IndiaCLEN Program Evaluation Network [IPEN]

VISION

Facilitate development and implementation of people friendly, effective Public Health Programs that are in harmony with their socio-cultural beliefs, thus creating a milieu where service providers get motivated and communities consider Public Health Services beneficial and willingly participate

Cover Design by: Mr. Gouri Shankar Mukherjee Injection equipment, technique, rational use along with waste disposal mechanism influence the safety of an INJECTION

Published by: Central Coordinating Team on behalf of IndiaCLEN Program Evaluation Network Website: http://www.ipen.org.in email: [email protected] Ph: 91-11-26960375 / 376

Printed at: Noble Vision, 198/29-B, (Basement), Ramesh Market, East of Kailash, New Delhi-110065, India, Ph: 9810115714 e-mail : [email protected] Investigators

Principal Investigator & Project Coordinator

Dr. Narendra K. Arora Professor Department of Pediatrics All India Institute of Medical Sciences New Delhi

CCT Members

Dr. Thomas Mathew Dr. S. Rema Devi Professor Associate Professor Department of Community Medicine Department of Community Medicine T.D. Medical College Medical College Alappuzha Thiruvananthapuram

Ms. Sneh Rewal Dr. Kiran Goswami Consultant Additional Professor Child Development & Nutrition Department of Community Medicine United Nations International Children’s Fund, All India Institute of Medical Sciences Lodhi Estate, New Delhi New Delhi

Dr. Kalyan K. Ganguly Dr. Ritu Priya Mehrotra Assistant Professor Associate Professor Institute of Human Behavior Department of Community Medicine & Allied Sciences Jawaharlal Nehru University Delhi New Delhi

Dr. M. Lakshman Dr. S. Vivek Adhish Consultant Social Scientist Reader, Department of Pediatrics Community Health Administration All India Institute of Medical Sciences National Institute of Health & Family Welfare, New Delhi New Delhi

Ms. Moumita Biswas Dr. Sanjay Chaturvedi Assistant Research Officer Professor Department of Pediatrics Department of Community Medicine All India Institute of Medical Sciences University College of Medical Sciences New Delhi Delhi

Dr. Ravindra M Pandey Additional Professor Dept. of Biostatistics All India Institute of Medical Sciences New Delhi Extended CCT Members

Dr. B. Mallikarjun Dr. T. D. Sharma Dean & Principal Principal M.R. Medical College Regional Health & Family Welfare Sedam Road Training Centre Gulbarga Kangra

Dr. Faruque U. Ahmed Dr. S.K. Pradhan Professor & Head Professor Department of Community Medicine Department of Community Medicine Assam Medical College Lady Hardinge Medical College Dibrugarh New Delhi

Dr. Sanjay P. Zodpey Dr. Deoki Nandan Professor Professor Department of Community Medicine Department of Community Medicine Government Medical College S. N. Medical College Nagpur Agra

Dr. S. L. Chadha Dr. Sandip K. Ray Consultant: Public Health Professor & Epidemiology Department of Community Medicine New Friends Colony Medical College New Delhi Kolkata

Dr. R. N. Basu Dr. Sunita Shanbhag Consultant: Public Health Associate Professor & Epidemiology Department of Community Medicine Yojana Vihar LTM Medical College, Sion New Delhi Mumbai

Dr. Sheffali Gulati Dr. Pankaj Hari Associate Professor Associate Professor Department of Pediatrics Department of Pediatrics All India Institute of Medical Sciences All India Institute of Medical Sciences New Delhi New Delhi

Dr. Shitanshu Uppal Dr. Vibhor Krishna Intern Intern All India Institute of Medical Sciences All India Institute of Medical Sciences New Delhi New Delhi

Dr. Kailash C. Malhotra Dr. Abdul Rauf Professor Emeritus Ex Principal & Dean Anthropometry & Human Genetics Unit Government Medical College Indian Statistical Institute, Kolkata Srinagar

Dr. Harish Pemde Dr. Naveet Wig Assistant Professor Associate Professor Department of Pediatrics Department of Medicine Lady Hardinge Medical College All India Institute of Medical Sciences New Delhi New Delhi

Dr. Tanu Singhal Dr. Hemant Kumar Associate Professor Health Management Specialist Department of Pediatrics Department of Pediatrics Hinduja National Hospital All India Institute of Medical Sciences Mumbai New Delhi Investigators at each Zone

Zone 01: Punjab, Chandigarh, Delhi, Haryana, Himachal Pradesh, Jammu & Kashmir Zonal Coordinator: Dr. Rajesh Kumar Government Medical College, Srinagar Post Graduate Institute of Medical Education & Dr. Muneer Ahmed Masoodi Research, Chandigarh Dr. Safoora Bilques Dr. Amarjeet Singh Dr. J.S Thakur Regional Health & Family Welfare Training Centre, Kangra Dr. S. Bandyopadhyay Dr. T.D. Sharma Dr. Sonu Goel Ms. Swaran Lata Post Graduate Institute of Medical Sciences, Government Medical College, Amritsar Rohtak Dr. Tejbir Singh Dr. Jay Kishore Dr. S.S. Deepti Dr. Manoj Bhardwaj Dr. O. Raj Goldi Dr. Sanjay Atri Dr. Kanwaljit Singh Dr. Ashwini Goel Dr. Jasleem Kaur Dr. K.C. Sharma Dr. Vikrant Prabhakar Dr. Purshottam Zone 02: Uttar Pradesh, Uttaranchal Zonal Coordinator: Dr. Ramesh C. Ahuja King George's Medical College, Lucknow Institute of Medical Sciences, Varanasi Dr. Vinod K. Srivastava Dr. S.C. Mohapatra Dr. Uday Mohan Dr. V. M. Gupta Dr. A. K. Srivastava Dr. Ramesh Chandra Himalayan Institute of Medical Sciences, Dehradun Dr. V.K. Srivastava Dr. Ramesh Chandra Dr. Yogesh Saxena Dr. S. D. Kandpal

S.N. Medical College, Agra Aligarh Muslim University, Aligarh Dr. Deoki Nandan Dr. Azra Ahmed Dr. S.K. Misra Dr. Syed Manazir Ali Dr. S.P. Agnihotri Dr. S.C. Gupta Santosh Medical College, Ghaziabad Dr. B. B. Maheshwari Dr. Gajendra Kumar Gupta Dr. S. N. Bhargawa Dr. Sangeeta Kansal Zone 03: Bihar, Jharkhand Zonal Coordinator: Dr. S.P. Srivastava Patna Medical College, Patna J.L.N. Medical College, Bhagalpur Dr. Raja Ram Prasad Singh Dr. R.K. Sinha Dr. Mala Sinha Dr. K.K. Sinha Dr. N.P. Verma Mahatma Gandhi Memorial Medical College, Jamshedpur Dr. Manju Prasad Dr. Arun Kumar Sharma Dr. J.P. Mishra Darbhanga Medical College, Darbhanga Dr. Ashok Kumar Rajendra Institute of Medical Sciences, Ranchi Dr. Amita Varma Dr. Vivek Kashyap Dr. Hemant Kumar Das Dr. S.K. Singh Ms. Kalpana Das A.N. Magadh Medical College, Gaya Dr. C.S. Sharma S.K. Medical College, Muzaffarpur Dr. K.N. Acharya Dr. Arbind Kumar Dr. Bijay Kishore Singh Dr. Manish Kumar Dr. S.N. Sharma Zone 04: West Bengal, Andaman & Nicobar Islands Zonal Coordinator: Dr. Sandip K. Ray

Medical College, Kolkata Dr. Prasanta Ray Karmakar Dr. Jayasri Mitra (Ghosh) Dr. N.C. Mondal Dr. Shyama Prasad Mitra Dr. Sarmila Mallik IUPHE, Kolkata Dr. Biswajit Biswas Dr. Madhumita Dobe Mr. Ram Narayan Mandal N.R.S. Medical College, Kolkata Dr. Ashok Kr. Mallick Dr. Samir Das Gupta Dr. Suprakas Hazra Dr. Palash Das Dr. Rabindra Nath Sinha Burdwan Medical College, Burdwan Dr. Ramaprasad Roy Dr. Nabendu Chaudhuri Dr. Bansi B Mukhopadhyay IPHA, Kolkata Dr. Nabanita Bhattacharyya Dr. Asoke Mondal Dr. Bijoy Mukherjee Dr. Dipak Pal

Zone 05: Assam, Arunachal Pradesh, Sikkim, Meghalaya Zonal Coordinator: Dr. Faruque U. Ahmed

Assam Medical College, Dibrugarh North East Society for Promotion of Youth & Masses, Dr. Alak Barua (NESPYM), Guwahati Dr. Bobyjeet Goswami Dr. Chiranjeeb Kakoty Dr. Swapna Kakoty Dr. Abdul Kalam Ajad Dr. Giriraj Kurse Mrs. Aloka Bhattacharjee Dr. P.K. Dutta Dr. Saumyendra Nath Sarma Dr. S.P. Sinha Dr. Ajmal Hussain Ms. Minakshi Borah Society for Nutrition Environment & Health Action (SNEHA), Dibrugarh NEIGRIHMS, Shillong Dr. Ganesh Ch. Barua Dr. C. Danaila Dr. Saurabh Borkatoki Dr. Bijit Bhattacharya Voluntary Health Association of Sikkim, Dr. Jugadhar Changmai (VHAS), Gangtok Dr. P.K. Bordoloi Dr. B. B. Rai Dr. P.J. Bhuyan

Zone 06: Manipur, Tripura, Mizoram, Nagaland Zonal Coordinator: Dr. E. Yaima Singh

Regional Institute of Medical Sciences, Imphal Aizwal Dr. L. Usharani Devi Dr. K. Zoramthanga Dr. Kh. Robindro Singh Dr. F. Lallianhlira Dr. A.K. Brogen Dr. B. Lalduhawma Dr. Thoiba Henba Dr. Vanlalrengpuia Dr. T. Gambir Singh Agartala Dr. A. Naranbabu Singh Dr. M.S. Chaudhury Dr. Tapan Kr. Das Nagaland State AIDS Control Society, Kohima Dr. Jayanta Kr. Das Dr. Kumini Kathipri Dr. Subasish Deb Barman Dr. Tiasnup Dr. Saroj Kr. Das Dr. L. Yanthan Dr. Pranab Chatterjee Dr. Limatula Dr. Kamal Reang Zone 07: Rajasthan Zonal Coordinator: Dr. Balvir S. Tomar National Institute of Medical Sciences, Jaipur Action Research & Training for Health (ARTH), Dr. Suresh Chand Gaur Udaipur Dr. S.L. Agarwal Dr. Pavitra Mohan Dr. S.C. Gupta Dr. Sanjna Mohan Dr. M.C. Poonia PRAYAS, Chittorgarh Dr. S.N. Medical College, Jodhpur Dr. Narendra Gupta Dr. B.L. Gupta Dr. Kanhaiya Lal Sanwaria Dr. S.L. Solanki Dr. Veena Dwivedi Dr. Suman Bhansali Dr. Tej Ram Jat Dr. S. R. Negi Dr. Rajendra Tater Dhara Sansthan, Barmer Mr. Mahesh Panpalia Jawahar Lal Nehru Medical College, Ajmer Mr. Gaurav Bhargava Dr. Anoop Tankha Dr. R.P. Yadav Dr. J.S. Broca Mr. S.L. Nepalia Zone 08: Gujarat, Diu, Daman Zonal Coordinator: Dr. Bhadresh R. Vyas M.P. Shah Medical College, Jamnagar Medical College, Vadodara Dr. K. N. Pandya Dr. P.V. Kotecha Dr. Deepak Pande Dr. Sangeeta Patel Dr. V.S. Majumdar Government Medical College, Surat Dr. J.R. Damar Dr. Ratan K. Srivastava Dr. Nipin Bagla Civil General Hospital, Bhuj Dr. Naresh Godara Dr. Chetana Shah Dr. Arvind Panwar Mr. Hemant J.S.

Government Medical College, Rajkot B.J. Medical College, Ahmedabad Dr. Yogesh Parikh Dr. B.S. Bhavsar Dr. Umesh Patel Dr. Geeta Kedia

Government Medical College, Bhavnagar C.U. Shah Medical College, Surendranagar Dr. Hiren Deshi Dr. Kamlesh Shah Dr. Sunil Panjwani Dr. Kinjal Baxi Zone 09: Madhya Pradesh, Chattisgarh Zonal Coordinator: Dr. Sheila S. Bhambal Gandhi Medical College, Bhopal G.R. Medical College, Gwalior Dr. A. K. Upadhyay Dr. Ashok Mishra Dr. Pradeep Tiwari Dr. Subodh Mishra Dr. R.K.S. Kushawaha Dr. B. L. Sharma Pt. J.N.M. Medical College, Raipur Dr. U. K. Dube Dr. N. Gandhi Dr. R. Kathal Dr. M. Toppo

Gramin Sewa Sanstha, Bilaspur N.S.C.D. Medical College, Jabalpur Mr. Vijay Tiwari Dr. D. K. Pal Mr. Basant Kumar Kashyap Dr. P.K. Kasar Mr. Raj Kumar Raj Mr. Babu Lal Kashyap S.S. Medical College, Rewa Mr. Prakash Pradhan Dr. S. Nandeshwar Mr. Rajendra Shukla Dr. R. Kakkar Zone 10: Orissa Zonal Coordinator: Dr. Bhagwati C. Das

State Institute of Health & Family Welfare, Bhubaneswar Dr. T. Sahu Mr. G.S. Patnaik Dr. N.C. Sahani Dr. B.K. Behera Dr. M.K. Panigrahi V.S.S. Medical College, Sambhalpur Dr. Nutan Panda Dr. O.P. Panigrahi Ms. G. Banalata Devi Dr. S.K. Misra Dr. T. Karuna Dr. H.P. Acharya Dr. A.K.Misra M.K.C.G. Medical College, Berhampur Dr. D.M. Satapathy S.C.B. Medical College, Cuttack Dr. Archana Patnaik Prof. B. Mahapatra Dr. P. Bharati Dr. K. Misra Dr. J.M. Das

Zone 11: Maharashtra, Goa Zonal Coordinator: Dr. Abhimanyu K. Niswade

Government Medical College, Nagpur Grant Medical College, Mumbai Dr. S. P. Zodpey Dr. Lalit R. Sankhe Dr. S. G. Deshpande Dr. Ranjit Mankeshwar Mr. Suresh N. Ughade Dr. Nishikant Rahate Dr. A. V. Saoji Dr. Sudhir Makrikar Dr. Abhay Gaidhane Dr. Quazi S. Z. Dr. D.Y. Patil Medical College for Women, Pune Dr. D. L. Ingole LTM Medical College, Mumbai Dr. J. S. Bhawalkar Dr. Unmesh Korde Dr. P. A. Bhuyar Dr. Leena Rasal Dr. B. S. Kamlapurkar Dr. Violet M. Desa Goa Medical College, Goa Dr. Trupti Dr. Dilip D. Motghare N. Bodhare Dr. A. M. A. Ferrira

Zone 12: Andhra Pradesh Zonal Coordinator: Dr. S. Narasimha Reddy

Osmania Medical College, Hyderabad Andhra University, Vishakapatnam Dr. M. Ram Prasad Dr. R. Sambasiva Rao Dr. K.V. S. Murthy Dr. V. Subramanyam Dr. C. Bala Krishna Dr. K. Ashok Kumar Reddy Kurnool Medical College, Kurnool Dr. C. Niranjan Paul Gandhi Medical College, Hyderabad Dr. A. Sreedevi Dr. G. Subrahmanyam Dr. N. Ananthaiah Chetty Dr. Venugopal Reddy Dr. G. Ravi Prabhu Dr. B. Prithviraj Dr. G. Kasiram Rangaraya Medical College, Kakinada Andhra Medical College, Vishakapatnam Dr. V. Chandrasekhar Dr. A. Sanjeeva Rao Dr. G.S.S. Ganesh Babu Dr. G. Krishnababu Dr. T.S.R. Sai Dr. R. Nageswara Rao Zone 13: Karnataka Zonal Coordinator: Dr. B. Mallikarjun

M.R. Medical College, Gulbarga Kasturba Medical College, Manipal Dr. Kapate Rajashekar Dr. R.S. Phaneendra Rao Dr. T. Prabhushetty Dr. Vinod Batt Dr. B.N. Patil Dr. Ramachandra Kamath Mr. Shrishail Ghooli Dr. Avinash Shetty B.M. Patil Medical College, Bijapur Dr. A.S. Akki Bangalore Medical College, Bangalore Dr. K.A. Masaki Dr. Shivananda Dr. H.M. Vishwanath Kumar Jawahar Lal Nehru Medical College, Belgaum Dr. Shivaprasad Dr. V.D. Patil Dr. S.C. Mogali Dr. N.S. Mahantshetti Dr. G.B. Belvadi Dr. A.S. Wantamutte Dr. Asha Benakappa Dr. Suresh Sommannavar

Zone 14: Tamil Nadu, Pondicherry Zonal Coordinator: Dr. Manjula Datta

Madras Medical College, Chennai Dr. G. Sugunadevi Dr. R. Sathianathan Dr. M. Seetharaman Mr. R. K. Padmanabhan Dr. S. Shaffi Ahmed Madurai Medical College, Madurai Mr. Edwin Amalraj Dr. P.A. T. Jagadeeswary Dr. V. Dhanalakshmi Christian Medical College, Vellore Dr. K. M. Maithreyi Dr. K.R. John Dr. S. Vijayalakshmi Dr. V.M. Soma Sundaram Dr. N.C. Appavoo Dr. T. Sathyaprakash Thirunelveli Medical College, Thirunelveli Dr. C. Indira Priyadarsini PSG Institute of Medical Sciences, Coimbatore Dr. R. Napoleon Dr. R. Meera Dr. K. Muthulakshmi Dr. K. Bhuvaneswari Dr. P. Gnanaguru

Zone 15: Kerala, Lakshwadeep Zonal Coordinator: Dr. S. Rema Devi

Medical College, Thiruvananthapuram Dr. P. K. Accamma Dr. C. Nirmala Dr. Nileena Koshy Dr. K.Sasikala Dr. V. Suja Medical College, Kottayam Dr. T. Unnikrishnan Dr. G. Syamala Kumari Mrs. C. G. Santha Medical College, Calicut Dr. A. Sobha Dr. M. Ramla Beegum Dr. M. G. Prasanna Dr. T. Jayakrishnan Dr. Thomas Bina Dr. T. Hymavathi Academy of Medical Sciences, Kannur Dr. M. Jayakumari Medical College, Trichur Dr. S. Jayadevan Dr. K.R. Leela Itty Amma Dr. Philomina Cardoz Dr. Lucy Rapheal Dr. S. Prasanth Kumar Report Writing Team

Central Coordinating Team Members

Dr. N.K. Arora Dr. S. Rema Devi Epidemiology & Epidemiology & Program Evaluation Health Social Science

Dr. R.M. Pandey Dr. Vibhor Krishna Biostatistics Intern

Dr. Hemant Kumar Dr. S. Vivek Adhish Health Management Epidemiology

Dr. Sanjay Chaturvedi Ms. Moumita Biswas Epidemiology Anthropology

Dr. (Brig) S. L. Chadha Dr. Shitanshu Uppal Epidemiology Intern

Research Associates Computer Staff

Ms. Vaishali Deshmukh (ARO) Ms. Sonia Kapoor Ms. Leena Sinha (ARO) Ms. Seema Mahla Ms. Priyanka Thakur Mr. Jitender Purohit Ms. Richa Shankar Mr. Sunil Kumar Mr. Mathew George Mr. Sachin Ailawadi Ms. Shweta Agarwal Mr. Gaurav Banyal Dr. Khollung Longmei Ms. Rukshana Zaman Administrative Support Ms. Srabasti Basu Mr. Shauket Ahmed Kouchey Mr. Rakesh Singh Mr. Wasim Raja Ms. Meenu Maheshwari Mr. Anil Kumar Singh Jha Ms. Himani Singh Ms. Rekha MBBS Students Mr. Anil Kumar Mr. Shailender Kumar Mr. Tarun Goyal Mr. Zia-ul Hoda Mr. Ashwani Gupta Mr. Mohd. Esam Mr. Amish Vora Contents

Acknowledgments Abbreviations List of Study Zones List of Tables List of Figures List of Annexures Definitions

Executive Summary i

1. Introduction 1

2. Objectives 3

3. Methodology 4 3.1 Study Design 3.2 Sample Size Calculations and Design Effects 3.3 Methods of Drawing Clusters 3.4 Data Collection 3.5 Ethical Issues and Consent 3.6 Network Structure and Dynamics 3.7 Network Monitoring 3.8 Quality Assurance Mechanism 3.9 Development of Interview Schedules and Observation Checklists 3.10 Data Management 3.11 Data Analysis 3.12 Potential Limitations and Biases

4. Results 4.1 Background Information 13

4.2 Burden of Injections 15 4.2.1 Proportion of Population Receiving Injections 4.2.2 Injections Administered Per Person Per Year 4.2.3 Type of Injections 4.2.4 Site of Injection Prescription 4.2.5 Prescriptions for Injections

4.3 Injection Equipment 18 4.3.1 Type of Injection Equipment Used at Health Facilities – Direct Observation 4.3.2 Categorization of Health Facilities According to Pattern of Syringe Use 4.3.3 Type of Syringe Used for Last Injection as Recalled (Community Survey) 4.3.4 Type of Needles Used for Injection 4.3.5 Availability of Injection Equipment at Health Facilities: Difficulties and Their Management 4.3.6 Purchase of Injection Equipment by Clients 4.4 Safety of Injections 21 4.4.1 Definition of an Unsafe Injection 4.4.2 Unsafe Injections 4.4.3 Injections Associated with Potential to Transmit Blood Borne Viruses (BBV) 4.4.4 Reuse of Syringe/Needle 4.4.5 Injection Safety and the Technique of Administering Injections 4.4.6 Determinants of Safety of Injections 4.4.7 Safety for Injection Administrators 4.4.8 Stakeholder Perceptions About Injection Safety

4.5 Process of Injection 29 4.5.1 Personnel Involved 4.5.2 Sterilization of Injection Equipment 4.5.3 Injection Environment

4.6 Waste Disposal 35 4.6.1 Guidelines for Waste Disposal 4.6.2 Waste Disposal at Health Facilities 4.6.3 Terminal Waste Disposal 4.6.4 Stakeholders’ Perspectives on Injection Waste

4.7 Determinants of Injection Prescription 39 4.7.1 Profile of Complaints Presented at Outpatient Clinics 4.7.2 Reasons for Receiving Last Injection 4.7.3 Decision about Injection Prescription 4.7.4 Determinants of Injection – Stakeholders’ Perception

5. Discussion 44 5.1 Burden of Injections 5.2 Safety of Injections 5.3 Waste Disposal 5.4 Rural Urban Differences 5.5 Zonal Variations 5.6 Quality Assurance and Hawthorne Effect 5.7 Summary

6. Recommendations 53

Annexures

Tables

References Acknowledgement

We are greatly indebted to the support and encouragement extended by the following for successful completion of the study.

