclusions, and recommendations for: Strengthening routine immunization at every level (section 4) Eight technical areas of protocol, to aid prioritisation for the MYP (section 5) Further discussion led the team to agree on up to five key recommendations to strengthen routine immunization (presented in the summary); and the priority actions for the MYP (section 5). The teams prepared a state presentation summarising the findings and initial recommendations that can be seen in detail in the state specific report. National level discussion with the other teams, and subsequent synthesis were used to finalise the state report.
54

The state review team identified up to three key successes, barriers, conclusions and recommendations for strengthening routine immunization at each level. These can be seen in more detail, with additional observations and recommendations in the full State report. Successes S T A T E
D I S T R I C T
State Task Force and core group formed for routine immunization. Adequate cold chain equipment.
Barriers
Inadequate political commitment. Poor coordination with: education, ICDS, private sector, & NGOs. Poor vaccine logistics; irregular central supply. Inadequate monitoring & supervision; no ANM training for many years. Insufficient cold chain; vaccine stock-outs. Inadequate staff (esp. for urban & peri-urban). No session plans; mobile & slum pops. not reached. Not delivered at hospitals: missed opportunities PPs not reporting, not coordinated.
Conclusions
All elements in place, but need political commitment and managerial capacity. Training is key need at all levels in priority areas [1].
Recommendations
Widen/strengthen Task Force; increase commitment for UIP. Train staff [1]and provide standard tools (e.g., registers). Mandatory monthly sessions at every AWC. Implement state level recommendations (above). DM to regularly review performance of validated coverage data [2]. Provide flexible funding for mobility and contingencies Integrate and plan with PPs & NGOs (use MOU) for service delivery and social mobilisation. Train private providers. Provide hospital service (screen for status and daily immunization). Strengthen planning to cover catchment, esp. hard-to-reach [3]. Provide contingency funds for BPHC / PHC / SC level. Clearly define duties of staff and facilities; reward best performing Panchayats & SCs Involve community (4) in planning, social mobilisation, and on fees to fund certain activities. Reorganize ANMs' workload to be realistic and rational. Use registers (linked to births) and cards to reduce leftand drop-outs.
Effective models for social mobilisation implemented (UNICEF/CARE). Adequate staffing.
Same as state level (above). Coordination with other departments and agencies needs to be strengthened.
U R B A N P H C
Some areas covered. Self motivated private practitioners (PPs) delivering UIP and willing to increase participation.
Urgent need to increase infrastructure. Need to create privatepublic partnerships for immunization and increase involvement of PPs and NGOs. UIP is low priority for all staff. Vaccine supply erratic. Role of additional PHC for UIP not clear.
Cold chain mostly intact and maintained up to block PHC level. Most sanctioned staff positions filled.
No operational funds (incl. get vaccine to ANM). No clear plans for hardto-reach. No immunization training for >10 years; supervision rare and of poor quality. Poor service quality and reliability; little community awareness & involvement. ANMs don't know target; large catchment for some. Weak record keeping and reporting.
S C
ANM positions generally filled. Some volunteers active in social mobilization. PPI has improved understanding of how to reach community.
Poor Service quality, incl. social mobilisation, is leading to low coverage with many left- and drop-outs. Staff feel PPI having negative effect on routine.
Notes: [1] Priority areas for training include micro planning; injection safety, waste disposal, record maintenance and reporting. [2] Coverage data should be validated through supervisory visits and annual evaluations [3] Planning needs to have focus on appropriate strategies for hard-to-reach populations. Planning should be strengthened by involving other departments (especially ICDS, PRI); funding operational costs according to plan; and regularly reviewing performance (incl. by ICDS supervisors). The MO and other supervisory staff need to be more active in planning and monitoring. [4] Community involvement includes training the ANMs to make better use of volunteers, and other local resources, for planning as well as service delivery. Community leaders & Organisations like the Gram Pradhans, Mahlia Mandals/MahilaSwasthya Sangh (MSS), religious leaders, and other community leaders need to be more actively involved in planning and monitoring services. Less than 30% of planned services were held.
55