J Ministry of Health & Family Welfare, Govt. of India

J World Bank, New Delhi

J State Governments and District Administration of study sites

J Principals and Directors of all the participating institutions

J International Clinical Epidemiology Network (INCLEN)

J United States Agency for International Development (USAID)

J Indian Clinical Epidemiology Network (IndiaCLEN)

J All India Institute of Medical Sciences (AIIMS), New Delhi

J All stakeholders who agreed to share their perceptions and views Abbreviations

AIIMS All India Institute of Medical Sciences ANM Auxiliary Nurse Midwife AWC Anganwadi Center AWW Anganwadi Worker CBO Community Based Organization CCO Central Coordinating Office CCT Central Coordinating Team CDPO Child Development Program Officer CEU Clinical Epidemiology Unit CHC Community Health Center FGD Focus Group Discussion FHAC Family Health Awareness Campaign FHAW Family Health Awareness Week GHW Government Health Worker ICDS Integrated Child Development Scheme IDII Infectious Diseases Initiative of IndiaCLEN IDSP Integrated Disease Surveillance Program IEC Information, Education and Communication INCLEN International Clinical Epidemiology Network IndiaCLEN Indian Clinical Epidemiology Network IPEN IndiaCLEN Program Evaluation Network JPHN Junior Public Health Nurse LMP Licentiate Medical Practitioner MO Medical Officer MOH & FW Ministry of Health and Family Welfare MPHW Multipurpose Health Worker NGO Non Governmental Organization NSI Needle Stick Injuries OPD Out Patient Department PHC Primary Health Center PMC Partner Medical College POL Petrol, Oil & Lubricants RA Research Associate RAP Rapid Appraisal Procedure RMP Registered Medical Practitioner SI Senior Investigator UNICEF United Nations International Children’s Funds VHN Village Health Nurse WHO World Health Organization List of Study Zones

Zone States in the Zone

01 Punjab, Candigarh, Delhi, Haryana, Himachal Pradesh, Jammu & Kashmir

02 Uttar Pradesh, Uttaranchal

03 Bihar, Jharkhand

04 West Bengal, Andaman & Nicobar Islands

05 Assam, Arunachal Pradesh, Meghalaya, Sikkim

06 Manipur, Mizoram, Nagaland, Tripura

07 Rajasthan

08 Gujarat, Diu, Daman

09 Madhya Pradesh, Chattisgarh

10 Orissa

11 Maharashtra, Goa

12 Andhra Pradesh

13 Karnataka

14 Tamil Nadu, Pondicherry

15 Kerala, Lakshadweep List of Tables

Table No. Description

3.1.1 Study Zones for the "Assessment of Injection Practices in India"

3.2.1 Sample Size Calculations for Population Survey

3.2.2 Age Distribution of Respondents

3.2.3 Total Sample Size for Population Cluster Survey

3.2.4 Sample Size Calculations for Health Facility Observation & Exit Interviews

3.2.5 Sample Size Calculations to Determine Proportion of Patients Prescribed Injections for Common Indicator Conditions

3.2.6 Total Sample Size for Health Facility Observation in Each Zone

3.2.7 Total Sample Size for Health Facility Observation at National Level

4.1.1 Profile of Observations and Interviews

4.1.2 Characteristics of Interviews (Community & Exit Surveys at Health Facilities)

4.1.3 Characteristics of Interviews (Health Facility Survey)

4.2.1 Burden of Injections in Community: Proportion of Population Receiving Injections in last 2 Weeks and 3 Months

4.2.2 Burden of Injections in Community: Estimated Number of Injections Received Per Person Per Year on 2 weeks' Recall

4.2.3 Burden of Injections in Community: Estimated Number of Injections Received Per Person Per Year on 3 Months' Recall

4.2.4 Burden of Injections in Community: Vaccination Injections as a Proportion of Total Injections Received (Based on 3 Months Recall)

4.2.5 Site of Preventive & Curative Injections in India

4.2.6 Prescription Containing Injections: Proportion of Clients Prescribed Injection [Direct observation of Prescriber Client Interactions]

4.2.7 Prescriptions Containing Injections: Proportion of Clients Prescribed Injections [Exit Interviews] Table No. Description

4.2.8 Prescriptions Containing Injection(s) (According to Type of Prescriber): Proportion of Clients Prescribed Injection

4.3.1 Plastic Syringe Use - As a Proportion of Total Injections Observed [Direct Observation]

4.3.2 Proportion of Health Facilities Using Only Plastic Syringes [Direct Observation]

4.3.3 Pattern of Syringes Used for Injections [Direct Observation]

4.3.4 Proportion of Health Facilities Using both Plastic & Glass Syringes [Direct Observation]

4.3.5 Pattern of Syringe Use for Injections [Direct Observation]

4.3.6 Proportion of Health Facilities Using Only Plastic Syringes - Prescriber Perspective

4.3.7 Proportion of Health Facilities Using both Plastic & Glass Syringes - Prescriber Perspective

4.3.8 Categorization of Health Facilities According to Patterns of Syringe Use - Prescriber Perspective

4.3.9 Plastic Syringe Use for Last Injection: Respondents' Recall [Community Survey]

4.3.10 Use Of Disposable Syringe For Injection- Direct Observation

4.3.11 Proportion of Health Facilities Using Only Disposable Needles - Prescriber Perspective

4.3.12 Proportion of Health Facilities Using both Disposable and Steel Needles - Prescriber Perspective

4.3.13 Categorization of Health Facilities According to Patterns of Needle Use - Prescriber Perspective

4.3.14 Problems Faced in Procurement of Plastic Syringes at Health Facilities - Prescriber Perspective

4.3.15 Measures to Overcome Shortage of Syringes at Health Facilities - Prescriber Perspective

4.3.16 Purchase of Syringe for Injection by Clients Exiting Health Facilities

4.4.1 Unsafe Injections (as % of Injections Observed)

4.4.2 Unsafe Injections (as % of All Injections) Given with Glass Syringes - Direct Observation Table No. Description

4.4.3 Unsafe Injections (as % of All Injections) Given with Plastic Syringes - Direct Observation

4.4.4 Unsafe Injections (as % of Injections Observed) According to Type of Health Provider

4.4.5 Unsafe Injections (as % of Injections Observed) Carrying a Potential Risk of Transmission of BBV

4.4.6 Unsafe Injections (as % of Injections Given with Glass Syringe) Carrying a Potential Risk of Transmission of BBV

4.4.7 Unsafe Injections (as % of Injections Given with Plastic Syringe) Carrying a Potential Risk of Transmission of BBV

4.4.8 Unsafe Injections (as % of Injections Observed) Carrying a Potential Risk of Transmission of BBV - According to Type of Health Provider

4.4.9 Reuse of Syringes/Needles (as % of Injections Observed)

4.4.10 Reuse of Syringes/Needles (as % of Injections Given with Glass Syringes) - Direct Observation

4.4.11 Reuse of Syringes/Needles (as % of Injections Given with Plastic Syringes) - Direct Observation

4.4.12 Reuse of Syringes/Needles (as % of Injections Observed) - According to Type of Health Provider

4.4.13 Presence of Syringes/Needles in Sterilization Equipment at Health Facilities: Direct Observation

4.4.14 Prescribers (%) Who Thought that Plastic Syringes could be Reused

4.4.15 Unsafe Injections (as % of Injections Observed) due to Faulty Technique

4.4.16 Unsafe Injections (as % of Injections Given with Glass Syringes) due to Faulty Technique - Direct Observation

4.4.17 Unsafe Injections (as % of Injections Given With Plastic Syringes) due to Faulty Technique - Direct Observation

4.4.18 Injection Practices in India: Health facilities with "All safe injections during Observation"

4.4.19 Injections where Needle was Recapped after Injection (as % of Injections Observed) Table No. Description

4.4.20 Recapping (%) after Injections Given with Plastic Syringe - Direct Observation

4.4.21 Recapping (%) after Injections Given with Glass Syringe - Direct Observation

4.4.22 Needle Stick Injury after Injection (as % of Injections Observed)

4.4.23 Stakeholders' Perception of 'A Safe Injection'

4.4.24 Stakeholders' Perception of Complications of Unsafe Injection

4.4.25 Potential Risks to Injection Giver with Faulty Injection Techniques: According to Type of Prescriber

4.5.1 Injections Prescribed by Allopathic Practitioners (as % of all Injections) - Community Survey

4.5.2 Injections Prescribed by Informally Qualified Practitioners (as % of All Injection) - Community Survey

4.5.3 Injections Prescribed by Practitioners of Indian Systems of Medicine (ISM) (as % of All Injections) - Community Survey

4.5.4 Injections Prescribed by Paramedics (as % of All Injections) - Community Survey

4.5.5 Profile of Injection Prescribers for <1 And ≥ 1 Year Age Group (Proportion of All Injections) - Community Survey

4.5.6 Injections Given by Paramedics (as % of All Injections) - Community Survey

4.5.7 Proportion of Injections Given by Allopathic Practitioners - Community Survey

4.5.8 Proportion of Injections Given by Informally Qualified Practitioners - Community Survey

4.5.9 Proportion of Injections given by Practitioners of ISM - Community Survey

4.5.10 Proportion of Injections Given by Others (Self / Friends) - Community Survey

4.5.11 Profile of Injection Givers (Proportion of all Health Facilities) - Prescriber Interview

4.5.12 Profile Of Injection Givers (Proportion of Health Facilities) - Direct Observation

4.5.13 Profile of Injection Givers for <1 And ≥ 1 Year Age Group (Proportion of all Injections given) - Community Survey Table No. Description

4.5.14 Formal Training Received by Injection Givers (Proportion of Health Facilities) - Prescriber Interview

4.5.15 On-The-Job Training Received by Injection Givers (Proportion of Health Facilities) - Prescriber Interview

4.5.16 Informally Trained Injection Givers (Proportion of Health Facilities) - Prescriber Interview

4.5.17 Sterilization of Injection Equipment done by Paramedics (Proportion of Health Facilities) - Direct Observation

4.5.18 Sterilization of Injection Equipment done by Paramedics (Proportion of Health Facilities) - Prescriber Interview

4.5.19 Sterilization of Injection Equipment done by Helper/ Attendants (Proportion of Health Facilities - Direct Observation

4.5.20 Sterilization of Injection Equipment done by Helper/ Paramedics (Proportion of Health Facilities) - Prescriber Interview

4.5.21 Availability of Written Guidelines for Sterilization of Injection Equipment (Proportion of Health Facility) -- Prescriber Interview

4.5.22 Proportion of Health Facilities where Sterilization Equipment was Available - Direct Observation

4.5.23 Proportion of Health Facilities where Available Sterilization Equipment was Found Functional- Direct Observation

4.5.24 Proportion of Health Facilities where Fuel for Sterilization was Available - Direct Observation

4.5.25 Proportion of Prescribers who had Incorrect Knowledge of Sterilization Process - Prescriber Interview

4.5.26 Unhygienic " Injection Environment" (Proportion of Health Facilities) - Direct Observation

4.5.27 Contents of Injection Tray: Number of Syringes Vs. Number of Needles - Direct Observation

4.6.1 Availability of Written Guidelines for Waste Disposal (Proportion of Health Facilities) - Prescriber Interview

4.6.2 'Satisfactory' Disposal of Used Plastic Syringes at Health Facility Level (Proportion of Health Facilities) -Direct Observation Table No. Description

4.6.3 Proportion of Health Facilities where Waste was Segregated by Using Colour-Coded Bags - Prescriber Interview

4.6.4 'Satisfactory'** Terminal Level Disposal of Used Plastic Syringes/Needles (Proportion of Health Facilities) - Direct Observation

4.6.5 Prescribers' Knowledge of 'Satisfactory' Waste Disposal Methods at Health Facility Level (Proportion of Prescribers) - Prescriber Interview

4.6.6 Prescribers' Knowledge of 'Satisfactory' Terminal Disposal Methods (Proportion of Prescribers) - Prescriber Interview

4.6.7 Stakeholders' Perception of Dangers of Improper Disposal of Used Plastic Syringes/ Needles: Community Perception vs. Prescribers' Perception (Community Survey and Prescriber Interview)

4.6.8 Selling of Injection Waste to Waste Pickers - According to Type of Health Facility

4.7.1 Profile of Presenting Complaints at Outpatient Clinics [Exit Interview]

4.7.2 Reasons For Receiving Last Injection - Community Survey

4.7.3 Reasons for Receiving Last Injection [Exit Interview]

4.7.4 Reasons for Receiving Last Injection: Community Recall vs. Exit Interview

4.7.5 Injection Prescription Rate for Indicator Conditions [Community Survey]

4.7.6 Injection Prescription Rate for Indicator Conditions [Exit Interview]

4.7.7 Reasons for Receiving Last Injection: Age Related Differences- [Community Survey]

4.7.8 Decision about Injection: Dynamics of Prescriber-Client Interaction [Direct Observation]

4.7.9 Determinants of Injection: Stakeholders Perspective

5.1.1 Burden of Injections in India

5.1.2 Annual Burden of Injections in India (Modeling Estimates Based on 3-months' Recall)

5.2.1 Characteristics of Unsafe Injections (% of all Injections)-All India

5.2.2 Profile of Unsafe Injections in Relation to Type of Health Facility and Type of Syringe Use List of Figures

Figure No. Description

4.2.1 Proportion of Population Receiving Injection- 2 weeks' vs. 3-Months Recall (in ascending order of proportion of injections per 3-months' recall)

4.2.2 Burden of Injections: Number of Injections Received Per Person Per Year 2 - Weeks' vs. 3- Months' Recall

4.2.3 Magnitude of Injections in India (3 month recall)

4.2.4 Immunization Injections Received by Community

4.2.5 Site of Preventive and Curative Injections In India

4.2.6 Observation of Client-Prescriber Interaction: Proportion of Clients Prescribed Injection

4.2.7 Training of Prescribers and Injection Prescription Habits

4.3.1 Plastic Syringe Use at Health Facilities-Direct Observation

4.3.2 Pattern of Syringe Use at Health Facilities-Direct Observation

4.3.3 Pattern of Use of Injection Equipment at Health Facilities-Prescriber Perspective

4.3.4 Plastic Syringe Used as a Proportion of Last Injection Given

4.3.5 Nature of Problems Related to Procurement of Syringes-Prescriber Perspective

4.4.1 Unsafe Injections: Profile According to Health Facilities

4.4.2 Unsafe Injection Use at Health Facilities

4.4.3 Unsafe Injections- According to Type of Health Facility and Syringe

4.4.4 Unsafe Injections- According to Type of Health Provider

4.4.5 Zone Wise Estimates of Unsafe Injections - [in ascending order]

4.4.6 Unsafe Injections with Potential to Transmit BBV: According to Type of Health Facility

4.4.7 Unsafe Injections with Potential Risk of BBV Transmission : According to Type of Health Facility and Syringe Figure No. Description

4.4.8 Zone Wise Estimates of Unsafe Injections Associated with Potential of BBV Transmission [in ascending order]

4.4.9 Unsafe Injections Due to Faulty Injection Technique and Type of Syringes

4.4.10 Stakeholders' Perception of Safe Injection

4.4.11 Stakeholders' Perception of Complication of Unsafe Injection

4.5.1 Profile of Injection Prescribers - Community Recall

4.5.2 Profile of Injection Prescribers - Community Recall

4.5.3 Profile of Injection Prescribers for Infants (<1 yr old) and Older Clients (≥ 1 yr old) - Community Recall

4.5.4 Profile of Injection Givers- Community Recall

4.5.5 Profile of Injection Givers: Government vs. Private Sector

4.5.6 Training of Injection Givers

4.5.7 Personnel Involved in Sterilization Process - Direct Observation

4.6.1 Satisfactory Disposal of Used Plastic Syringes at Health Facility Level - Direct Observation

4.6.2 Satisfactory Health Facility Level Waste Disposal - Zonal Variations (Direct Observation )

4.6.3 Satisfactory Health Facility Level and Terminal Level Injection Waste Disposal (Direct Observation)

4.6.4 Satisfactory Injection Related Waste Disposal - Direct Observation vs. Prescriber Perspective

4.6.5 Dangers of Improper Disposal of Used Syringes / Needles - Prescriber and Community Perceptions

4.7.1 Injection Prescription as a Function of Presenting Symptoms: Exit Interview of Clients at Health Facilities

4.7.2 Reasons for Last Injection: Prescription Rate for Fever/Cough/Diarrhoea- Zonal Variations

4.7.3 Age Related Differences in Reasons for Injection Figure No. Description

4.7.4 Client Prescriber Interaction: Dynamics of Decision About Injection (Direct Observation)

5.1.1 Injection Preference and Prescription : A Hypothetical Model for Client and Prescriber Behaviour

5.2.1 Immunization Clinics : Relationship of Unsafe Injections and Potential Risk of BBV Transmission with Use of Plastic Syringes

5.2.2 Government Health Facilities : Relationship of Unsafe Injections and Potential Risk of BBV Transmission with Use of Plastic Syringes

5.2.3 Private Health Facilities : Relationship of Unsafe Injections and Potential Risk of BBV Transmission with Use of Plastic Syringes

5.2.4 Unsafety of Injections - Glass vs Plastic Syringes

5.3.1 Satisfactory Injection Related Waste Disposal - Direct Observation vs. Prescriber Perspective List of Annexures

Annexure No. Description

Annexure 1 Map Showing Study Sites

Annexure 2 State Wise List of Clusters

Annexure 3 Interview Schedule Log Sheet for Team Leaders

Annexure 4 Log Sheet for Households

Annexure 5 List of Team Members

Annexure 6 CCO Activities at a Glance

Annexure 7 Summary of Daily Activities

Annexure 8 Zonal Telephone Monitoring Sheet

Annexure 9 Zonal Monitoring Sheet of Cluster Interview Schedules Received

Annexure 10 Zonal - Network Progress at a Glance

Annexure 11 Plan for Interviews

Annexure 12 Quality Assurance Visit by CCT Member

Annexure 13 Schedules in Each Cluster Definitions

Government Health Facility: PHC/CHC/Dispensary/Hospital located in or nearest to the selected cluster.

Private Health Facility: Clinic/Nursing home/Hospital located in or nearest to the selected cluster and where injections are given. [If more than one private health facility, one which was reported to give more injections was selected]

Immunization Clinic: Outreach/sub-center/PHC/CHC/Dispensary/Hospital located in or nearest to the selected cluster and where routine immunization was done. [In case it was not possible, then immunization session was observed at the PHC/CHC or the block/tehsil/district hospital]

Household: All individuals sharing food from a common kitchen.

Two weeks / three months recall: Recall period with reference to the date of interview with community members.

Unsafe Injection: An injection was considered/ defined as unsafe if: • It had the potential to transmit Blood Borne Viruses (BBV) and/or; • It was administered using faulty techniques (and could cause local infection and/or reaction).

Satisfactory Disposal of Injection Waste: If disposed in any of the following methods: a. put in a jar containing hypochlorite solution, b. collected in a dustbin, c. broke the syringe and threw

Unsatisfactory Disposal of Injection Waste: If disposed in any of the following methods: a. thrown on the floor/littered, b. put in a tray/placed on a table, c. put in a boiler, sterilizer or a pan of water

Satisfactory Terminal Disposal of Injection Waste: If disposed in any of the following methods: a. buried in a pit, b. carried away by Municipality/ Panchayat workers, c. sent to incinerator

Unsatisfactory Terminal Disposal of Injection Waste: If disposed in any of the following methods: a. thrown out of the health facility, on road, lane or into a drain, b. dumped in a dustbin along road, lane, c. sold/ given away to waste pickers/ kabadiwallas. Assessment of Injection Practices in India

Executive Summary

1. Background 4. Proportion of health care facilities (public/private/ immunisation clinics) where the injections processes The World Health Organisation (WHO) estimated that are unsafe at least 50 percent of the world’s 12 to 16 billion injections administered each year are unsafe, 5. Magnitude of unsafe injections (both curative and particularly in developing countries, posing serious preventive) health risks to the recipients, health workers and the 6. Proportion of health care facilities where sharps public. waste management is inadequate

In India, the popularity of curative injections remains 7. Proportion of patients with common indicator high due to various factors influencing the behaviour conditions (fever, diarrhoea and ARI) attending of the prescribers/injection givers as well as the clients. outpatient clinics and prescribed injections. A large proportion of these injections may be unnecessary and unsafe due to lack of safe injection 2.2 Secondary Objectives practices. The available reports also highlight the To determine problem of inappropriate sharps waste management. 1. The characteristics of providers/prescribers of The present study of the assessment of prevalent injections (public/private) through community injection practices provided baseline information on the survey magnitude of the problem (e.g. injection frequency, proportion of unsafe injections, unnecessary injections, 2. The settings of injections (home/health facility) status of disposal of injection related waste) and through community survey identified the locally relevant determinants of 3. The awareness and perceptions of providers/ prevailing injection practices. The study covered rural prescribers and clients about injection procedures and urban communities across the country along with and sharps waste disposal health facilities in the government and private sectors. 4. The process of injection at health facilities (public/ We expected that the study results would initiate an private/immunization clinics) by direct observation informed debate among various stakeholders. The aim 5. The process of waste management at health was to facilitate the formulation of a National Safe facilities by direct observation. Injection policy encompassing a multi-dimensional approach involving behaviour change of prescribers/ 3. Methodology injection givers and clients to reduce the frequency and increase the safety of injections, increase availability/ 3.1 Study Design accessibility of safe injection equipment and appropriate sharps waste management. A rapid population based cluster survey at the household level and observation at health facility in 2. Objectives these clusters was carried out. The sample communities were selected using the ‘probability proportionate to 2.1 Primary Objectives size’ (PPS) technique. The whole country was divided To estimate into 15 zones on the basis of socio-cultural and geographic factors (Figure 1). The sampling universe 1. Frequency of injections in the community was therefore a zone and each zone comprised of either (injections/person/unit time) single states or a group of two to five small states of 2. Indications of injections (curative/preventive) India. The clusters were drawn separately for urban and rural areas, as there are inherent differences in the 3. Proportion of prescriptions given at health facilities availability of health facilities and infrastructure in (public/private) that include injection(s) these two areas.

i Executive Summary Assessment of Injection Practices in India

3.2 Development of Interview Schedules and Excel spreadsheets for data cleaning and analysis. The Observation Checklists survey feature of STATA release 7.0 was used for analysis of the whole data set. The draft instruments were developed by the Central Coordinating Team (CCT), in close partnership with Magnitude of injections, proportion of unsafe the programme managers in the Ministry of Health injections, awareness and perceptions regarding and Family Welfare, Government of India and all zonal injection practices and inappropriate sharps waste investigators. Draft instruments were piloted at eight disposal have been calculated for the individual zones sites across the country. These were finalised during and thereafter for the whole country by imputing the national orientation workshop at New Delhi. weights for the population. The zone wise estimate of

Figure 1: Assessment of Injection Practices in India (2002-2003): An IndiaCLEN Program Evaluation Network Study Study Centers (Quantitative Component)
Central Coordinating •Srinagar Office ♦ Zonal Center Amritsar Kangra Chandigarh• ♦• Partner Institution
Dehradun • Rohtak• •Ghaziabad Jodhpur♦ • Aligarh Gangtok Jaipur • Agra Muzaffarpur• Barmer • • Lucknow Guwahati ♦Dibrugarh(2) Ajmer • Kohima Udaipur• • Chittorgarh ♦ • Darbhanga Shillong• • Gwalior• Gaya♦Patna• • • • • ♦ Varanasi• ♦Imphal Zone 1 Bhuj Rajkot Ranchi• Agartala Aizwal •♦ Bhopal Jabalpur •Burdwan • • Zone 2 Jamnagar• Baroda • Raipur• ♦Kolkata(4) • ♦ • Cuttack Zone 3 • Nagpur • Bilaspur• Bhavanagar • Sambhalpur♦Bhubaneshwar Zone 4 Surat • Berhampur • Zone 5 Mumbai Pune Hyderabad(2) • Visakhapatnam Zone 6 • • •Kakinada ♦GulbargaVijayawada• • Zone 7 Panaji • •Bijapur •Belgaum •Kurnool Zone 8 Manipal Zone 9 Bangalore♦Chennai • Vellore Zone 10 Calicut • • Kannur• Coimbatore Zone 11 Thrissur• • Madurai • •Thirunelveli Kottayam♦• • Zone 12 Thiruvananthapuram Zone 13 Zone 14 Zone 15

The interview schedules and observation checklists urban and rural population were used according to were developed keeping in mind the objectives of the the 2001 census. These observations are presented study. The domains emerging from the qualitative separately for urban and rural areas and also for study were used as responses for close-ended immunisation and therapeutic injections. All point questions. Instruments included a mixture of estimates have 95 percent confidence intervals (CI) and structured close-ended and semi-structured open- design effect (Deff). Suitable tests were applied to ended questions. assess the statistical significance.

3.3 Data Analysis For health facility based data, all India estimates were derived by applying weightage for proportion of Data was scanned using the Abbyy Form Reader 4.0 injection given at different health facilities (as software. This scanned data could be transferred into determined during community survey).

Executive Summary - iiii - Assessment of Injection Practices in India

3.4 Potential Limitations and Biases organisations) necessitated the need to strictly adhere to quality assurance measures from the start of the The main problem areas were considered to be the evaluation programme. observation of health facilities and the process of injection. The Hawthorn Effect was likely to change Members of the Central Coordinating Team made the injection prescribing and injection administering surprise quality assurance visits to 150 clusters (out of practices during observation. Hence, we were likely to a total of 1201 clusters; 12.5%) spread over 15 zones. underestimate the unsafe and irrational injections. The At the Central Coordinating Office (New Delhi), the quantum of this error could not be estimated, although entire data along with the Intelligent Character Reading direction was possible to assess from other questions (ICR) sheets were screened for completeness and in the instruments. Care was taken to get the appropriate coding of responses. Range checks and professional activities observed by another doctor. logical runs were incorporated in the data management software to minimise errors. While analysing the results of observation of health facilities, the data did not have sufficient power to interpret findings according to rural and urban strata 4.2 Characteristics of Interviews at the zonal level. However, for all India estimates, urban-rural stratification was possible. Finally, The participation rate during the community survey economic implication of the prevailing injection was 93.9 percent. Participation rate among the exit practices in India and for the recommendation patients was 86.5 percent at the government health emerging from the study were not assessed. facilities and 87.9 percent at private health facilities.

4. Results Of the total 4,332 health facilities that were approached by the research teams, 3,842 of the prescribers/ 4.1 Quality Assurance Measures providers agreed to participate in the study (Table 1). At the health facilities, the participation rate was 93.7 The magnitude and span of field operations and percent. The participation rate was 99.5 percent in involvement of 918 researchers from 84 partner government, 87.1 percent in private and 99.2 percent institutions (medical colleges / non-governmental in immunisation clinics.

Table 1: Sample Size for the Study "Assessment of Injection Practices in India"

Zonal Sample Zones Deff Sample Size

Respondents Strata Clusters Observations / Total sample Proposed Done Cluster per zone

I. Community 2 40 20 clients 2x40x20=1600 15 2 24,000 24,021 Survey (Rural/ Urban) II. Health Facility (HF): Government (1), Private (1), Immunization Clinic (1) a) Observation 1 80 3 1x80x3=240 15 1 3,600 3,592 (Generic) (GHF+PHF+IC) b) Observation of 1 80 5 per HF 1x80x5x3=1200 15 5 18,000 17,844 Injection Process (specific) c) Observation of 1 80 10 per HF 1x80x10x2=1600 15 5 24,000 24,030 Client Prescribers Interactions d) Exit Interview of 1 80 5 per HF 1x80x5x2=800 15 5 12,000 12,012 Patients at Health Facility e) Prescriber 1 80 1 per HF 1x80x1x2=160 15 1 2,400 2,402 Interview

iii Executive Summary Assessment of Injection Practices in India

4.3 Burden of Injections The burden of injections was estimated by calculating the total number of injections received per person per At any given time, a large proportion of the population year. Overall, 5.8 injections (95% CI 5.3-6.3) were was receiving injections. Two recall periods were used received per person per year in the country (two-week for estimating the burden of injections in the country: recall) (Fig II). The corresponding figure based on Two-week and three-month recall prior to the date of three-month recall was 2.9 injections per person per interview with community members. In the two weeks year (95% CI 2.8-3.2) (Fig II). The large variation in prior to the survey, 10.8 percent of the population in the figure for the two recall periods was probably due India had received injection(s). This proportion to the respondents’ recall bias. Another reason could increased to 27.1 percent for the three-month recall be the cohort effect, a proportion of population was period. more likely to get injections repeatedly.

Figure II

Table 2: Burden of Injections in India

Age Category

< 1 year ≥ 1 year Total

No. of injections / person / year Rural 5.3 2.9 3.0 (based on three month recall) Urban 6.3 2.7 2.9 Total 5.6 2.8 2.9 No. of injections / person / year Rural 8.4 6.0 6.1 (based on 2 week recall) Urban 9.3 4.6 4.9 Total 8.7 5.6 5.8 Proportion of injections as Rural 60.9 11.1 15.9 vaccines in past three months Urban 68.0 15.1 21.6 Total 63.2 12.2 17.5

Executive Summary - iviv - Assessment of Injection Practices in India

The burden of injections among infants (<1 year old) preventive injections with two third (66%) was almost twice as compared to that among the older immunisation related injections being given in the population for both recall periods. This excess injection government sector. Due to the national immunisation rate among infants was due to immunisation. Overall, programme, over three fourths (78.3%) of vaccine 63.2 percent (95% CI 56.8-69.6) of injections received injections to infants (<1 year old) were administered by infants were vaccines compared to 12.2 percent (95% in the public sector (Fig III). CI 10.9-13.4) among older individuals (Table 2). Of all the injections received by the community, 17.5 Figure III percent (95% CI 16.0-18.9) were administered for preventive purposes (immunisation injections). The remaining 82.7 percent of injections were given for curative reasons.

Prescriptions for Injection(s) One of the determinants of burden of injections is the proportion of prescriptions for injection(s). Senior investigators directly observed prescriber-client interactions. Irrespective of the presenting complaints, overall 44.1 percent of all clients received prescriptions for injections. A larger proportion of clients in the private health facilities received injections (45.9 %) as compared to those attending outpatient clinics in government health facilities (38.5 %) (P=0.000). Profile of Injection Prescribers Informally trained prescribers were prescribing 12-15 Practitioners of the allopathic system of medicine percent more injections as compared to allopathic prescribed the largest proportion of injections (50.9 %). doctors. Informally trained practitioners had prescribed 14.1 percent and practitioners of ISM had prescribed 8.5 In order to capture the Hawthorne Effect on the percent of injections (Fig IV). injection prescription habit of prescribers, exit interviews of a separate group of clients coming out of the same health facilities were conducted. At the Figure IV country level, almost half (48.1 %) of all clients coming out of health facilities had received injections during their visit. A significantly higher proportion of clients (50.6 %) coming out of private health facilities had received injections as compared to 40.7 percent clients exiting government health facilities.

Zonal Variations Burden of injections was higher in Zone 12 (Andhra Pradesh), Zone 13 (Karnataka) and Zone 14 (Tamil Nadu) as compared to the national average for both periods of recall (two week and three month recall) (Fig II). The data from several sources e.g. observation of client-prescriber interaction and exit interviews of patients also indicated higher injection rates in these Reasons for Injection Prescription zones. An important study question was to assess the rationale of prescription of these injections, particularly for Site of Injection Prescription indicator conditions viz. fever, cough and diarrhoea. More than three fourths (77%) of curative injections in Patients with these conditions constituted over half the country were prescribed in the private health (53.3 %) of all patients attending the out patient facilities and the proportion was almost reverse for departments of public and private health facilities.

v Executive Summary Assessment of Injection Practices in India

Community survey as well as data from exit interviews Figure V indicated that half (51.7 %) - Community Survey; 51.1 % - Exit Interview of the curative injections at the All India level were prescribed for symptoms of fever/ cough/diarrhoea. Patients with other symptoms like swelling, injuries and symptoms of other infections received the remaining half [44.4 % - Community Surveys; 47.7 % - Exit Interviews] of all injections. Almost half of the patients received an injection (48.1 %) irrespective of the nature of symptoms (fever/ cough/ diarrhoea - 46.1 %; weakness - 50.6 %; other symptoms - 50.4 %) (Fig V).

Determinants of Injection Prescription When prescribers and community were questioned about why people prefer to give/receive injections injections. These probably reflected client expectations they revealed that almost three fourths of the clients from injections. A vast majority of clinicians (88.6 %) (73.8 %) perceived several benefits (e.g. quick relief, across the country understood their patients' more effective way of treatment of illness) of the expectations and perceived that injections gave

Figure VI: Injection Preference & Prescription: A Hypothetical Model for Client and Prescriber Behaviour

Executive Summary - vi - Assessment of Injection Practices in India psychological relief to the patients (53.8 %). Overall, 63.5 percent of all health facilities in India were Notwithstanding these observations, most of the times exclusively using plastic syringes for administering (70.6 -92.2 %) doctors took a decision about the injections. The exclusive use of plastic syringes was prescription and the clients accepted it. Enquiries with highest in the private sector (70.2 %) followed by clients also revealed that a significant proportion of government health facilities (50.0 %) and immunisation clients (44.1 %) accept the doctor's decision to clinics (40.9 %). administer injections even when these were perceived to be for unnecessary reasons occasionally. During direct observations, disposable needles were used for 89.9 percent injections. It was interesting to Overall it appeared that though medical reasons might observe that disposable needles were being used for be important consideration for prescribers to write for 65.0 percent of injections administered with glass injections, these practices were also influenced by syringes. Private health facilities were almost attempts to fulfil client expectations. To certain extent exclusively (96.3 %) using disposable needles for giving clients accept the prescription laid out by their 'doctor' injections irrespective of the type of syringe used. and might not be able to adequately differentiate between 'necessary' and 'unnecessary' injections. Thus 4.5 Safety of Injections in the current context of a high volume of prescriptions for injections, it appeared that the prescribers might be Several factors combine to make an injection safe. These further reinforcing client misgivings about its could be broadly grouped under factors associated with effectiveness and quick relief from any type of injection equipment and its sterilisation and those symptoms. We propose a hypothetical model that associated with the technique of administering an attempts to explain the dynamics of injection injection. Both these factors were studied in detail by prescription in the country (Fig VI). senior investigators, through direct observation of the injection administration. 4.4 Injection Equipment A checklist for safe/unsafe injections was developed The types of syringes used for injections at various for this assessment. This checklist was based on various health facilities were determined through direct criteria given by WHO, SIGN, PATH and a list was observation of the injection process by senior prepared by the Central Coordination Committee investigators. At the all India level, three fourths of the (CCC) of the project. This checklist was the basis of the total injections (74.6 %) were administered with plastic instrument used for the specific observation of the syringes. In the urban areas 80.8 percent injections were injection process. administered with plastic syringes as compared to 72.2 percent in the rural areas. The use of plastic syringes Definition of an Unsafe Injection was much higher in the private sector (80.7 %) as For the purpose of this study an injection was classified compared to that in the government health facilities as unsafe if: (62.7 %) and immunisation clinics (52.3 percent) (p=0.000) (Fig. VII). • It had the potential to transmit Blood Borne Viruses (BBV) like HIV, HBV and HCV, because the Figure VII injection was being given using inadequately sterilised syringe/needle and/or if syringe/needle were reused for another patient; and/or • It was administered using faulty technique (and could cause local infection and/or reaction).

The purpose of this classification was to delineate public health actions for two types of risks related to injection administration. To avoid and minimise the risk of transmitting Blood Borne Virus, the intervention(s) have to address issues related to the sterilisation of glass syringes and metal needles and prevent re-use of disposable syringes and needles.

vii Executive Summary Assessment of Injection Practices in India

Improvement in injection technique will require major there was a linear but inverse relationship between efforts to train injection givers across the country. the quantum of plastic syringe use in a zone and Hence, the interventions will be qualitatively different overall prevalence of unsafe injection as well as for different aspects of safety. potential risk of Blood Borne Virus transmission irrespective of the type of health facility (Fig. VIII). Unsafe Injections Thus, frequent use of glass syringes (48 %) appeared The combined effects of above-mentioned two to be the most important reason for the highest parameters were the overall cause of unsafe injections. proportion of unsafe injections at immunisation clinics. Of all the injections administered in India, one third [31.6 %; 95% CI 29.4-33.0] carried a potential risk of It was interesting to note that for a particular type of transmitting Blood Borne Virus. Unsafe injection due syringe, unsafe injections remained very similar at all to faulty technique was observed in 53.1 percent [95% types of health facilities (Fig. IX). The proportion of CI 50.8-55.4] of injections. Together these two factors, potential risk of spread of blood borne viruses with at the country level made nearly two third (62.9 %; glass syringes was higher in private clinics as 95% CI 60.7-65.0) of the injections unsafe (Table 3). compared to other types health facilities, reflecting

Table 3: Characteristics of Unsafe Injections (% of all Injections) in India

Characteristics Percentage of Unsafe Injections with Unsafe Injections with Total Injections Plastic Syringe (%) Glass Syringe (%) Overall Unsafe 62.9 53.3 90.8 Potential Risk of BBV Transmission 31.6 18.2 70.7 Faulty Technique 53.1 46.2 73.0

Figure VIII Unsafe injection was the highest at immunisation Relationship of Unsafe Injections and Potential clinics (74.0 %; 95% CI 71.4-76.6) followed by Risk of BBV Transmission with use of Plastic government health facilities (68.7 %; 95% CI 66.1-71.3) Syringe Injections and Type of Syringe and private health facilities (59.9 %; 95% CI 56.9-62.8) (Table 4). Plastic Syringe Use Potential Risk of Overall Unsafe Injection BBV Transmission The type of injection equipment (glass or plastic syringe) had a profound effect on the safety of injections, be it potential risk of Blood Borne Virus transmission (glass 70.7 % vs. plastic 18.2 %); faulty injection technique (glass 73.0 % vs. plastic 46.2 %); and overall unsafe of injections (glass 90.8 % vs. plastic 53.3 %)- (Table 3). Regression analysis showed that

Table 4: Profile of Unsafe Injections in relation to type of Health Facility and Type of Syringe Use

Type of Health Overall Unsafe Injections with Injections Carrying Potential Risk Facility Injections Plastic Syringe (%) of BBV Transmission (As % of total) Overall With Plastic With Glass Syringe Syringe

Government Health Facilities 68.7 62.7 35.4 18.5 63.7 Private Health Facilities 59.9 80.7 30.1 18.1 80.1 Immunisation Clinics 74.0 52.3 33.5 18.0 50.5 All India 62.9 74.6 31.6 18.2 70.7

Executive Summary - viiiviii - Assessment of Injection Practices in India

Figure IX In view of the above factors, along with the extra effort and patience required to properly sterilise the glass syringes, particularly in the wake of crowded out patient settings, it was not surprising to observe that most of the injections administered through glass syringes were unsafe (90.8 %) with a potential risk of Blood Borne Virus transmission (70.7 %).