The state review team identified up to three key successes, barriers, conclusions and recommendations on eight technical areas, detailed below. From these, the national team identified priority actions from a subset of the recommendations. With many potential priorities, the final list was limited to feasible actions most likely to have an impact in relation to the overall goal - protecting children from disease. Each priority action was linked, if possible, to one of the 20 objectives in the MYP. The objectives are numbered and given a short title here, with the full description and associated goal can be seen in the detailed state report Implementing the priority action for that objective provides a focus for implementing the MYP.
1. Provide support to help each district, block, PHC, and SC develop coverage improvement plan (CIP) 2. Develop and provide simple tools and job-aids to register and track each child, and to monitor progress, and to validate coverage 3. Provide training and supplies for safe injection and disposal 4. Develop state social mobilisation plan to engage community resources and ownership 5. Enhance coordination with AWWs for social mobilisation and service delivery
1.1: regular sessions 6.3: Coverage monitoring 1.5: safe injection 4.1: social mobilisation 1.1: regular sessions
In the table describing the eight technical areas, the abbreviation used is in square brackets: Service delivery & injection safety [DEL]; Surveillance & monitoring [S&M]; Vaccine distribution & logistics [LOG]; Programme management [MGT]; Cold chain management [CC]; Human resources [HR]; Training [TRN]; IEC and social mobilization [IEC] Successes D E L
Basic supplies provided. UIP delivered by variety of institutions and private providers. ANMs and AWWs collaborating in many districts. Coverage data regularly compiled and reported. Some sessions monitored by NPSP (SMO/Block Monitors). Quarterly state level review meeting. Zonal vaccine cold store function& well maintained. Stock records are in good order. First expiry first out is practiced.
Barriers
Services irregular & poor quality [1]. No mobility support for ANMs to collect vaccine or do outreach. Unclear guidelines/policies Printed registers and report forms not supplied. Unreliable data reported; data not analyzed or used; limited tracking. VPDs (except AFP) and AEFI rarely reported.
Conclusions
Poor service quality causes low utilization, aggravated by irregular and unpredictable delivery. Unsafe injections and practices leading to potential harms. Monitoring and surveillance systems need to be improved at all levels.
Recommendations
Provide training, tools, and supplies to improve service delivery and injection safety. Use AWCs in addition to SC for regular, predictable sessions. Increase delivery through hospitals, private sector and NGOs. Provide training, tools, and supplies (e.g., registers) to improve coverage and disease surveillance. Use ANM registers and counter-foils. Supervisors to validate reported data accuracy; use external agency for evaluation; make staff accountable. Use doses (not vials) for vaccine stock records. Provide funds (based on micro plan) to get vaccine and supplies to ANM. Provide standard stock registers and temperature records/charts.
S & M
L O G
Frequent stock outs Vaccine supply system is "push" - not related to need. ANMs travel 8-10 times a month to collect and return vaccines.
Supply shortages of all vaccines is a serious problem in all districts.
56
Successes M G T
State Task Force. District level group to review immunization (PPI). Senior officers at district level involved in UIP.. Cold chain capacity mostly adequate and well maintained; generators for back-up power available; adequate staff. Temperatures routinely monitored and recorded. Very few EPI staff vacancies at all levels. . Designated staff in charge of cold chain at all level, incl. refrigerator mechanic.
Barriers
Task Force not meeting regularly; needs other members. Roles not clearly defined; no dedicated UIP officer Poor planning and monitoring. Insufficient cold chain space at district level; some equipment beyond repair. Some freezing observed in ILRs; poor CC mgt. in private sector. Long repair times; insufficient POL. No accountability or recognition for performance; insufficient staff for workload (aggravated by PPI demands and failure to use male workers). Staff lack skills; no supportive supervision. Most ANMs non-resident - security concerns and SC building not available. No training on immunization for many years for most staff. Absence of guidelines, job aides, periodic refreshers and reference materials for all levels Major deficiencies in injection practice.
Conclusions
Too much political interference at every level. Inadequate coordination with other stakeholders and agencies. No appropriate micro plans at any level. Cold chain is well maintained despite constraints, poor electric supply, and equipment aged. Guidelines needed on process for non-functional equipment.
Recommendations
Increase priority of UIP: senior staff to manage and review performance; collaboration with other departments, private, and NGOs to strengthen UIP. DIO with UIP as only duty, trained and stay in place for min for minimum time Consider auto-start power generators at critical storage points. Provide sufficient POL funds at all levels, and new generators where needed. Provide standard stabilizers for cold chain equipment. State to increase staffing, and rationalise allocation for workload; use contracted staff for vacant position. Use male workers, where present, to support RI. Institutionalize performance assessment and accountability mechanisms linked to rewards and recognition. Train all levels on coverage improvement using RED strategies, including mapping and planning at district and block level. Train all providers (incl. private and NGO) on service delivery. Create district level trainers who can train on all aspects of UIP with practical, hands-on training followed by refreshers and supervisory support. Collaborate with community and partners for social mobilisation and community ownership. Train providers on interpersonal communication (incl. on vaccine reactions) and demand generation through user-friendly services. Media campaign at national/state level.
C C
H R
Overall motivation and commitment of staff are very low.
T R N
ANM training centre in each district. Manual developed and piloted (Agra) for skill based training for MOs. Periodic trainings on RCH supported by SIFPSA, UNICEF and CARE, though not exclusively on immunization. . Highly dedicated and partially trained (SIFPSA) volunteers and NGOs available for social mobilisation. UNICEF/CARE good experience in involving community. Some printed materials, but mostly for PPI.
Training is an urgent priority for all levels in: UIP policies and guidelines; safe injection and disposal; vaccine and cold chain management; micro planning, including follow-up and analysis of coverage data; and record maintenance and reporting.
I E C
Limited community understanding/demand; resistance in some communities aggravated by attitude of service providers. Negative attitude to NGOs who mobilise communities. Urban communities not aware of services.
Much work needed to address community barriers and improve awareness/demand.
Notes: [1] Service quality poor in many areas including the lack of planning in urban areas; no follow-up; unsafe injections; poor communication; improper injection sites; and missed opportunities.
57
ANNEX 8
FIELD VISIT FLOW DIAGRAM
58
ANNEX 9 UIP REVIEW