4.6 Waste Disposal

The study brought into focus the need to handle the waste generated with the widespread use of plastic syringes. additional human factor in combination with As was observed for sterilisation guidelines, the technology. guidelines for waste handling were available at only 14.2 percent of the health facilities. Satisfactory disposal In multivariate logistic analysis, use of glass syringes of plastic syringes and disposable needles was observed consistently emerged as the highest risk for unsafe at 61.3 percent of the health facilities and was found to injections (OR=8.4 for overall unsafe injection; OR =12.2 be least at immunisation clinics (50.9 %). Waste for risk of Blood Borne Virus transmission and OR=3.0 segregation was being done only at 6.2 percent of health for unsafe injection due to faulty techniques). The type facilities at country level. Satisfactory terminal disposal of health facility (OR=0.9-1.3) did not influence the of injection waste was observed in less than half the unsafe injection as much as the type of syringe use health facilities (44.8 %) and was found to be the least made. Unsafe injection was marginally lower in urban at private health facilities (41.5 %). The problem of areas (OR=0.7-0.9) as compared to rural areas. It was unsatisfactory waste disposal was more in rural areas interesting to observe that risk of unsafe injection when than at health facilities located in urban areas (Fig. X). administered at non-allopathic health facilities (ISM and informally trained prescribers) was almost one and Figure X half times (OR=1.3-1.9) more as compared to that with allopathic prescribers.

Sterilisation of Injection Equipment Written guidelines for sterilisation were available at only 10.1 percent of all health facilities across the country. It was disturbing to note that more than half (55.6 %) of the prescribers reported an incorrect sterilisation process. At the country level, sterilisation equipment was available at 84.2 percent of the government health facilities, 76.9 percent of the immunisation clinics and 57.7 percent of private health Prescriber perspectives were not obtained at immunization clinics facilities. Over three fourths (75.9 %) of the available sterilisation equipment was functional. A significant difference existed between the observed status of waste disposal methods at the health facilities Direct observation revealed that sterilisation was and the terminal level versus that claimed by the primarily done by paramedics in government health prescribers working in these health facilities (Fig. X). facilities (58.2%) and immunisation clinics (59.8%) and Direct observation at health facilities revealed that the by a mix of prescribers (19.1%), paramedics (14.9%) and selling of used plastic syringes/needles to kabadiwalas helpers (14.1%) at private health facilities. At all health was more from private health facilities (15.2%) as facilities, attendants or helpers were involved in the compared to that from government health facilities sterilisation process albeit to a variable extent. (3.2%).

ix Executive Summary Assessment of Injection Practices in India

4.7 Rural Urban Differences Although basic issues related to the burden of injection, safety and waste disposal remain the same for rural Contrary to the general belief, large numbers of and urban areas; the magnitude of these problems in injections were being administered in both urban and rural areas appeared to be higher than in urban areas. rural areas (Table 1). The direct observation of clients A significant challenge will be managing injection and prescribers at health facilities reveal that the related waste generated in remote villages and outreach proportion of clients prescribed injections was higher clinics. in rural areas (46.6 %) as compared to those in urban areas (37.6 percent). Thus, the quantum of injection was 4.8 Model for Burden of Injections in India higher in rural areas mostly due to a larger proportion of the population along with a marginally higher injection rate at the individual level. Overall vaccines Based on the estimates obtained from the community were prescribed more often to those residing in urban survey, in a population of little over 100 crore, almost areas (21.6 %) as compared to the communities in rural 300 crore (based on three-month recall) to 600 crore areas (15.9 %). (based on two-week recall) injections were administered annually in India. On the basis of The proportion of unsafe injections was approximately observations made in the study regarding the location 10 percent higher in villages (65.9 %) as compared to of these injections and their safety profile, a model those in cities (54.9 %). This difference was maintained about total injections and their location in different when data was stratified according to the type of health sectors was developed for India (Table 5). facilities and type of health providers. The proportion of injections carrying a potential risk of spread of blood In addition to the enormous burden of injections, the borne viruses was also somewhat higher in villages model also suggested that: (33.4 %) as compared to that in urban areas (26.6 %). These differences in injection safety could be explained a) Besides government sector, private sector will also by the higher use of glass syringes in rural areas, be an important stakeholder to address all issues variations in the profile of prescribers and their safety related to injections and their safety. records and training of the injection givers. Availability and functional status of sterilisation equipment was b) Immunisations particularly those given to children similar in the two areas. below one year are absolutely essential and all of these must be administered in a safe manner. These Appropriate waste disposal was consistently a bigger injections assume additional significance in view problem at health facilities located in villages. Health of the findings that 74% injections at immunization facility levels of plastic syringe disposal were better in urban areas (69.6 % of the country as compared to their clinics were administered in unsafe manner. rural counterparts (57.9 %) in all sectors. Similarly, satisfactory terminal disposal was more in urban health c) The huge quantum of unsafe injections (189 crore) facilities (51.2 %) as compared to that of health facilities can potentially be associated with major public in rural areas (42.2 %). health problems.

Table 5: Annual Burden of Injections in India* (Modelling Estimates Based on three-months' Recall)

Type of Injections Public Sector Private sector Total

Curative 58 191 249

Vaccines <1 yr 14 4 18 ≥1yr 18 15 33 Total @ 90 210 300 (Unsafe) (63) (126) (189)

*All numbers in Crore/year. @ Overall 63% injections were unsafe, 70% in public sector and 60% in private sector

Executive Summary - x - Assessment of Injection Practices in India

5. Recommendations • All public and private sector health facilities must adhere to the guidelines for injection waste The aim of the recommendations is to improve injection management issued by the Central Pollution safety in India. It must be emphasised that injections Control Board. are administered in almost every village, hamlet, - All district/municipal bodies should evolve remote inhabitations and other rural as well as urban locally workable waste management systems areas of India. Wide varieties of formally and conforming to these guidelines. informally trained personnel prescribe and administer - Waste management guidelines should be made injections. A variety of injection equipment (plastic available at all health facilities and these syringes/needles, glass syringes/metal needles and a should be prominently displayed at these combination of glass syringes with disposable needles) facilities. is used to administer injections. Also, injections appear - Special logistical needs of rural and remote to be a popular mode of therapy for a significant areas should be addressed. proportion of the community. II Training and Capacity Building Against this backdrop, the task of improving injection practices will require collaborative efforts from all • Institutionalise the process of training of injection stakeholders’ viz. political leadership, programme prescribers and administrators. managers, professionals and professional - Incorporate the subject of injection safety in organisations, the pharmaceutical and injection medical and nursing curricula. equipment manufacturing industry, and community. - Set up Model Injection Corners in teaching and The recommendations are grouped under three tertiary care hospitals. These would serve as headings: policy and programme, training and centres for pre- and in- service training of communication. health professionals from all sectors. - Professional bodies like IMA, IAP, FOGSI, etc. I Policy and Programme should make injection safety a part of their CME programmes and are encouraged to • Encourage the universal use of ‘pre-sterilised disseminate guidelines among their members. syringes/needles with a mechanism for prevention These should also include education on: of reuse’ – for administering injections. Drug/Injection therapy. • Need for immediate steps to make all injections given under the Government of India’s Universal III Communication for Behaviour Change Immunisation Programme (UIP) safe. • Reduction in the large burden of injections in the • Avoid the common practice of use of the same country would require separate and specific syringe with different needles. Based on the communication to both health professionals and experience with the use of auto-disabled (AD) the community. syringes in national immunization program, - The model of determinants of injection currently available disposable syringes may be proposed by the study could serve as a modified to have fixed needles so that the syringe guideline for developing a communication (plunger-piston) could not be reused with another strategy for prescribers and the community. needle. - Communication messages should reach • In the interim injection prescribers and administrators in all
Ensure availability of sterilisation guidelines, sectors (including informally trained functional sterilisation equipment at all health personnel). facilities where glass syringes/metal needles are - The community should be sensitised to the used. harmful effects of injections.
Ensure adequate quantities of syringes/needles - Rational use of injections should be a key thrust according to requirement.
area. Discourage use of inadequately sterilised glass - Teaching institutions, professional bodies, syringes/metal needles or the reuse of disposable syringes/needles through closer supervision at NGO’s, communication and media experts, all levels of healthcare. agencies and government will need to establish partnerships for this purpose

xi Executive Summary Assessment of Injection Practices in India

IV Follow up studies • To set up a mechanism to monitor the impact of • To assess the economic aspect of prevailing interventions for improving injection safety on the injection practices and of interventions to improve prevalence/incidence of Hepatitis-B, Hepatitis-C them and HIV in the community • To estimate the contribution of unsafe injections • To establish periodic evaluation system in the to the burden of blood borne viral infections in country to assess the impact of different the community interventions on injection practices.

No T 22011/2001-CC&V Government of India, Ministry of Health and Family Welfare (Department of Family Welfare) Nirman Bhawan, New Delhi, Dated the 25th May, 2005 To Dr. N.K. Arora Professor (Pediatrics) AIIMS & Co-ordinator for IndiaCLEN Study AIIMS, Ansari Nagar, New Delhi

Subject: Acceptance of the final report of the study for Assessment of Injection Practices in India by IndiaCLEN - Reg.

Sir, Please refer to the aforesaid subject and your communication thereon.

I am to inform you that this Ministry have accepted the final report of the study for Assessment of Injection Practices in India submitted by India- CLEN. The minutes of the meeting of experts held on 15th April, 2005 and the action taken report of the Ministry thereon may please be incorporated in the final report (A copy of the minutes and ATR is enclosed herewith), We may intimate to you later regarding the number of copies of the report required.

Encl. As Above Assistant Commissioner (UIP)

Record note of meeting

Minutes of the consultative meeting of experts held on 15th April, 2005 in the chamber of Dr.V.K. Arora, Addl DG, Nirman Bhawan, New Delhi.

Participants: 1. Dr. V. K. Arora, Addl DGHS …..Chairman 5. Mr. Samresh Gupta, UNICEF 2. Dr. Pradeep Haldar, AC (UIP)…..Member Secretary 6. Dr. Yusuf Hussain, UNICEF 3. Dr. N. K. Arora, INCLEN 7. Dr. Paul Francis , WHO 4. Dr. Dubey, President IAP, Delhi 8. Dr. A. Hashim, WHO

The consultative group meeting was called under the chairmanship of Dr. V.K. Arora, to discuss and endorse the draft recommendations of the injection safety study conducted by the INCLEN with special focus to the recommendations made at page M46 of the study report.

The findings and the recommendations were reviewed and the group recommended the following:

• Since the review findings highlighted that 74.0% of injections were unsafe in the immunization sector, the group recommended and appreciated the prompt action taken by the Department of Family Welfare to introduce Auto Disabled (AD) syringes in the immunization programme in all the States of the country. The ADG stated that the procurement process for the same is underway and in all probability the AD syringes will be ready for distribution by mid 2005. • The group also recommended and appreciated the steps taken by the Department of Family Welfare and the Central Pollution Control Board for development and dissemination of guidelines for safe disposal of immunization waste. • In view of the finding of reuse of the same syringe with different needles and a recommendation for introduction of disposable syringes with fixed needles, it was decided that feedback on handling of AD syringes in the field after their introduction in the UIP would be studied, to come up with options for introduction of disposable syringes with fixed needles. • The group encouraged the inclusion of the subject of injection safety in medical and nursing curriculum and conduct of CMEs by profes- sional bodies like IMA, IAP, FOGSI, etc. • The group endorsed the establishment of Model Injection Corners in teaching and tertiary care hospitals for pre- and in- service training of health professionals from all sectors. • The group also recommended the Communication for Behavior Change (CBC).

Executive Summary - xiixii - Assessment of Injection Practices in India

1. Introduction

1. Background syringes (9). However, the extent of the problem has been quantified poorly by the developing countries. By mid 20th century, it was established that syringes Global estimates arrived at by using mathematical and needles get contaminated (1) and hence much models suggest that unsafe injections transmit 50-60% attention needs to be paid to the sterilization. of new HBV infections (22 million), 80-90% of new Transmission of blood borne pathogens through HCV infections (2 million) and 7-30% of new HIV unsafe injections was documented as early as 1917, infections (260,000) in year 2000 (8). These injections when an outbreak of malaria among British soldiers would lead to a heavy burden of chronic liver diseases was linked to injection given for the treatment of and AIDS with loss of nine million disability adjusted syphilis (2). Later the research studies confirmed the life years (DALYs) between 2000 and 2030 (10). Unsafe possibility of transmitting hepatitis B and AIDS by injections can also transmit parasitic (malarial), fungal, serum or blood (3, 4) bacterial and other types of infections. Some infections such as abscesses, septicaemia may appear relatively Injections are among the most frequently used medical quickly, whereas other infections spread by used procedures with an estimated 12 to 16 billion injections needles/syringes may not be obvious for years or administered each year worldwide. A large majority decades. In addition, unsafe injections may also (90% to 95%) of these injections are administered for increase the risk of local trauma and nerve damage. curative purposes and only 5% to 10% are given for immunization (5). The use of injections appeared to be increasing overtime, particularly in developing countries (11). In The World Health Organization (WHO) estimated that India, studies providing such definite temporal at least 50 percent of the world’s injections changes in injection frequency were not available. administered each year are unsafe, more particularly However, trends might be observed between studies in developing countries, posing serious health risks to done over a period. Indian studies also showed an recipients, health workers and the public (6). Moreover increase from 1.2 injections/person/year in 1987 (12) most of the curative injections were unnecessary, to 2.46 injections/person/ year in 2001 (13). ineffective or inappropriate. Assessments by WHO suggest that people residing in South East Asia region Issues of safety and proper disposal gained importance receive more than 5 injections per capita per year and with increased use of syringes and needles. The glass almost 75% of these might be associated with reuse syringes that required sterilization after each use were (7). replaced by plastic disposable syringes, designed to be discarded after a single use. More recently, auto- By definition, a safe injection does no harm to the disable disposable syringes, which disable themselves recipient, does not expose the healthcare worker to automatically by the plunger blocking after single use, any risk, and does not result in waste that is dangerous have been developed. However, many countries to the community (8). Breaks in safe injection practices cannot afford these more advanced technologies coupled with overuse of injections may expose the because of economic reasons (14). In countries like recipients, healthcare workers, or the community to India (15), syringes and needles are scavenged for several harms including life-threatening blood borne resale. While in African continent, syringes and viral infections. Besides the problem of blood borne needles are reused until they break, as, culturally waste virus, inadequate supplies and improper waste is not acceptable. The inadequate management of disposal has led to large-scale reuse of such equipment without sterilization. In addition, the improperly wastes generated, such as sharps and infectious non- disposed sharps pose a threat to the environment. sharp wastes can cause direct negative health impacts on the community and the personnel working during The most common and serious infections transmitted and after the campaign. In addition, pollution due to by unsafe injections are Hepatitis B, Hepatitis C and inadequate treatment and disposal of these wastes can HIV. Hu DJ et al recognized the transmission of blood cause indirect health effects in the community and borne viruses through contaminated needles and affect the environment.

- 11 - ProgrammeIntroduction Evaluation 2004 Assessment of Injection Practices in India

2. Need for Current Study India. This assessment of prevalent injection practices provided baseline information on the magnitude of Conforming to the pattern noticed in many developing the problem (e.g. injection frequency, proportion of countries, the few studies that have been carried out unsafe injections, unnecessary injections) and in India along with anecdotal evidence pointed identified the locally relevant determinants of towards a large number of unnecessary, inappropriate, prevailing injection practices. unsafe injections and inadequate sharps waste management (8). A high proportion of the 200 million 3. Expected Outcome of the Study injections given in India for immunization may be unsafe due to reuse of needles/syringes. The The information was to be used to design locally popularity of curative injections remains high due to relevant interventions, allocate resources, predict various factors influencing the behaviour of impact on blood borne diseases and solve disposal prescribers/injection givers as well as clients (16). A problems. For a meaningful and effective intervention, large proportion (almost 50 percent) of these injections planners needed culture specific information on the may be unsafe due to breaks in safe injection practices meaning of injections in local context. It was necessary and they may also be unnecessary (13, 16, 17, 18). The to prevent and limit the administration of harmful and available reports also highlight the problem of unnecessary injections without damaging the inappropriate sharps waste management. perception of useful injections among the public.

The transition to safe injection practices i.e. reduced This detailed information would hopefully initiate an frequency, increased safety and appropriate sharps informed debate among various stakeholders. The aim waste management needs to be undertaken was to facilitate formulation of National Safe Injection immediately to reduce further transmission of blood Policy encompassing a multi-dimensional approach borne infections and avoid cases of abscesses, paralysis involving behaviour change of prescribers/injection and other complications. givers and clients to reduce the frequency and increase the safety of injections, increase availability/ Therefore, there was a need for quantitative and accessibility of safe injection equipment and promote qualitative information on trends in injection use in appropriate sharps waste management.

ProgrammeIntroduction Evaluation 2004 - 22 - Assessment of Injection Practices in India

2. Objectives

The study was undertaken to determine: private/immunisation clinics) where injection processes are unsafe. • The magnitude of injections in Indian populace. 5. The magnitude of unsafe injections (both curative • The proportion of health facilities both in the public and preventive) and private sectors with unsafe injection practices, 6. The proportion of health care facilities where • The proportion of prescriptions that include sharps waste management is inadequate injections 7. The proportion of patients with common indicator • The locally relevant determinants of prevailing conditions (fever, diarrhoea and ARI) attending injection practices. outpatient clinics and prescribed injections.

The whole country was divided into 15 zones and 2.2 Secondary Objectives cluster sampling was done using the PPS (population proportionate to size) technique to achieve the first To determine three objectives [Quantitative Component]. Qualitative 1. The characteristics of providers/prescribers of methods were employed to fulfil the fourth objective. injections (public/private) through community The domains emerging from the qualitative study were survey used for developing the quantitative questionnaire. 2. The settings of injections (home/health facility) 2.1 Primary Objectives through community survey To estimate 3. The awareness and perceptions of providers/ prescribers and clients about injection procedures 1. The frequency of administered injections in the and sharps waste disposal community (injections/person/unit time) 4. The process of injection at health facilities (public/ 2. The indications of injections (curative/preventive) private/immunisation clinics) by direct observation 3. The proportion of prescriptions given at health facilities (public/private) that include injection(s) 5. The process of waste management at health facilities by direct observation. 4. The proportion of health care facilities (public/

- 33 - Objectives Assessment of Injection Practices in India

3. Methodology

3.1 Study Design 3.2 Sample Size Calculations and Design Effects

Logistics and cost effectiveness determined the 3.2.1 Sample size selection of methods of data collection, namely, rapid Sample size was calculated taking into account the population based cluster survey at the household level requirement of all primary objectives as well as a and observation at health facility in selected clusters. review of similar studies done in different parts of the The sample communities were selected using the world with similar socio-economic and cultural ‘probability proportionate to size’ (PPS) technique. milieus and the small studies published from India. This ensured that the likelihood of a community being selected was in relation to the proportion of its The sample size required for the cluster survey is larger population size i.e., larger villages or cities were more than that required for a random or stratified sample likely to be selected than smaller ones. The whole country was divided into 15 zones on the basis of socio- because of the phenomenon of design effect (Deff). If cultural and geographic factors (Annexure 1). The the frequency of injections is approximately the same sampling universe was therefore a zone. Each zone in each sample cluster, Deff will be around the null comprised of either single states or a group of two- value of one. The more the clusters differ from one five small states of India (Table 3.1.1). The Census data another, the larger the Deff. As the Deff increases of 1991 (Registrar General of India) was utilised for (which increases the variance around the proportion selecting the clusters after adjusting for the population estimate), the sample size must be increased to maintain decennial growth rate from 1991-2001. a desired level of precision. Table 3.1.1 Study Zones for the "Assessment of Injection Practices in India"

Zone No. States

01 Punjab, Chandigarh, Delhi, Haryana, Himachal Pradesh, Jammu and Kashmir 02 Uttar Pradesh, Uttaranchal 03 Bihar, Jharkhand 04 West Bengal, Andaman and Nicobar Islands 05 Assam, Arunachal Pradesh, Meghalaya, Sikkim 06 Manipur, Mizoram, Nagaland, Tripura 07 Rajasthan 08 Gujarat, Diu, Daman 09 Madhya Pradesh, Chattisgarh 10 Orissa 11 Maharashtra, Goa 12 Andhra Pradesh 13 Karnataka 14 Tamil Nadu, Pondicherry 15 Kerala, Lakshadweep

The clusters were drawn separately for urban and rural The Deff gave an idea about the extent of variation areas due to the differences in the available health within the zone and across the zones post-hoc i.e., facilities and infrastructure, and in the socio-cultural during the stage of analysis, Deff was also estimated and demographic features of the urban and rural for every variable analysed. populations.