TEAM MEMBERS
UTTAR PRADESH TEAM
LUCKNOW & SITAPUR DISTRICT (TEAM 1) Mr. Vikram Singh, GoI Dr. Anne Golaz, UNICEF Mr. Iqbal Hussein, USAID Dr. Karan Singh Sagar, WHO Mr. Sanjay Saxena, WHO GORAKHPUR DISTRICT (TEAM 2) Dr. Dev, UNICEF Mr. Gopa Kumar, EU Mr. Joby George, CARE Ms. Carrie Tudor, WHO MEERUT DISTRICT (TEAM 3) Mr. Jaya Rao, Government of Andra Pradesh Dr. S. Wiersma, WHO Dr. YP Gupta, DFID Dr. Samaresh Sengupta, UNICEF
ORISSA TEAM
BUBENESHWAR AND KHEONJHAR DISTRICT (TEAM 8) Dr. Biswal, GoI Dr. Craig Burgess, WHO Dr. Subroto Mukherjee, CARE Dr. Godbole, UNICEF BARAGARH DISTRICT (TEAM 9) Dr. Paul Prabhakar Francis, WHO Mr. James Patterson, UNICEF Dr. Kumar Madhu Sudan, CARE Dr. Shannon Stokley, CDC
RAJASTHAN TEAM
JAIPUR & AJMER DISTRICT (TEAM 10) Dr Ashok Dutta, Lady Harding Medical College, Delhi Dr Osman Mansoor, WHO Dr Deoki Nandan, UNICEF Mr Chris Barrett, USAID JAISALMER DISTRICT (TEAM 11) Dr. Dipti Jain, Govt. Medical College, Nagpur Mr. Uma Shankar, CARE Dr. Raj Kumar, CVP PATH Dr. Vibhavendra S Raghuvanshi, UNICEF
BIHAR TEAM
PATN1A AND AURANGABAD DISTRICT (TEAM 4) Dr. S. Vivek Adish, GoI Dr. Sumant Mishra, WHO Dr. Pranita Achyut, UNICEF Dr. Robert Steinglass, USAID KISHANGANJ DISTRICT (TEAM 5) Dr. Sanjay Rai, AIIMS, Delhi Dr. R.K. Pal, WHO Mr. K.A. Balaji, CVP PATH Dr. Narayan Gaonkar, UNICEF
MADHYA PRADESH TEAM

BHOPAL AND GUNA DISTRICT (TEAM 12) Dr. Pradeep Haldar, GoI Mr. A.L. Makhijani, GoI Dr. Hussain Yusuf, UNICEF Dr. Vinod Bura, WHO MADHYA PRADESH SEONI DISTRICT (TEAM 13) Dr. Pradhan, Professor, Lady Harding Medical College, Delhi Dr. A. Varma, WHO Dr. Pravin Khobragade, UNICEF Mr. J.K. Kantimalla, CARE
JHARKHAND TEAM
RANCHI AND SINGHBHUM DISTRICT (TEAM 6) Dr. Sunil Tore, State Government representative Dr. John Clement, WHO Dr. R K Kumaraswamy, UNICEF Mr. M Satish Kumar, CARE Ms. Ratna Singh (SHRISTI Environmental) GODDA DISTRICT (TEAM 7) Dr. P. K. Das, State Government Representative Dr. K. Lewis-Bell, WHO Dr. Arun K. Aggarwal, UNICEF Dr. Jina Shah, CDC Dr. Ambujam Kapoor, ICMR
59

Routine Immunization UIP-ANNEX

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Routine Immunization UIP-ANNEX

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ANNEX 1

TEN NATIONAL RECOMMENDATIONS

The key recommendations to strengthen routine immunization in Bihar

4. Strengthening routine immunization

Sale of other vaccines can attract people for UIP vaccines.

5. Priority areas for implementation of the multi year plan

India Universal Immunization Programme Review

The key recommendations to strengthen routine immunization in Jharkhand

4. Strengthening routine immunization

India Universal Immunization Programme Review

5.Priority areas for implementation of the multi year plan

India Universal Immunization Programme Review

India Universal Immunization Programme Review

India Universal Immunization Programme Review

The key recommendations to strengthen routine immunization in Madhya Pradesh

4. Strengthening routine immunization

India Universal Immunization Programme Review

5.Priority areas for implementation of the multi year plan

Service delivery & injection safety

India Universal Immunization Programme Review

Surveillance & monitoring

Vaccine distribution logistics

Cold chain management

India Universal Immunization Programme Review

IEC and social mobilization

India Universal Immunization Programme Review

The key recommendations to strengthen routine immunization in Orissa

4. Strengthening routine immunization

India Universal Immunization Programme Review

5.Priority areas for implementation of the multi year plan

Cold chain is in relatively good shape.

India Universal Immunization Programme Review

Social mobilisation is inadequate and not using all potential resources.

India Universal Immunization Programme Review

The key recommendations to strengthen routine immunization in Rajasthan

4. Strengthening routine immunization

5. Priority areas for implementation of the multi year plan

4.1: social mobilisation 1.1: regular sessions 1.5: safe injection

India Universal Immunization Programme Review

Vaccine distribution infrastructure working.

Programme is poorly managed and appears demoralised.

Cold chain generally functioning well.

Main issues are management, monitoring, and training of staff.

India Universal Immunization Programme Review

The key recommendations to strengthen routine immunization in UP

India Universal Immunization Programme Review

4. Strengthening routine immunization

Effective models for social mobilisation implemented (UNICEF/CARE). Adequate staffing.

India Universal Immunization Programme Review

5. Priority areas for implementation of the multi year plan

Supply shortages of all vaccines is a serious problem in all districts.

India Universal Immunization Programme Review

Overall motivation and commitment of staff are very low.

Much work needed to address community barriers and improve awareness/demand.

India Universal Immunization Programme Review

India Universal Immunization Programme Review

ANNEX 9 UIP REVIEW

MADHYA PRADESH TEAM

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