Methodology - 44 - Assessment of Injection Practices in India

3.2.2. Sample The zone was taken as the main population universe Population survey: As per the reports available from a with two strata: rural and urban. Hence we few developing countries, including India, interviewed 800 individuals in each stratum. For approximately 30-50 percent of the individuals in the convenience, the sample was drawn from 40 clusters community receive at least one injection over a three- and from each cluster 20 subjects were selected and month period. Adopting a conservative approach to interviewed. calculate sample size, we assumed that 50 percent of the individuals received at least one injection during To maintain age and sex balance in the study the previous three months and calculated the sample population similar to census data, two out of 20 size at 95 percent CI with an admissible error of ±5 subjects in each cluster were those with an age less than one year, six were in the age group one to 14 years percent, the sample size required was 384 subjects and the remaining 12 were aged 15 years and above (approximately 400). (Table 3.2.2). This proportion was approximately the population pyramid in India except for children under There was bound to be variations in the injection one year as their proportion in the study had been practices in different parts of the same zone and hence taken as ten percent, as compared to five percent in Deff had to be more than one. However taking into the population. This sample included an equal number consideration the fact that the differences within a state of men and women. were not expected to be very large due to a similar socio-cultural milieu, the sample size was calculated Thus, it was envisaged that a total of 24,000 clients with a Deff of two. At a Deff of two, the required (12,000 rural and 12,000 urban) would be interviewed sample of community members to be surveyed in (Table 3.2.3). Later at the analysis stage, one infant from every sampling stratum would be 800 (sample size for each cluster was randomly dropped to make the random selection technique and design effect i.e., sampling pyramid similar to the actual population 400x2) (Table 3.2.1). pyramid of India.

Table 3.2.1 Sample Size Calculations for Population Survey

S. No. Objectives Estimated Admissible Sample size Deff Total Sample Prevalence error (95% Size Confidence level/strata/ zone)

1. The frequency of injections in the community (injections/person/ unit time) 50% ± 5% 384 2 768 (Approx 800)

2. The indications of injections (curative/preventive) 90% ± 10% 35 2 70 (Approx 80)

Table 3.2.2 Age Distribution of Respondents

S No. Age group No. of Respondents in No. of Respondents in 40 (years) each cluster clusters

1. <1 2 80 2. 1-14 6 240 3. ≥15 12 480 Total 20 800

- 55 - Methodology Assessment of Injection Practices in India

Table 3.2.3 Total Sample Size for Population reason mentioned earlier. A total of 3,600 health Cluster Survey facilities (1,200 each at public, private and immunisation) were to be observed in the country. Strata Clusters Clients Zones Total per Strata per Cluster Sample It was assumed that 70 percent of the injections 2 40 20 15 24,000 administered at any of the health facilities were unsafe. (Rural (1,600 The sample size for determining the magnitude of / Urban) per zone) unsafe injections at 95 percent confidence level and an admissible error of ±10 percent was calculated to Health facilities: In each zone, we wanted to estimate be 80 i.e., observation of 80 injections at every type of the current status regarding injection practices at health facilities or one injection per health facility. government health facilities, private health facilities However there was bound to be variation between and immunisation clinics run by the state health injection practices within the same health facility and department. Thus there were three sampling strata in between the same categories of health facilities across every zone. the clusters; therefore a Deff of five was taken. In view of this, five consecutive injections at each health facility According to various published reports, an estimated were observed leading to a total sample size of 400 70 percent of the health facilities administered unsafe injection procedures to be observed per type of health injections. This proportion was used to calculate the facility in every zone (Table 3.2.4). Thus, a total of 1,200 sample size to determine the proportion of health injection procedures were to be observed in every facilities where processes of injections were unsafe. The zone. This translated into directly observing 6,000 (80 sample size at 95 percent confidence level and an health facilities x 5 injections x 15 zones) injections per admissible error of ±10 percent was calculated to be 1,200 government health facilities, 1,200 private health 80 i.e., observation of 80 health facilities of each type facilities and 1,200 immunisation clinics spread across (public, private and immunisation) in every zone the country (Table 3.2.6). (Table 3.2.4). A random selection of health facilities in every zone without rural-urban stratification was To determine the proportion of prescriptions for injection, done. Hence a Deff of one was considered for the at an estimated prevalence of 50 percent, admissible

Table 3.2.4 Sample Size Calculations for Health Facility Observation and Exit Interviews

S. Objective Estimated Admissible Sample size Deff Total No. prevalence error (95% CI/ sample (absolute strata/zone) size precision)

1 Proportion of prescriptions given at health facilities (public / private) that prescribe injections 50% ± 10% 96 4 384 (Say 400) 2. Proportion of health care facilities where process of injections are unsafe 70% ± 10% 80 1 80 3. Magnitude of unsafe injections in health facilities 70% ± 10% 80 5 400 4. Proportion of health facilities where sharps waste management is inadequate 70% ± 10% 80 1 80 5. Proportion of client-prescriber interaction where clients demand injection 30% ± 4.5% 398 2 796 (say 800)

Methodology - 66 - Assessment of Injection Practices in India

Table 3.2.5 Sample Size Calculations to Determine Proportion of Patients Prescribed Injections for Common Indicator Conditions

Total Estimated Effective Admissible error prescriptions proportion sample size ±5% ±6% ±7% studied in of prescriptions Confidence levels exit for common interviews indicator diseases 90% 95% 90% 95% 90% 95%

400 50 % 200 271 384 188 267 138 196 60 % 240 260 369 180 256 133 188 70 % 280 227 323 158 224 116 165 error of ±10 percent and confidence level of 95 percent, percent and 70 percent. We estimated the injection a sample size of approximately 400 exit interviews was prescribing practices for indicator conditions with an required per strata. The Deff was taken as four admissible error of ±7 percent at 95 percent CI, by assuming that provider(s) with similar injection taking a conservative sample based on 50 percent prescribing practices governed at each health facility. prevalence of prescriptions for injections. The power Moreover the characteristics of client attending a at various sample sizes at different levels of prevalence particular health facility were likely to be similar and is depicted in the table (Table 3.2.5). the provider(s) were the same for all the clients who were interviewed. Hence, in each cluster, we were Observation of client-prescriber interactions: The study likely to observe a high degree of homogeneity and a was used as an opportunity to directly observe client- prescriber interactions for two objectives: proportion greater degree of variability between clusters. of interactions leading to prescription for an injection (this was thought to serve as a data triangulation In every zone, we were to undertake 400 exit mechanism for exit interviews) and understanding the interviews each at government and private health dynamics of this interaction, particularly for assessing facilities. At immunisation clinics, no such interviews the proportion of interactions when clients demand were conducted for obvious reasons. Thus, there were injections. 800 exit interviews per zone and 12000-exit interviews country-wide (6,000-at government health facilities It was estimated that 30 percent clients may demand and 6,000-at private health facilities) (Tables: 3.2.6, injections. Hence, sample size of client-prescriber 3.2.7). interactions at 95 percent CI and an admissible error of 4.5 percent, was 398. A Deff of two was used for Sample size calculations to determine the proportion two reasons: (i) within the same health facility there of patients prescribed injections for common indicator was likely to be high degree of homogeneity and (ii) conditions have been done by taking the proportion between health facilities the client profile would be of patients of indicator conditions as 50 percent, 60 variable.

Table 3.2.6 Total Sample Size for Health Facility Observation in Each Zone

Clusters Health facilities Observation of Exit Observations per strata Per cluster Per zone client-prescriber interviews of injections interaction per zone Per Per Per Per health Zone health zone facility facility

80 Public Public 10 Public 5 Pulic Public 1 80 80x10 80x5 80x5 Private Private Private Private Private 1 80 80x10 80x5 80x5 Immunization Immunization Immunization 1 80 80x5 Total 3 240 10 1600 5 800 1200

- 77 - Methodology Assessment of Injection Practices in India

Table 3.2.7 Total Sample Size for Health Facility Observation at National Level

Health facilitries Client-prescriber Exit interviews Injections to to be observed interactions to with clients be observed Per Entire be observed in Per Entire Per Entire zone country entire country zone country zone country (15 zones) (15 zones) (15 zones)

240 3,600 24,600 (1600x15) 800 12,000 1,200 18,000

Providers: In addition, one prescriber from every dispensary where routine immunisation was done government and private health facility included in the nearest to the selected cluster. In case it was not study was also to be interviewed to assess their possible, then an immunisation session was observed perceptions regarding the rationale and safety of at the PHC/CHC or at the block/tehsil/ district/ injection practices. Thus, there were 160 prescriber hospital nearest to the cluster. interviews (with 80 government and 80 private providers) per zone and 2,400 in 15 zones. An account of all health facilities visited was maintained by filling log sheets (Annexure 3). 3.3 Methods of Drawing Clusters 3.4.2 Selecting clients for exit interviews The sampling universe was a zone. Each zone was Five consecutive patients coming out of both the public stratified into urban and rural populations and and private health facilities were interviewed among separately processed for drawing clusters. The those who agreed to participate. Log sheets were sampling interval was obtained by dividing the total maintained to keep an account of all patients population of the respective zonal strata by the number approached for an interview. of clusters desired. A random number between one and the sampling interval was chosen as the starting 3.4.3 Selecting households and respondents/clients point and subsequently the sampling interval was All the individuals sharing food from a common added to the random number until the desired number kitchen constituted a household. Selecting households of clusters was obtained. The villages/towns/cities involved two steps: first, identifying the first whose cumulative population included these numbers household and second, the selection of a respondent were selected for the cluster survey. / client from within the household. Only a single respondent was selected from a household (Annexure The selected clusters (Annexure 2) were plotted on a 4). map of the respective zone and a logical sequence (route map) for the fieldwork was developed for each STEP 1: A landmark in the centre of the village/urban of the survey teams. ward such as a temple, market place, mosque, church or chaupal (Panchayat Ghar) was located. If no landmark 3.4 Data Collection could be identified, a central place used by the community for social activities was ascertained from 3.4.1 Selecting health facilities for observation the people. Government: A government health facility (PHC/ CHC/dispensary) located in or nearest to the cluster STEP 2: A direction to select houses for interviewing was selected for the study. male respondents was chosen randomly by spinning a bottle on the ground. The research associate went in Private: A private health facility located in or nearest whichever direction the neck of the bottle pointed. A to the cluster where injections were administered was direction opposite to the first one was chosen for selected for the study. If more than one private health selecting houses to interview women. facility existed in the cluster, the one, which was reported to administer more injections, was selected. STEP 3: After deciding on the direction, the research associate walked towards the periphery counting the Immunisation Clinic: Information was gathered number of houses in that segment of the village / regarding a nearby out-reach area/sub-centre/ locality.

Methodology - 88 - Assessment of Injection Practices in India

STEP 4: A random number was selected [last two / issues of understanding the magnitude and three digits on a currency note]. That was the number determinants of unsafe injections were more important of the first house where the survey commenced [e.g. to plan and implement the interventions for improving If the total number of houses was 99 and below, then the injection practices. The ethics committee also raised the last two digits on a currency note were selected]. the concern regarding the Hawthorne Effect. It was noted that the injection practices observed would be STEP 5: After reaching the household, all the family reported with the above-mentioned potential bias. members (either male or female) were listed and if more than one was available at that time, one In the above background, a prior written consent was individual was randomly selected. The first preference was given to a child less than one year, second obtained from all study participants/interviewees. The preference to children aged one to 14 years and third consent forms were prepared in local languages and preference to individuals aged 15 years and above. In one copy was given to the interviewees for their case of children less than 15 years of age, mothers were records. For those unable to read, a person not interviewed. connected with the study read out the consent form.

STEP 6: Once the first household was completed, the 3.6 Network Structure and Dynamics (Annexure 5) one closest to the first was selected as the next household. This was repeated until 10 clients were 3.6.1 Zonal coordinators: The study was conducted interviewed. An account of all the houses visited was in 15 zones. A zonal coordinator was nominated for kept by maintaining the log sheet for houses surveyed each zone. The zonal coordinator along with for both women and men respondents separately. investigators and field staff from that zone implemented the study, with assistance and guidance 3.4.4. Personnel involved in data collection from the CCT members. Every individual in the field team was assigned specific tasks. For details of the tasks and their location see table below. 3.6.2 Partner medical colleges / NGOs: There were five

Personnel Activity Location

Senior investigator Generic observation Health facility/immunisation clinic Observation of client-prescriber interactions Health facility Prescriber interview Health facility Doctors/ Interns Observation of injection process Health facility Exit interviews with clients Health facility Research Assistant Interview with community members Community field survey

3.5 Ethical Issues and Consent to six partner institutions in each zone. Each partner institution contributed two to three survey teams. We were assessing injection practices in the country. No National policy or programme was in place to 3.6.3 Survey teams: In every zone 10 survey teams were guide safe injection practices at the time the study was constituted; each team visited eight clusters thereby conducted. Hence, the study was considered a needs 10 teams covered 80 clusters (40 urban and 40 rural) assessment survey. Furthermore, the ethics committee in the zone. Each survey team comprised of six allowed a “no-interference” strategy during the field members: two senior investigators, two doctors or data collection if “unsafe injection practices” were interns and two research associates (one male and observed, for two reasons: (i) the quantum of injections female each). Thus, it was a unique opportunity where that will be observed as part of the study will be too senior faculty members along with the whole research small as compared to total injections given and team were in the field to undertake data collection of therefore its impact will be miniscule; (ii) the larger the highest quality. It was estimated that each team

- 99 - Methodology Assessment of Injection Practices in India would be able to cover one cluster in two to three days of the progress. They also faxed the details of network and all eight clusters in about twenty days. progress of their zone to CCO on every Monday, Wednesday and Friday and communicated the 3.6.4 Central coordinating office (CCO): The study was problems faced by any team (Annexure 8, 9, 10). coordinated by the Clinical Epidemiology Unit (CEU), AIIMS, New Delhi (henceforth called Central iii. CCT members who were out in the field to ensure Coordinating Office), Central Coordinating Team the quality of data being collected contacted the CCO (CCT) comprised of the Principal Investigator cum every evening regarding details of clusters visited, any Project Coordinator along with 15 Principal Co- problems in methodology and corrective measures investigators from AIIMS-CEU and other institutions taken and plans for the next day. in Delhi. In addition 15 investigators were co-opted as extended CCT members to support quality 3.8 Quality Assurance Mechanism assurance measures (Annexures 6, 7). This was done at five stages: 3.7 Network Monitoring Level 1: Zonal coordinators and senior investigators assembled at New Delhi from March 3-5, 2003 to 3.7.1. Zonal control room and data collection finalise the study protocol, methodology of data The zonal coordinator along with a CCT member set collection, observation checklists and interview up a control room in every zone. The tasks of this duo schedules. were to: • Conduct a three-day orientation workshop on the Level 2: Zonal coordinators along with CCT members objectives and methodology including hands-on organised three-day orientation workshops for all the experience for all team members who were to survey team members from their respective zones at conduct the interviews and observe health the zonal centres from March 16 to April 10, 2003. All facilities. participants gained hands-on experience in conducting • Chart out route maps for every team to cover eight interviews and observing health facilities under the clusters per team. close supervision of zonal coordinators and CCT • Plan the teams’ visits to the field in consultation members. The plan of interviews was finalised and a with other senior investigators. copy forwarded to CCO after the zonal workshop • Disburse funds for field travel. (Annexure 11). • Coordinate the movement of all teams, solve problems and facilitate local arrangements. Level 3: Each CCT member visited at least ten clusters • Identify triggers to problems and take pre-emptive in every zone (each team was visited in the field) to action. assess two parameters: • Monitor the movement of the teams in the field - authenticity of data that had actually been and facilitate quality assurance visits by CCT collected in that cluster till then, and members. - quality of interviews being conducted by the • Facilitate smooth data transmission. researchers by direct observation (Annexure 12). • Group insurance for all team members. The schedule of quality assurance visits was not made 3.7.2 Monitoring tasks of investigators known to the survey teams. The place and time of visits i. Senior Investigators of each field team contacted their was synchronised with the route maps prepared in zonal coordinator every evening to appraise them consultation with the zonal coordinators. Accordingly about the CCT members prepared their field report • The number of interviews completed on that day separately for each cluster. • The number of health facilities observed that day • Plan for the next day and problems faced, if any. Level 4: After completing a cluster, the investigators along with their research associates and doctors ii. Zonal Coordinators were in constant touch with the scrutinised the completed schedules for appropriate CCO, New Delhi. Soon after the zonal workshop, the marking of the answers and ensured that nothing had plan of field activities was faxed to CCO. Zonal been left out. If satisfied, they countersigned the coordinators contacted the CCO to give a daily update schedules or else the researcher was asked to do an

Methodology - 1010 - Assessment of Injection Practices in India extra interview to replace it. Later, the senior 3.9.1 Unique serial number investigators themselves filled all the Intelligent Every interview schedule was given a six digit unique Character Reading (ICR) sheets from which the data serial number. The first two digits indicated the zone were directly transferred to the computers through number (1-15), the next two digits the cluster number scanning. (1-40 for rural and 41-80 for urban) and the last two digits were serial numbers that indicated the category Level 5: Interview schedules were in close-ended to which the respondent belonged. Thus from the formats. Numerical values like age in years, number unique number, it was possible to identify the category of injections received etc. were entered as it is. For to which a respondent belonged or the type of health questions dealing with perceptions, the interview facility where observations were made (Annexure 13). schedules were designed to include verbatim responses (as open-ended answers) and thereafter 3.9.2 Data collection and Transmission to CCO coded according to pre-determined close-ended Within 72 hours of data collection, the team made a answers. The whole data was screened to ensure photocopy of all the completed instruments and ICR complete and appropriate coding of responses at CCO, sheets along with the schedule log sheet. While the New Delhi. For translation of schedules in different original set was dispatched to the CCO, the photocopy languages, help was taken from translators. The was retained by the survey team and submitted to the scanned data was subjected to various range checks zonal coordinator at the end of the survey after for plausible and non-plausible values. completing all eight clusters. This was done to safe guard against accidental data loss during the 3.9 Development of Interview Schedules and transmission to the CCO, New Delhi. The data from Observation Checklists across the 15 zones was collected between March 16 and May12, 2003 (i.e., eight weeks). The draft instruments were developed by the CCT in close partnership with the programme managers in 3.10 Data Management the Ministry of Health and Family Welfare, Government of India and all partners. Draft Data scrutiny and quality check was commenced instruments were pilot tested at eight sites across the immediately on arrival at CCO. The entire data was country. These were finalised during the National checked to ensure that it was complete and Orientation Workshop at New Delhi. appropriately coded. Help was taken from translators for different languages. Simultaneously, all the The interview schedules and observation checklists Intelligent Character Reading (ICR) sheets were also were developed keeping in mind the objectives of the scrutinised for correct entries. The task of data cleaning study. They included a mixture of structured close- was entrusted to a multidisciplinary team of fifteen ended and semi-structured open-ended questions. A research assistants, one intern and two research list of responses for the close-ended questions was officers. The team included postgraduates of printed below the respective questions to facilitate on- anthropology, social sciences, economics and medical the-spot marking by the research associates. For the social work. The team worked under close supervision open-ended questions, space was provided to write down the respondent replies ‘verbatim’. of three CCT members who clarified the doubts and facilitated corrections on a daily basis. The manual These were later coded by research associates in screening of ICR sheets required almost 3.5 months consultation with their senior investigators. The (May 12 to August 22, 2003). response alternatives were picked up from the extensive literature review, analysis of focus group This data was then scanned using a Software, Abbyy discussion (done as part of the qualitative study) and Form Reader 4.0 (between July 24 and August 22, field-testing of draft instruments. Open-ended 2003). This scanned data was then transferred into questions obviously allowed the respondents to give Excel spreadsheets for data cleaning and analysis. One multiple responses and hence the totals often exceeded of the CCT members who was a trained bio-statistician 100 percent. supervised the data cleaning process.

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3.11 Data Analysis observation. This could lead to an underestimation of unsafe and irrational injection procedures. The Magnitude of injections, proportion of unsafe quantum of this error could not be estimated. injections, awareness and perceptions regarding injection practices and inappropriate sharps waste Attempts were made to minimise several potential disposal were calculated for the individual zones and limitations of the study through rigorous training of thereafter for the whole country by imputing weights the research teams. The instruments were for the population. The zone wise estimates of urban administered in the local language with due attention and rural populations were used according to the 2001 paid to the cultural sensitivities and the manner in census. These observation are presented separately for which questions were asked. Care was taken to get urban and rural areas and also for immunisation and the professional activities observed by another senior therapeutic injections. All point estimates have 95 % doctor (who was usually a faculty member). CI and Deff. Suitable tests were applied to assess the statistical significance. To explore perceptions of stakeholders on key issues, within-stakeholder consistency checks (more than one For health facility based data, All India estimates were question on a similar issue) were conducted. derived by applying weightage for proportion of Additionally, as the qualitative studies were injections given at different health facilities (as conducted during the same period as the quantitative determined during community survey). ones, some issues could be resolved by comparing the 3.12 Potential Limitations and Biases data from both sources immediately.

Injection practices at health facilities involve sensitive While analyzing the results of observation of health and professional issues. The information on these facilities, the data did not have sufficient power to practices could have problems related to validity as interpret findings according to rural and urban strata well as reliability. The main problem areas were at the zonal level. However, for all India estimates, considered to be the observation of health facilities and urban-rural stratification was possible. Finally, the observation of the injection process. The Hawthorn economic implication of the prevailing injection Effect was likely to influence the injection prescribing practices in India and that for the recommendations and injection administering practices during emerging from the study were not assessed.

Methodology - 1212 - Assessment of Injection Practices in India

4. Results

4.1 Background Information measures strictly from the start of the assessment program. A total of 3562 health facilities were observed and 2402 prescribers were interviewed for the study (Table The team leaders ensured that the team reached the selected cluster, followed the protocol in selecting the 4.1.1). Also, 24000 clients (12023 men and 11974 households, health facilities and individuals for women; 3 interview whose sex not mentioned by interviews and adhered to the guidelines while interviewers) and 12012 exit patients were interviewed interviewing the respondents. After completing the for fulfilment of the primary objectives using the interviews in a cluster, they also scrutinized all the probability proportionate to size (PPS). In all 17868 questionnaires, filled the ICR sheets, rejected the injection procedures were also observed in the entire incomplete / defective ones and organized extra country. interviews to replace the rejected ones.

Table 4.1.1 Profile of Observations and Interviews

* Clients included whose sex was not recorded (n=3)

4.1.1 Quality Assurance Measures Members of the Central Coordinating Team made The magnitude and span of field operations, and surprise quality assurance visits to a total of 150 (out involvement of 918 researchers (150 teams each with of 1200 clusters; 12.5%) clusters spread over 15 zones. 2 research associates, 2 doctors and 2 senior On arrival at Central Coordinating Office, AIIMS, New investigators) from 84 partner institutions (medical Delhi, the entire data along with the Intelligent colleges / non-governmental organizations) Character Reading (ICR) sheets were screened for necessitated the need to adhere to quality assurance completeness and appropriate coding of responses.

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Range checks and logical runs were incorporated in were not available in the house and another 1482 the data management software to minimize errors. refused, as they were busy with household or some other work, or due to absence of male members/elders All the households visited for selecting the respondent at home, or simply refused to participate. Participation were listed and reasons for not interviewing that rate among the exit patients was 86.5% at government household were specified. After reaching a house, all health facilities and 87.9% at private health facilities. the eligible clients available at that time were listed. At the health facilities, the participation rate was 94.4% The participation rate during the community survey (Table 4.1.3). Of the total 4089 health facilities that were was 94.2% (Table 4.1.2). Of the total 32704 households approached by the research teams, 3592 (1266 in that were approached by the research teams, 24021 government, 1549 in private and 1274 in immunization clients agreed to participate in the study while 7201 clinics) of the prescribers/providers agreed to

Table 4.1.2 Characteristics of Interviews (Community & Exit Surveys at Health Facilities)

* These columns together are denominators for Participation rate

Table 4.1.3 Characteristics of Interviews (Health Facility Survey)

* These columns together are denominators for Participation rate

Results - 1414 - Assessment of Injection Practices in India

participate in the study while 214 refused. The weeks' recall. The corresponding figure based on three- participation rate was found to be a little less in the months' recall was 2.9 (95% CI 2.8-3.2) injections/ private health facilities (85.9%) than the government person/year (Fig. 4.2.2). The large variation in the health facilities (99.4%) and immunization clinics figures for the two periods was probably due to the (99.2%). respondents' recall bias (Table 4.2.2 and Table 4.2.3). Another reason could be the cohort effect, a proportion 4.2 Burden of Injections of population was more likely to get injections repeatedly. 4.2.1 Proportion of Population Receiving Injections A large proportion of the population was receiving The magnitude of injections in both rural and urban injections at any point of time. areas was nearly the same for respective periods of recall [two week recall: 6.1 injections in the rural vs. 4.9 injections in urban areas; three month recall: 3.0 Figure 4.2.1 injections per person in rural vs 2.9 in urban areas] Proportion of Population Receiving Injection as per (Table 4.2.2, 4.2.3 and Figure 4.2.2.). 2-Weeks Recall and 3 months recall

Figure 4.2.2

Burden of injections : Number of injections receiced per person per year 2-weeks’ vs. 3-Months’ Recall

The magnitude of injections administered among In the two weeks prior to the date of survey, 10.8 infants (<1year old) was almost twice as compared to percent (95% CI 10.1-11.5) of the total population in those administered among the older population for India had received injections. This proportion both recall periods. Based on two weeks recall, infants increased to 27.1 percent (95% CI 25.9-28.3) for a three- (<1 year old) were receiving 8.7 injections per infant months' recall period (Fig. 4.2.1). There were no per year (95% CI 7.3-10.0) as compared to 5.6 injections significant urban-rural differences. Higher proportions per individual above one year of age annually (95% of infants (<1 year old) (23%: 95% CI 20.1-26.0) had CI 5.1-6.2) (p=0.000) (Table 4.2.2). received injections in the previous two weeks as compared to those older than one year (10.0%: 95% CI The same trend was observed for three months' recall 9.3-10.8) (p=0.000) (Table 4.2.1) period also with estimates of 5.6 injections annually (95% CI 5.0-6.2) in every infant (<1 year) and 2.8 4.2.2 Injections Administered per Person per Year injections (95% CI 2.6-3.0) amongst individuals older The total burden of injections in the country was than one year. (Table 4.2.3) estimated by calculating the number of injections received per person per year. Two recall periods were For two weeks recall period, the injection rates were used for this estimation; two weeks' and three months' significantly higher in the states of Orissa [Zone10] (8.0 recall at the time of community survey. injections per person per year), Andhra Pradesh [Zone 12] (9.8 injections per person per year) and Tamil Nadu Overall 5.8 (95% CI 5.3-6.3) injections were received [Zone 14] (9.9 injections per person per year) as per person per year in the country according to two- compared to the national average (p<0.001). Andhra

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Pradesh (4.9 injections per person per year) and Tamil received by infants (<1 year old) were vaccines as Nadu (5.6 injections per person per year) maintained compared to 12.2 percent (95% CI 10.9-13.4) among this excess injection rate over the national average even older individuals (p<0.001) (Fig. 4.2.4). Infants as well in the three month recall period (p<0.001)(Figure 4.2.3) as older individuals residing in urban areas were (Table 4.2.2). receiving more injections for preventive reasons than Figure 4.2.3. those in rural areas. Overall, vaccines were given more often to those residing in urban areas (21.6%: 95% CI Magnitude of Injections in India (3 month recall) 18.9-24.4) as compared to those in rural areas (15.9%: 95% CI 14.3-17.6) (p<0.001) (Table 4.2.4).

4.2.4 Site of Injection Prescription Given the enormous burden of injections in India, it was important to determine the type of health facilities and prescribers who prescribed injections.

Figure 4.2.5.

4.2.3 Type of Injections Injections were prescribed mainly for two purposes – preventive (immunisation) and curative. The classification of injections was done on the basis of three- month recall data only. More than three fourths [77.0%: 95% CI 75.1-79.0] of Preventive Injections curative injections in the country were prescribed in Of all the injections received by clients, 17.5 percent the private health facilities compared to less than one (95% CI 16.0-18.9) were administered for preventive fourth [22.9%: 95% CI 20.9-24.9] in the government purposes (immunisation injections). sector (Fig. 4.2.5). The proportion was reversed for preventive injections with two thirds [66.0%: 95% CI 62.5-69.6] of the immunisation injections being Figure 4.2.4. administered in the government health facilities as against one third that are being given in the private health facilities (p<0.001) (Fig. 4.2.5).

Vaccine injections to infants (<1 year old) were mostly [78.3%: 95% CI 74.2-82.3] given in the public sector particularly in rural areas [84.2%: 95% CI 78.8-89.6] vis-à-vis urban areas [66.0%: 95% CI 59.3-72.8] (p<0.001). The difference in the contribution of public sector health facilities [57.7%: 95% CI 52.9-62.4] and private providers [43.8 %: 95% CI 38.9-48.8] to preventive services was not as large for older individuals. (Table 4.2.5)

More than three fourths [76.8%: 95% CI 73.1-80.5] of There were no major inter-state variations in the site these were given to children below one year of age. of both preventive and curative injections except in Overall, 63.2 percent (95% CI 56.8-69.6) of injections Orissa where private providers administered 44.9

Results - 1616 - Assessment of Injection Practices in India percent (95% CI 35.3-54.4) of curative and 7.9 percent The proportion of clients visiting health facilities and (95% CI 1.3-14.6) of vaccine injections. These figures being prescribed injections was much higher in the were significantly lower (p<0.001) as compared to the southern states as compared to the national average. national average. Almost two thirds of all clients [Zone12 (Andhra Pradesh) - 65.8%; Zone 13 (Karnataka) - 65.2% and Private providers administered a similar proportion Zone 14 (Tamil Nadu) - 72.6%] visiting a health facility of curative injections in rural [76.1%: 95% CI 73.6-78.6] in these zones received an injection. (Table 4.2.6) and urban areas [79.7%: 95% CI 77.6-81.7]. However, (Figure 4.2.6) preventive injections among all groups were administered in private facilities more often in urban It was interesting to note that in the state of Kerala areas [48.8%: 95% CI 43.6-54.1] than in villages [29.0%: (Zone15), which borders the states with the highest 95% CI 23.7-34.3] (p<0.001). (Table 4.2.5) burden of injections, the proportion of prescriptions for injections was the lowest in the country [24.3%: 4.2.5 Prescriptions for Injections 95% CI 20.1-28.6]. (Table 4.2.6) One of the indicators of the burden of injections is the proportion of prescriptions for injections. This was Exit Interviews of Clients Coming Out of Health assessed by two methods: prescriber-client interactions Facilities under Study were directly observed by senior investigators to assess In order to triangulate the data obtained through the the proportion of clients who were prescribed an direct observation of prescriber-client interactions, injection and exit interview of patients who were prescription auditing was done through exit coming out of health facilities. interviews of the clients coming out of the health facilities. Direct Observations of Prescriber-Client Interactions Irrespective of the presenting complaints, overall 44.1 The estimates derived from exit interviews generally percent (95% CI 42.6-45.6) of all clients received a reflected the trend seen in direct observations. At the prescription for an injection. The proportion of clients country level, almost half [48.1%: 95% CI 46.3-49.9] of receiving injections was higher in the rural areas all the clients coming out of a health facility had [46.6%: 95% CI 44.8-48.4] as compared to those in received an injection, irrespective of their illness. The urban areas [37.6%: 95% CI 35.1-39.9] (p=0.000). A proportion of clients receiving an injection was higher larger proportion of clients who went to private health in the health facilities in rural areas (50.0%) as facilities received injections [45.9%: 95% CI 44.2-47.7] compared to those in urban areas (43.2%). (Table 4.2.7) than those who went to government health facilities [38.5%: 95% CI 36.7-40.3]. This trend of a higher Similar to direct observations, a higher proportion of proportion of injections in the private sector was the clients [50.6%: 95% CI 48.5-52.7] coming out of observed in the private health facilities located in both private health facilities received an injection as rural and urban areas (Table 4.2.6). compared those coming out of government health facilities [40.7%: 95% CI 38.6-42.9]. (Table 4.2.7) Figure 4.2.6 The trends observed in direct observations across types of health facilities from rural and urban areas were also reflected in estimates derived through exit interviews. The estimates obtained during direct observation were consistently lower (4-10%) as compared to that obtained through exit interviews. The difference in the two estimates i.e., direct observation and exit interviews for the same parameter would also be indicative of the Hawthorne Effect as the two observations were made at different time periods.

Zone 13 Karnataka Zone 15 Kerala Training of Prescribers and their Injection Prescription Zone 12 Andhra Pradesh Zone 6 Manipur, Nagaland, Mizoram ,Tripura Habits Zone 14 Tamil Nadu Zone 3 Bihar and Jharkhand A prescriber's training (allopathic or ISM or informal)

- 1717 - Results Assessment of Injection Practices in India influenced their injection prescription habits and thus administered with plastic syringes. In the urban areas the magnitude of injections. The prescribers were 80.8 percent (95% CI 78.3-83.3) injections were given classified as allopathic (had a MBBS degree at least); with plastic syringes as compared to 72.2 percent (95% formally trained under the Indian Systems of Medicine CI 69.5-74.9) in the rural areas. (Table 4.3.1) (Figure (ISM) and informally trained practitioners. 4.3.1.)

Exit interviews revealed that the least number of The use of plastic syringes was much higher in the prescriptions for injections were from allopathic clinics private sector [80.7%: 95% CI 78.2-83.2] as compared (42.6%) followed by ISM clinics (52.6%) and clinics to that in government health facilities [62.7%: 95% CI managed by informally trained practitioners (57.5%). 59.8-65.5]. In the public sector immunisation clinics, The trend of prescribing injections as assessed through only about half [52.3%: 95% CI 49.1-55.5] of the direct observation of the client-prescriber interaction injections were administered by plastic syringes. (Fig. was similar to that obtained from exit interviews 4.3.1) (Table 4.3.1). (Figure 4.2.7). Thus, informally trained practitioners Figure - 4.3.1. were prescribing 12 percent to15 percent more injections than the allopathic practitioners. (Table 4.2.8)

The injection prescription habits of all types of practitioners were similar in both rural as well as urban areas.

Figure 4.2.7.

In Tamil Nadu (Zone14), plastic syringes were used for only 15.8 percent (95% CI 9.9-21.7) of the injections administered at government health facilities. This observation was further confirmed through estimates derived from prescribers' interviews and the community survey.

4.3.2 Categorisation of Health Facilities According 4.3 Injection Equipment to Pattern of Syringe Use Assessment Through Direct Observation The type of injection equipment has an important Overall, 63.5 percent (95% CI 60.9-66.1) of health bearing on the safety of injections and has implications facilities in India were exclusively using plastic for waste disposal. Data on injection equipment was syringes for administering injections; both plastic and collected from three sources: interview of the glass syringes were used in one fifth of the health prescribers, direct observation of the injection process facilities [20.4%: 95% CI 18.3-22.7] (Table 4.3.2). by senior investigators and the community survey. The exclusive use of plastic syringes was the highest 4.3.1 Type of Injection Equipment Used at Health in private health facilities [70.2%: 95% CI 66.9-73.5] Facilities - Direct Observation followed by government health facilities [50.0%: 95% The type of syringes used for injections at various CI 46.5-53.6] and immunisation clinics [40.9%: 95% CI health facilities was determined through the direct 37.4-44.4]. (Table 4.3.3) observation of the injection process by senior investigators. At all India level, three fourths of the Further, the maximum use of glass syringes either total injections [74.6%: 95% CI 72.6-76.6] were exclusively [36.3%: 95% CI 32.9-39.7] or along with

Results - 1818 - Assessment of Injection Practices in India plastic syringes [22.8%: 95% CI 19.7-25.9] were in the While a similar proportion of government health public sector immunisation clinics. (Table 4.3.3 and facilities in both rural [49.9%: 95% CI 45.5-54.3] and Table 4.3.4) urban areas [44.1%: 95% CI 39.2-48.9] reported the use of both glass and plastic syringes, the use of mixed In general, the proportion of health facilities types of syringes in the private sector was more in the exclusively using plastic syringes was significantly rural areas [29.8%: 95% CI 25.0-34.6] as compared to lower in rural areas [60.4%: 95% CI 57.0-63.8] as the urban areas [16.5%: 95% CI 12.2-20.8] (Table 4.3.7). compared to urban areas [71.7 %: 95% CI 68.4-74.8] (p=0.000) (Table 4.3.3). The exclusive use of glass syringes was higher in the rural areas both in the government as well as in the The prevalence of health facilities either exclusively private sectors. (Table 4.3.8). using glass syringes or both glass and plastic syringes was over 50 percent in Madhya Pradesh and Figure 4.3.3 Chhattisgarh (Zone 9) [51.5%], Andhra Pradesh (Zone Pattern of Use of Injection Equipment at Health 12) [55.1%] and Tamil Nadu (Zone 14) [58.9%]. On the Facilities - Prescriber Perspective other hand, in Bihar (Zone3) [79.2%] and Kerala (Zone15) [76.3%] over three fourths of the health facilities were using only plastic syringes. (Table 4.3.5) Figure 4.3.2 Pattern of Syringe Use at Health Facilities - Direct Observation

The exclusive plastic syringe use pattern stood out in two zones. In Zone 10 (Orissa), prescribers of 91.1 percent health facilities reported the use of only plastic Prescribers' Perspective syringes. Exclusive plastic syringe use was very high Overall, prescribers at 60.7 percent (95% CI 57.9-63.5) both in government health facilities [93.0%: 95% CI of the health facilities said that only plastic syringes 85.8-100.2] and in private sector [90.4%: 95% CI 81.9- were used at their facilities. Exclusive plastic syringe 98.9]. (Table 4.3.6) use was much higher in the private health sector [68.9%: 95% CI 65.4-72.4] and was almost double when On the other hand, in Zone 14 (Tamil Nadu and compared to the health facilities in the government Pondicherry), the exclusive use of plastic syringes in sector (36.5%: 95% CI 33.1-39.9) (p=0.000), which government health facilities was very low (4.3%: 95% exclusively used plastic syringes. (Table 4.3.6) (Figure CI 0.7-7.9), while the proportion of private health 4.3.2) facilities using only plastic syringes was at 68.7 percent The exclusive use of plastic syringes at all types of (95% CI 57.7-79.6%) (Table 4.3.6). The categorisation health facilities was higher [71.7%: 95% CI 68.2-75.2] of health facilities based on the pattern of syringe use in the urban areas as compared to its exclusive use in (plastic, glass or both) revealed similar trends as those the rural areas [56.4%: 95% CI 52.9-59.9] (p=0.000). obtained through direct observation and through (Table 4.3.6) prescribers' interviews (Table 4.3.8) (Figure 4.3.3).

- 1919 - Results Assessment of Injection Practices in India

4.3.3 Type of Syringe Used for Last Injection as injections (Table 4.3.11). The exclusive use of Recalled (Community Survey) disposable needles was much higher in private sector An estimation of the type of injection equipment health facilities [87%: 95% CI 84.5-89.5] as compared (plastic or glass syringe) used in the country was also to government health facilities (48.2%: 95% CI 44.7- done through a community survey where respondents 51.7). (Table 4.3.11) in the community were asked about the type of syringe that was used for the last injection they had received. On the other hand, the proportion of government health facilities using both disposable as well as steel Recall by the clients reflected nearly the same trend as needles was much higher [42.4%: 95% CI 38.8-45.9] obtained through direct observation of the injections. than that of private sector clinics [10.7%: 95% CI 8.3- Two-third (64.9%: 95% CI 62.7-67.0) of all the 12.9] (Table 4.3.12 and Table 4.3.13). respondents said that a plastic syringe was used for the last injection they had received (Figure 4.3.4). The 4.3.5 Availability of Injection Equipment at Health use of plastic syringes was reported more in the urban Facilities: Difficulties and their Management areas [74.9%: 95% CI 72.7-77.3] as compared to the The procurement of injection equipment and rural areas [60.9%: 95% CI 57.9-63.9]. (Table 4.3.9) associated problems significantly influenced the (Figure 4.3.4). manner in which different types of injection equipment was used at various types of health facilities. Figure - 4.3.4. Prescribers at government and private health facilities were asked about the difficulties they faced in the procurement of plastic syringes in their settings and the actions taken by them to overcome the difficulties.

Overall, 85.3 percent (95% CI 83.5-87.2) prescribers at the country level said that they faced no difficulty in the procurement of syringes, while 5.3 percent (95% CI 4.1-6.4) of the prescribers said that they were not involved or were not sure about procurement related problems and only 13.3 percent (95% CI 11.8-14.9) prescribers reported difficulties with the procurement of syringes. Difficulties in procurement were reported more in rural areas [14.7%: 95% CI 12.7-16.8] as compared to that in urban areas [9.7%: 95% CI 8.0- 11.4]. Procurement related problems were much 4.3.4 Type of Needles Used for Injection higher in the government sector [36.9%: 95% CI 33.5- The different types of needles (disposable / steel / or 40.3] than in the private sector [5.4%: 95% CI 3.8-7.0]. both) used for injections generally mirrored the trend The observations discussed under section 4.3.5 refer observed in the use of syringes (Figure 4.3.3) . Figure - 4.3.5. During direct observations, it was seen that generally disposable needles were used for injections [89.9%: 95% CI 88.9-90.9]. It was interesting to observe that disposable needles were being used for 65.0 percent (95% CI 61.5-68.5] of injections administered with glass syringes. Private health facilities were almost exclusively [96.3%: 95% CI 95.2-97.4] using disposable needles for administering injections irrespective of the type of syringe used (Table 4.3.10).

Prescribers at more than three fourths of all health facilities (77.2%: 95% CI 75.1-79.3) at the country level reported the exclusive use of disposable needles for

Results - 2020 - Assessment of Injection Practices in India to the proportion of prescribers and health facilities significant rural and urban differences. A nearly facing difficulties. identical proportion of clients reported purchasing a syringe for their last injection at government (34.8%) Procurement problems related mainly to three and private health facilities (34.5%). (Table 4.3.16) domains: supply related (inadequate supply/delay in supply from central stores/suspected quality of A high proportion of clients attending government syringes), administrative (misappropriation of health facilities in the states of Orissa [70.8%: 95% CI supply/audit objections on local purchase/inaccurate 60.0-81.6], Rajasthan [81.7%: 95% CI 73.2-90.2], Bihar estimation) and financial difficulties (lack of funds/ and Jharkhand [73.3%: 95% CI 58.9-87.6] had patients inability to afford plastic syringes). (Figure purchased their own syringes. (Table 4.3.16) 4.3.5) (Table 4.3.14) 4.4 Safety of Injections Inadequate or irregular availability of syringes were the dominant problems faced in both the private and A combination of several factors contributes towards public sectors. Among those prescribers who injection safety. These can broadly be grouped as complained of difficulties in the procurement of factors associated with injection equipment and its syringes in their settings, nearly three fourths [73.9%: sterilisation and those associated with the technique 95% CI 69.4 -78.5] claimed to make extra efforts (indent of administering an injection. Both these factors were for more supplies/purchase locally/ask patient to studied in detail by senior investigators through direct purchase) to overcome the shortage of syringes/ observation of the process of giving injections needles. Interestingly, these proactive efforts were (including the type of injection equipment used for cited more often by prescribers in the government administering injections). sector [85.2%: 95% CI 81.9-88.5] as compared to those in the private sector [66.6%: 95% CI 59.7-73.5]. A checklist for safe/ unsafe injections was developed Proactive efforts were cited more often in the urban by the CCT basing on various criteria given by WHO, areas [81.1%: 95% CI 74.8-87.4] as compared to that in SIGN, PATH. This checklist was the basis of the study the rural areas [71.9%: 95% CI 65.8-78.1] (Table 4.3.15). instrument used for specific observations of the injection process. It was a matter of concern that 13.8 percent (95% CI 10.2-17.3) prescribers who had complained of 4.4.1 Definition of an Unsafe Injection shortages said that they used glass syringes after For the purpose of this study an injection was flushing/used the same syringe with a different considered/ defined as unsafe if: needle/used the same syringe and needle for another patient. These unsafe practices were much more • It had the potential to transmit Blood Borne common in the private sector [16.6 %: 95% CI 11.1- Viruses (BBV) and/or; 22.1] as compared to the government sector [9.5%: 95% • It was administered using faulty technique (and CI 6.9-11.9] (Table 4.3.15). could cause local infection and/or reaction).

Only a small proportion of prescribers [7.9%: 95% CI Although conditions leading to any of the outcomes 5.2-10.6] changed their prescription (prescribed oral mentioned above would be termed unsafe, distinction drugs/prescribed less injections/referred to other between the two types of unsafe injection was made health facilities) when there was a shortage of syringes for operational ease of understanding the public health at their health facilities (Table 4.3.15). dimension and later for assessing the impact of appropriate intervention on different aspects of the 4.3.6 Purchase of Injection Equipment by Clients unsafe injection. Clients when coming out of health facilities were asked if they had purchased the syringe themselves for i) Injection with Potential to Transmit Blood Borne receiving an injection at the health facility. Viruses (BBV) Potential risk of transmission of blood borne virus was Overall, more than one third [34.6%: 95% CI 31.7-37.5] taken if an injection was found to have been given of the respondents had purchased the syringes for the using inadequately sterilized syringe/needle and/or injections they had just received. There were no if syringe/needle were reused for another patient.

- 2121 - Results Assessment of Injection Practices in India a) Injection Given Using Inadequately Sterilized iii) Unsafe injections (Overall) Syringe/Needle. If an injection fulfilled criteria given under (i) and/or If an injection was given making any ONE of the (ii), it was categorised under being unsafe. following errors, it was taken as indicative as unsafe injection (Table below): 4.4.2 Unsafe Injections

1. (Unwrapped) Glass syringe picked up from tray Overall Unsafe Injections 2. Plastic syringe taken from open pack At the country level, nearly two thirds [62.9%: 95% CI 3. (Unwrapped) Steel needle picked up from tray 60.7-65.1] of all injections were found to be unsafe. The 4. Disposable needle picked from open pack proportion of unsafe injections was higher at health facilities in the rural areas [65.9%: 95% CI 62.9-68.9] as compared to those in the urban areas [54.9%: 95% CI b) Reuse 51.3-58.6] in India (p = 0.000) (Table 4.4.1). An injection was deemed as a reused syringe/needle Figure - 4.4.1 if any ONE of the following was observed. (Table below).

1. Plastic syringe picked up from steriliser/boiler 2. Disposable needle picked up from steriliser/boiler 3. Same syringe used for another patient 4. Same needle used for another patient

An injection was considered unsafe because of the potential to transmit blood borne virus if any ONE of the errors given under (a) and/or (b) was observed. Among various types of health facilities, the ii) Criteria for Considering an Injection Unsafe on percentage of unsafe injections was the highest at Account of Faulty Injection Administering Technique. immunisation clinics, where at the all India level, If the injection giver made three or more of the nearly three fourths [74.0%: 95% CI 71.4-76.6] of all following errors in the process of administering the injections were observed to be unsafe (Figure 4.4.1). injection it was considered unsafe (Table below). At other government health facilities, 68.7 percent (95% CI 66.1-71.3) injections were administered in an unsafe manner as compared to 59.9 percent (95% CI 1. Syringe/needle flushed before drawing medicine 56.9-62.8) at private health facilities (Table 4.4.1) 2. Injection given over clothes (Figure 4.4.2). 3. Needle wiped with a swab before injecting 4. Needle touching any surface before use Figure - 4.4.2. 5. Not wearing gloves / not washing hands before giving injection 6. (Unwrapped) Glass syringe / needle with metal hub picked up from boiler / steriliser / bin / drum 7. Drug drawn from broken / already opened ampoule or multi-dose vial with needle or mixing two to three medicines 8. Multi-dose vial not cleaned / wiped with a swab before drawing medicine 9. Injection site not cleaned before injecting 10. After injecting, glass syringe and metal needle not flushed

Results - 2222 - Assessment of Injection Practices in India

Injection Safety and Injection Equipment While the percentage of unsafe injections in both The influence of type of injection equipment on the allopathic and ISM facilities was lower in the urban safety of injections was highly significant. When glass areas, for the informal sector, the percentage of unsafe syringes were used, 90.8 percent (95% CI 88.8-92.8) injections was similar in the urban [80.0%: 95% CI 69.9- injections were unsafe as compared to 53.3 percent 90.2] and the rural areas [72.8%: 95% CI 64.8-80.9] (95% CI 50.6-55.9) injections administered with plastic (p>0.1) (Table 4.4.4). syringes. (p=0.000). (Table 4.4.2 & Table 4.4.3) Zonal Variations in Number of Overall Unsafe It was interesting to note that overall for a particular Injections type of syringe, the proportion of unsafe injections There were significant variations in the percentage of remained very similar at all types of health facilities. overall unsafe injections between different zones. The (Fig. 4.4.3). proportion of unsafe injections was the lowest in Figure - 4.4.3. Zone15 (Kerala) [47.5%: 95% CI 40.9-54.2], followed Unsafe Injections : According to Type of Health Facility and Injection Syringe by Zone 7 (Rajasthan) [51.1%: 95% CI 42.9-59.3] and Zone 6 (Manipur, Nagaland, Mizoram and Tripura) [51.5%: 95% CI 42.8-60.2] (Fig.4.4.5) (Table 4.4.1).

Figure - 4.4.5.

Unsafe Injections and Type of Health Providers At the country level, the overall number of unsafe injections was highest in the health facilities in the informal sector, where nearly three-fourths [73.4%: 95% CI 66.5-80.3] injections were found unsafe. Nearly two third injections were unsafe [64.8%: 95% CI 59.2- On the other hand, the three Zones with the highest 70.4] in the health facilities of the Indian Systems of number of unsafe injections were; Zone 9 (Madhya Medicine (ISM). Comparatively, the proportion of Pradesh and Chhattisgarh) [82.9%: 95% CI 77.7-88.0], unsafe injections at allopathic health facilities was the Zone12 (Andhra Pradesh) [71.0%: 95% CI 63.4 -78.7] lowest [57.9%: 95% CI 55.5-60.4] (Fig.4.4.4) (Table and Zone13 (Karnataka) [70.5%: 95% CI 64.3-76.6] 4.4.4). (Table 4.4.1). Figure - 4.4.4. 4.4.3 Injections Associated with Potential to Transmit Unsafe Injections : According to Type of Health Provider Blood Borne Viruses (BBV) The use of inadequately sterilised syringes/needles and/or the reuse of the same syringe/needle without sterilisation in other patient(s) has the potential to transmit blood borne viruses.

Unsafe Injections due to Potential Risk of Spread of Blood Borne Viruses At the national level, 31.6 percent (95% CI 29.4-33.7) of all the injections carried the potential risk of spread of blood borne viruses. The proportion of injections carrying such a potential risk was marginally higher

- 2323 - Results Assessment of Injection Practices in India in the rural areas of the country [33.4%: 95% CI 30.4- Figure - 4.4.7. 36.5] as compared to urban areas [26.6%: 95% CI 23.2- 30.1] (Table 4.4.5).

Figure - 4.4.6.

virus transmission when administered with glass syringes [50.5%: 95% CI 45.8-55.2] followed by that in The overall potential risk of spread of blood borne government health facilities [63.7%: 95% CI 59.1-68.3] viruses was quite similar at various types of health and private sector health facilities [80.1%: 95% CI 74.7- facilities: government health facilities [35.4%: 95% CI 85.5]. 32.7-38.1]; immunisation clinics [33.5 %: 95% CI 30.5- 36.5] and private sector health facilities [30.1%: 95% In contrast to the use of glass syringes, where the CI 27.3-32.9] (Fig.4.4.6) (Table 4.4.5). potential risk of the spread of blood borne virus varied considerably among various types of health facilities, A similar proportion of injections administered at when plastic syringes were used, the estimates of such government health facilities and immunisation clinics a risk were nearly the same (between 18.0% and 18.5%) in both rural and urban areas had the potential to irrespective of location. (Fig.4.4.7) (Table 4.4.7) transmit blood borne viruses, but there were significant differences in estimates for blood borne Blood Borne Virus Transmission Risk and Type of viruses transmission related unsafe injections in rural Health Provider and urban private health facilities [32.5% in rural and As with the overall unsafe injections, the proportion 23.8% in urban private health facilities] (p=0.000) of injections with the potential to transmit blood borne (Table 4.4.5). virus was significantly higher in the informal sector [45.3%: 95% CI 38.0-52.7] as compared to that in allopathic facilities [26.9%: 95% CI 24.7-29.0] or ISMs Blood Borne Virus Transmission Risk and Injection [32.6%: 95% CI 26.5-38.7]. (Table 4.4.8) Equipment As with the overall unsafe injections, the proportion Zonal Variations in Blood Borne Virus Transmission of injections - 70.7 percent (95% CI 67.2-74.3) with the Risk potential to transmit blood borne virus was found to There were considerable inter-zonal variations in the be almost four times more when glass syringes had proportion of injections that carried a risk of been used for injections as compared to use of plastic transmission of blood borne viruses. syringes - 18.2 percent (95% CI 16.3-20.1) (p = 0.000) (Fig.4.4.7). There were no significant rural-urban As was the case in the overall unsafe injections, the differences in this potential risk (Table 4.4.6 and Table highest proportion of injections that were unsafe due 4.4.7). to potential of blood borne virus spread were in Zone 9 (Madhya Pradesh and Chhattisgarh) [51.3%: 95% CI It was heartening to note that the safe handling of glass 43.2-59.5] followed by Zone 12 (Andhra Pradesh) syringes was the best at immunisation clinics. [48.7%: 95% CI 40.5-57.0] and Zone 13 (Karnataka) Immunisation clinics had the lowest proportion of [48.4%: 95% CI 40.6-56.2]. Similarly, the lowest injections carrying the potential risk of blood borne proportion of injections associated with risk of blood

Results - 2424 - Assessment of Injection Practices in India

Figure 4.4.8 that in others (p=0.000). The reuse rates were similar Zone Wise Estimates of Unsafe Injections in rural as well as urban areas for the respective types Associated With Potential of BBV Transmission of health facilities. (p>0.5) (Table 4.4.10) [In ascending order] Reuse of Plastic Syringes In sharp contrast to the reuse of glass syringes that

All India Average varied significantly with the type of health facility, the reuse rates for plastic syringes were remarkably similar for all types of health facilities.

In government health facilities, plastic syringes were reused for 13.9 percent (95% CI 11.6-16.3) cases as compared to 13.8 percent (95% CI 11.7-15.8) cases in the private sector and 13.4 percent (95% CI 10.8-16.0) at immunisation clinics. (Table 4.4.11)

At the country level, the reuse of plastic syringes was marginally higher though insignificant in the rural borne virus transmission was observed in Zone15 areas [14.7%: 95% CI 12.9-16.5] as compared to urban (Kerala) [14.2%: 95% CI 10.0-18.3] (Fig.4.4.8) (Table areas [11.6%: 95% CI 9.4-13.7]. This trend was observed 4.4.5). for all types of health facilities.

4.4.4 Reuse of Syringe/Needle However, reuse rates were significantly higher [35.0%: Overall, for nearly one-fourths [23.5%: 95% CI 21.5- 95% CI 27.9 – 42.1] at health facilities managed by 25.5] of all injections at the country level, the syringes informally qualified practitioners as compared to those and/or needles were reused. The percentage of reuse managed by allopathic doctors [19.1%: 95%CI 17.8- was significantly higher in health facilities in the rural 21.7] (Table 4.4.11 and Table 4.4.12). areas of the country [25.2%: 95% CI 22.4-27.9] as compared to those in the urban areas [19.1%: 95% CI Presence of Plastic Syringes/Needles in Sterilisation 16.7-21.4]. (p=0.000). (Table 4.4.9) Equipment In addition to the direct observation of injections to Reuse rates were similar in all types of health facilities: assess injection safety, senior investigators also 24.2 percent (95% CI 21.8-26.7) at government health inspected the injection rooms at all the health facilities. facilities, 23.4 percent (95% CI 20.8-26.0) at private The presence of plastic syringes and/or needles in the health facilities and 21.4 percent (95% CI 18.9-23.8) at sterilisation equipment was taken as a proxy indicator immunisation clinics (Table 4.4.9). of their reuse.

Reuse and Injection Equipment At almost one-third [32.9%: 95% CI 30.2-35.6] health The type of injection equipment used had a very facilities, plastic syringes/needles were found to be significant bearing on reuse rates. present in the sterilisation equipment [boiler/ autoclave/cooker]. This phenomenon (of sterilisation Reuse of Glass Syringes of disposable injection equipment) was observed in Reuse of same syringe for the next injection was much similar proportions at all the three types of health higher when glass syringes were used [51.9%: 95% CI facilities [37.6% of government; 31.8% of private health 47.8-56.1] as compared to that with plastic syringes facilities; and 27.2% of immunisation clinics]. This [13.8%: 95% CI 12.2-15.4; p=0.000]. Reuse rates of glass observation however cannot be extrapolated to syringes were the lowest at immunisation clinics estimate reuse rate as indicated in previous section. [30.1%: 95% CI 26.2-34.1] followed by 41.5 percent (Table 4.4.13) (95% CI 36.9-46.1) in the government health facilities and the private sector [63.9%: 95% CI 57.6-70.2]. Thus Prescriber Perspectives on Injection Safety reuse rate with glass syringes was almost 1.5 to two In addition to the direct observation of the injection times more in private health facilities as compared to and sterilisation processes, the study explored the

- 2525 - Results Assessment of Injection Practices in India injection prescribers’ perspectives on injection safety, [73.0%: 95% CI 69.9-76.1] of injections were unsafe as as these would have a crucial bearing on the way compared to less than half [46.2%: 95% CI 43.5-48.9] injection equipment was used at their health facilities. of injections when plastic syringes were used (Fig. 4.4.9). (Table 4.4.16 and Table 4.4.17). During their interviews, the prescribers were asked about the number of times a plastic syringe could be Figure 4.4.9 reused. Overall, 11.7 percent (95% CI 9.7-13.7) Unsafe Injections Due to Faulty Injection prescribers said that a plastic syringe could be used Technique and Type of Syringe more than once. This perception was similar among prescribers from the rural areas [12.8%: 95% CI 9.9- 15.7] and urban areas [8.9%: 95% CI 6.2-11.5] (p>0.1). However, the proportion of prescribers holding this dangerous notion was nearly twice in the private sector prescribers [13.1%: 95% CI 10.6-15.6] as compared to those in the government sector [7.5%: 95% CI 5.7-9.3] (p<0.001). (Table 4.4.14)

4.4.5 Injection Safety and the Technique of Glass syringe Plastic syringe Government Health Facilities Private Health Facilities Immunization Clinics All India Administering Injections The technique of administering an injection has an Thus, unsafe injections due to faulty techniques were important bearing on the overall safety of the injection. primarily dependent upon the type of syringe used Several steps are required in the process of injecting. and not on the type of health facility or its location in Injections were deemed unsafe on account of faulty urban or rural areas. injection technique as per the methodology discussed in the section (4.4.1) above. 4.4.6 Determinants of Safety of Injections In multivariate logistic regression analysis, the use of At the national level, more than half [53.1%: 95% CI glass syringes consistently emerged as the highest and 50.8-55.4] of the injections were unsafe on account of independent risk for unsafe injections irrespective of faulty injection administering technique. The its location, type of health facility and type of proportion of such unsafe injections was highest at prescriber/giver (Table). The odds of unsafe injections immunisation clinics, where nearly two-third [65.2%: administered through a glass syringe were 8.4 for 95% CI 62.3-68.0] injections were unsafe; next were overall unsafe injections, 12.2 for the risk of blood the government health facilities [56.9%: 95% CI 54.1- borne virus transmission and 3.0 for faulty technique. 59.8] followed by 50.7 percent (95% CI 47.6-53.7) in The type of health facility (OR 0.9-1.3) did not influence the private sector (Table 4.4.15). the safety of the injection as much as the type of syringes did. It was interesting to observe that the risk Unsafe injections due to faulty injection technique were of unsafe injections at the hands of non-allopathic more evident in the rural areas [56.3%: 95% CI 53.5- practitioners (ISM and informally trained prescribers) 59.1] as compared to urban areas [44.7%: 95% CI 41.5- was almost one and half times (OR 1.3 to 1.9) more as 47.9] across all type of health facilities (p = 0.000). compared to that with allopathic prescribers.

Technique of Administering Injection and Injection Health Facilities with Safe Injections (Where all Equipment observed injections were safe): One of the most interesting as well as intriguing At each health facility, five injection administrations findings was the association of injection equipment were observed. If all observed procedures were safe, with injection safety on account of injection the health facility was labelled as a “Health facility with administering technique. As seen during the safe injections”. At the all India level, only 17.5 percent observation made for the risk of blood borne virus (95% CI 15.5-19.6) of the health facilities could be transmission, faulty injection techniques were also labelled as safe places for injections. The proportion more often observed with glass syringes as compared of safe private health facilities was marginally more to errors occurring with plastic syringes. Nationally, (19.1%) compared to government health facilities when glass syringes were used, nearly three fourths (14.0%) and immunisation clinics (13.3%). Almost one

Results - 2626 - Assessment of Injection Practices in India

Table: Determinants of Safety of Injections (Multivariate - Logistic Regression Analysis)

fourth of the health facilities (24.4%: 95% CI 20.8-28.1) syringes [16.5%: 95% CI 13.1-19.8]. (Table 4.4.20 and in urban areas were administering injections safely as Table 4.4.21). compared to 14.9 percent (95% CI 12.6 - 17.2) in rural areas (p=0.000). (Table 4.4.18) In the private sector, the recapping rates of needles used with glass syringes [24.9%: 95% CI 19.1-30.8] as 4.4.7 Safety for Injection Administrators well as for plastic syringes [32.6%: 95% CI 29.2 – 35.9] Safety of the injection administrator is as important as were comparable. In contrast, in the government sector the safety of the recipient of the injection. The injection recapping was much lower with glass syringes [6.8%: administrator is at risk because of needle stick injuries 95% CI 4.6-9.0] than that observed with plastic syringes (NSI) that have the potential to infect the injection giver [23.1%: 95% CI 19.6-26.6]. with blood borne viruses. There are two issues that have an effect on the safety of the injection Data analysis pointed towards two things: recapping rates were higher when plastic syringes were used and administrator - recapping of the needle after injection recapping was done much more in the private sector, which increases the risk of needle stick injury and because disposable needles were used more often even actual needle stick injury to the administrator during with glass syringes. the process of administering injections. Senior investigators directly observed both these parameters Needle Stick Injury (NSI) during the assessment of injection process. Needle stick injuries were observed during 2.4 percent (95% CI 1.8-2.9) of the injections given at the country Recapping of Needles level. The proportion of injections, which resulted in Recapping was observed after 27.2 percent (95% CI needle stick injury (NSI) was similar in the rural [2.5%: 24.8-29.5) of injections. The recapping rates were 95% CI 1.9-3.1] and urban areas [1.9%: 95% CI 1.3-2.6]. similar in rural [27.4%: 95% CI 24.3-30.5] and urban [26.595% CI 23.3-29.7] areas (p>0.5). The percentage of needle stick injury was highest in Recapping rates in private health facilities [31.1%: 95% the immunisation sector [4.2%: 95% CI 3.4-5.0] CI 28.1-34.1] were almost twice of those in government followed by the private sector [2.4%: 95% CI 1.8-3.1] health facilities [17.0%: 95% CI 14.6-19.4] and were and the government health facilities [1.6%: 95% CI 0.9- followed by immunisation clinics [21.4%: 95% CI 18.7- 2.2] (Table 4.4.22). 24.2]. (Table 4.4.19) In the multivariate logistic regression analysis, (Table Recapping and Injection Equipment below), disposable needles, glass syringes, and As expected, recapping was nearly double when immunisation clinics emerged as independent and plastic syringes were used [30.8%: 95% CI 27.9-33.6] significant risk factors for needle stick injuries among as compared to injections administered with glass injection administrators. As stated in the previous

- 2727 - Results Assessment of Injection Practices in India paragraph, recapping was almost an exclusive Fig. 4.4.10 phenomenon associated with the disposal of needles. Therefore, recapping is probably one of the risk factors leading to needle stick injury while administering injections, with disposable needles.

The odds of needle stick injury were the maximum with glass syringes, probably due to the practice of cross checking the tip of the metal needle before injecting (Table). At immunisation clinics, while handling children, injection administrators were likely to injure themselves and thus there was a high risk of needle stick injury. It could also be due to high error rates of injection techniques at immunisation clinics. * Multiple responses obtained

Table: Risk factors for needle stick injuries coming out of the health facilities [14.9%: 95% CI 13.5- Independent variable Odds ratio 95 % CI P value 16.3] perceived technique related issues as important parameters of the safety of the injections (Table 4.4.23). Disposable Needle 4.1 1.9-9.2 0.003 Glass Syringe 6.0 3.9-9.0 0.000 While most clients and community members did not consider injections harmless, it was worrisome to note Private Health Facility 1.7 1.0-2.7 0.051 that a small proportion of prescribers [4.8%: 95% CI Immunisation Clinic 2.8 1.8-4.4 0.000 3.3-6.3] had dangerous misconceptions such as all injections are safe/ it was safe to reuse injections. The 4.4.8 Stakeholder Perceptions about Injection Safety prevalence of these misconceptions among different The technical aspects of safety were assessed through types of health providers was similar (p=0.91). direct observation of the injection process according to a standard checklist. However, injection safety as It was disappointing to note that for all categories of perceived by the various stakeholders viz. the stakeholders, the rationale of administering/receiving prescribers, clients coming out of health facilities and an injection and its effectiveness was not perceived to the community was explored during interviews with be linked to its safety. them. Stakeholders’ Perception of Problems Due To Unsafe Stakeholders’ Perception of a Safe Injection Injections Issues pertaining to sterility/cleanliness of the injection Prescribers, respondents in the community and clients equipment such as the use of new syringe/properly coming out of health facilities were asked about the sterilised syringe/avoidance of reuse – were the most complications/diseases that could occur in the important parameters of safety for all the stakeholders: recipient through an injection administered with an 84.4 percent [95% CI 82.4-86.4] of prescribers; 68.2 unsterilised syringe/needle. percent [95% CI 66.6-69.7] of people in the community and 58.7 percent [95% CI 56.9-60.5] of clients coming Clear differences in the perceptions of prescribers and out of a health facility. (Fig. 4.4.10) (Table 4.4.23). community could be observed on the issue of complications of an unsafe injection. While three fourth As expected, issues related to injection administering of the [74.1%: 95% CI 71.3-76.9] prescribers thought techniques like – giving injections slowly and properly that transmission of blood borne viruses like hepatitis / painless injections / cleaning the site of injection, and HIV could take place because of unsafe injection, washing hands before administering injection - were only one third [33.3%: 95% CI 31.9-34.6] of the described as determinants of a safe injection by more respondents in the community and approximately one than half [53.5%: 95% CI 50.6-56.4] of the prescribers. fourth [27.3%: 95% CI 25.8-28.8)] of clients coming out Compared to this, a much smaller proportion of the of health facilities were aware of these complications community [15.1%: 95% CI 13.9-16.4] and patients (p=0.000) (Fig. 4.4.11) (Table 4.4.24).

Results - 2828 - Assessment of Injection Practices in India

Fig. 4.4.11 different types of health providers. While more than half [57.3%: 95% CI 53.9-60.7] of allopathic practitioners were aware that blood borne infections could be contracted by the injection giver, only 29.8 percent (95% CI 23.2-36.5) of ISM practitioners and 18.1 percent (95% CI 12.1-24.1) of informally qualified practitioners were aware of these risks (Table 4.4.25).

However, compared to allopathic practitioners [44.8%: 95%CI 41.6-48.1] a higher proportion of informally trained practitioners [55.1%: 95%CI 46.6-63.5] and ISM practitioners [46.5%: 95%CI 38.6-54.2] thought that other infections like syphilis/ TB/ measles/ leprosy Similarly, a much larger proportion of prescribers could be contracted by the injection administrator in [59.5%: 95% CI 56.6-62.4] enumerated local the process of administering injections. complications of injections viz. reaction/fever/ abscess/pain due to unsafe injections as compared to Similarly, a larger proportion of allopathic less than one third [28.6%: 95% CI 27.0-30.1] of practitioners [52.5%: 95% CI 49.2-55.8] were aware of respondents in the community and one fourth [24.9%: local reactions as a risk to injection administrators as 95% CI 23.3-26.7] of clients coming out of health compared to 40.4 percent (95% CI 32.7-48.0) of ISM facilities. and 41.7% percent (95% CI 33.2-50.1) of informally A large proportion of both the prescribers [53.1%: 95% trained practitioners. CI 50.2-56.0] as well as the respondents in the community [66.6%: 95% CI 65.1-67.9] and exit 4.5 Process of Injection interview respondents [56.6%: 95% CI 54.8-58.4] thought that diseases like measles/leprosy/syphilis/ 4.5.1 Personnel Involved TB could be transmitted because of unsafe injections An assessment was made of the various types of (Table 4.4.24). Data suggested that the community in personnel involved in the injection process. general, must be made more aware about the potential Understanding the patterns of involvement of various risks of unsafe injections, specifically possibility of types of personnel in the administration of injections acquiring blood borne virus infections. was important because of its ramifications in training and communication for injection safety. Risks to the Injection Administrator of an Unsafe Injection The profile of injection prescribers as well as injection In addition to the prescribers’ perspectives on the administrators was determined. Three sources were complications caused by unsafe injection to the utilised for making these assessments: community recipient, their views on the risks to the injection survey, prescriber interview and direct observation by administrator due to improper injection practices were senior investigators. also explored. Profile of Injection Prescribers Overall, at the country level, 44.7 percent (95% CI 41.7- Respondents in the community were asked to recall 47.2) prescribers thought that the injection the type of injection prescriber (in terms of the system administrator could contract blood borne infections of medicine) who had prescribed the last injection to (hepatitis/HIV) if improper injection practices were them (or their child). followed. Local reactions were cited by 48.2 percent (95% CI 45.1-51.2) and another 47.1 percent (95% CI It was seen that practitioners of the allopathic system 44.1-50.1) prescribers were of the view that other of medicine had prescribed the largest proportion of complications (like measles/syphilis/TB, death) could injections [50.9%: 95% CI 48.4-53.5]. Informally trained occur. practitioners had prescribed 14.1 percent (95% CI 12.1- 16.2) and practitioners of ISM had prescribed 8.5 There were significant differences in the awareness percent (95% CI 7.2-9.7) of injections (Fig. 4.5.1). about risks to the injection administrator between Paramedics had prescribed injections in 21.0 percent

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Fig. 4.5.1 last injection on the advice of their friends or had self- prescribed it (Table 4.5.1; Table 4.5.2; Table 4.5.3 and Table 4.5.4).

There were prominent rural-urban differences in the profile of injection prescribers in the country (Fig.4.5.2). Allopathic practitioners provided a larger proportion of injections in urban areas [61.6%: 95% CI 58.3-64.9] as compared to that in rural areas [46.9%: 95% CI 43.8- 49.9] (Table 4.5.1). Informally trained practitioners had prescribed almost three times [17.6%: 95% CI 14.9-20.2] more injections in the rural areas as compared to that in the urban areas [4.9%: 95% CI 3.7-6.2].

In Zone 9 (Madhya Pradesh and Chhattisgarh) [30.6%: 95% CI 22.9-38.2], Zone 12 (Andhra Pradesh) [27.6%: 95% CI 21.3-33.9] and Zone 2 (Uttaranchal and (95% CI 19.2-22.9) cases; a large proportion of these UttarPradesh) [26.8%: 95% CI 19.1-34.4] over one appeared to be vaccines. A small but significant fourth of the injections were prescribed by informally number of respondents [6.7%: 95% CI 3.8-9.5] had their qualified practitioners (Table 4.5.2).

Figure 4.5.2 Profile of Injection Prescribers -Community recall

Figure 4.5.3 Profile of Injection Prescribers for Infants and Older Clients - Community Recall Clients <1 yr old Clients >1 yr old

Results - 3030 - Assessment of Injection Practices in India

Injection Prescriber Profile According To Age of Client allopathic practitioners who had administered a higher Allopathic doctors [35.8%: 95% CI 31.9-39.6] or proportion of injections in the urban areas [33.6%: 95% paramedics [54.0%: 95% CI 50.1-58.0] e.g. ANMs were CI 30.8-36.4] as compared to those in rural areas prescribing and administering the injections, most of [20.5%: 18.2-22.8] (p=0.000). (Table 4.5.7 and Table which were vaccines, to infants. Approximately 11.0 4.5.8) percent injections to infants were prescribed by ISM doctors, informally trained prescribers and others. In The paramedics had given 70.5 percent (95% CI 66.8- contrast, about 32 percent injections received by the 74.2) injections to the <1 year age group compared to older population (=1 yr old) were prescribed by these 45.5 percent (95% CI 42.9-48.1) injections to the =1 year categories of prescribers (p=0.000) (Fig. 4.5.3) (Table age group. This was possibly due to the large number 4.5.5). of immunisation injections administered by ANMs/ health workers in the <1 year age group (Table 4.5.6). Profile of Injection Administrators In addition to the injection prescribers, the profile of Profile of Injection Administrator: Doctors' View injection administrators was also studied. Data for this Doctors at health facilities were asked about the assessment was drawn from three sources: perception various types of personnel involved in administering of the respondents in the community, information injections at their facility. provided by the doctors at health facilities and direct observation by senior investigators. At the country level, at more than half [55.8%: 95% CI 53.3-58.4] of the health facilities the doctors themselves Community's Perception on the Type of Injection administered injections. Paramedics administered Administrator injections at half [51.7%: 95% CI 49.2-54.3] of the health Paramedics (ANM/compounder/nurse/pharmacist) facilities at the country level. Helpers/attendants administered almost half of all injections in the country administered injections at less than one fifth [17.3%: [48.9%: 95% CI 46.4-51.5]. Overall, the prescribers 95% CI 14.9-19.7] of the health facilities (Table 4.5.11). themselves administered 47.1 percent of the injections The actual variations in the type of personnel [24.1% by allopaths; 7.1% by ISM practitioners, and; administering injections was noticed when the data 15.9% by informally trained practitioners] (Fig. 4.5.4) was disaggregated for government and private sector (Table 4.5.6, Table 4.5.7, Table 4.5.8, Table 4.5.9, and health facilities (Fig.4.5.5). Table 4.5.10).

Fig. 4.5.5 Fig. 4.5.4

Profile of Injection Givers - Community Recall

Paramedics were the predominant injection administrators in the government sector [94.9%: 95% CI 93.5-96.4], while doctors themselves administrated Consistent with the prescribing pattern, informal injections more often in the private sector [67.2%: 95% practitioners had administered a much larger CI 63.9-70.5] (p=0.000). The involvement of helpers/ proportion of injections in the rural areas [19.8%: 95% attendants administering injections was more than CI 16.9-22.7] as compared to that in urban areas [5.3%: twice in the private sector [20.0%: 95% CI 17.0-23.0] 95% CI 3.9-6.7] (p=0.000). The reverse was true for than in the government sector [9.2%: 95% CI 6.8-11.5].

- 3131 - Results Assessment of Injection Practices in India

The profile of the injection administrators was similar Fig. 4.5.6 in the government sector both in the rural as well as the urban areas. Interestingly, in the private sector, doctors were administering injections at a larger proportion of health facilities in the rural areas [71.2%: 95% CI 67.3 -75.1] as compared to urban areas [57.1%: 95% CI 52.4-61.7]. (Table 4.5.11)

Profile of Injection Administrator: Direct Observation of Personnel Administering Injections Senior investigators themselves observed the types of personnel actually administering injections at various types of health facilities and the estimates were triangulated with the views of the doctors and the community on this issue. training injection administrators in the private sector [49.2%: 95% CI 45.7-52.7], while this was practically Direct observations revealed that doctors gave negligible in the government sector [8.3%: 95% CI 6.1- injections at 44.7 percent (95% CI 42.3-47.2) of health 10.5] (Fig. 4.5.6) (Table 4.5.14). facilities, paramedics at 52.9 percent (95% CI 50.6-55.3) and helpers/attendants at 16.5 percent (95% CI 14.3- Also, while the proportion of formally trained injection 18.7) health facilities. At several health facilities more administrators in the government sector remained than one type of personnel were seen administering nearly the same in rural [92.1%] and urban [94.9%] injections (Table 4.5.12). areas at the national level, (probably reflecting standard eligibility criteria for such personnel); in the Thus, there was a remarkable degree of congruence private sector significantly more injection between the three sources of information regarding administrators had received formal training in the the type of personnel involved in administering urban areas [62.3%: 95% CI 58.5-66.1] as compared to injections i.e., direct observation, prescribers’ views that in rural areas [43.7%: 95% CI 39.9-47.4] (Table and community recall (Table 4.5.11,Table 4.5.12, Table 4.5.14) (Table 4.5.15 and Table 4.5.16). 4.5.13). 4.5.2. Sterilisation of Injection Equipment Training of Personnel Administering Injections Sterilisation of injection equipment is a critical The prescribers were asked about the mode of training component of injection safety. The appropriate (formal, informal or on-the-job) received by the sterilisation of injection equipment, in turn is injection administrators at the health facility. dependent upon a variety of factors viz. the type of personnel involved in the sterilization process, their Nearly two thirds [60%: 95% CI 57.3-62.7] of injection training, the availability and efficient functioning of administrators at the all India level had received the sterilisation equipment. formal training and a little more than one third [38.9%: 95% CI 36.2-41.6] had received on-the-job training in administering injections. A small proportion of All these factors were studied in detail through direct injection administrators had received informal training observation by the senior investigators of the health [5.2%: 95% CI 3.8-6.5] (Table 4.5.14). facilities as well as through interviews of doctors at the health facilities. There were prominent differences in the training mode of injection administrators in the government and the Personnel Involved in Sterilisation private sector. Two things stood out from this profiling. Assessment of the personnel involved in sterilisation One, that nearly all the injection administrators in the was done by asking the prescribers about the types of government sector were [92.9%: 95% CI 90.7-95.0%] personnel involved in the process of sterilisation at formally trained to give injections compared to less their health facilities and this was triangulated through than half in the private sector [48.9%: 95% CI 45.4-52.4]. direct observation of the sterilisation process (where Second, on the job training was the preferred mode of possible) by the senior investigators.

Results - 3232 - Assessment of Injection Practices in India

The estimates derived from prescriber interviews and much higher proportion of government health facilities those obtained through direct observations were found [23.6%: 95% CI 20.5-26.7] than in the private sector to be consistent. [5.5%: 95% CI 4.3-6.8] (Table 4.5.21).

Through direct observation, it emerged that Sterilisation Equipment sterilisation was primarily done by paramedics in the Among other aspects related to sterilisation, senior government health facilities (58.2%) and immunisation investigators directly observed the availability and clinics (59.8%). On the other hand, doctors themselves functioning of the sterilisation equipment (one or more [19.2%: 95% CI 16.2-22.2], paramedics [14.9%: 95% CI of: autoclave/ cooker/ boiling pan) at various types 12.5-17.5] and helper/attendants [14.1%: 95% CI 11.6- of health facilities. 16.7] were all involved at private health facilities in the sterilisation process. Doctors were rarely involved At the country level, where the investigators could in government health facilities [2.4%: 95% CI 1.1-3.6] check the health facilities for sterilisation equipment, (Fig. 4.5.7) (Table 4.5.17 and Table 4.5.19). it was available at two thirds [65.2%: 95% CI 62.5- 67.9] of the health facilities. Surprisingly, the Fig. 4.5.7 availability of sterilisation equipment was nearly identical in both the rural [65.1%: 95% CI 61.1-69.1] and urban [65.4%: 95% CI 61.6-69.3] areas. (Table 4.5.22)

Sterilisation equipment was available at a much higher proportion of government health facilities [84.2%: 95% CI 81.4-87.1] and immunisation clinics [76.9%: 95% CI 73.9-80.0] as compared to the private sector facilities [57.7%: 95% CI 54.1-61.3]. (Table 4.5.22)

Direct observation revealed the exclusive use of disposable injection equipment at a larger proportion It was interesting to note that facilities for sterilisation of private health facilities as compared to those in the did not exist at 23 percent of government health government sector and this could be a possible facilities, 51 percent of private health facilities and 26.5 explanation for the lower availability of sterilisation percent of immunisation clinics. These probably equipment at these facilities. reflected the exclusive use of plastic/disposable syringes/needles at their health facilities. (Table 4.5.18, Mere availability of equipment does not ensure that it Table 4.5.19 and Table 4.5.20) is used. It is not uncommon to find that various types of equipment is available, but remains unused or Guidelines for Sterilisation become non-functional and in need of repair. To get a Prescribers were asked about the availability of written true measure of the availability of sterilisation guidelines for the sterilisation of syringes and needles equipment, the investigators also assessed whether the at their health facilities. available equipment was functional.

It was disappointing to note that written guidelines It was comforting to note that at the all India level, were available only at one tenth [10.1%: 95% CI 8.8- three fourths [75.9%: 95% CI 72.7-79.0] of the available 11.4] of all health facilities at the country level. At 4.4 sterilisation equipment was functional. The proportion percent (95% CI 3.4-5.5) health facilities the prescribers of functional sterilisation equipment was similar in said that they weren’t aware/were not sure if such both the urban [73.7%: 95% CI 68.9-78.4] and rural guidelines were available at their facility. (Table 4.5.21) areas [76.7%: 95% CI 72.5-80.9]. (Table 4.5.23)

Such guidelines were available at a higher proportion Fuel Availability for Sterilisation of health facilities in the urban areas [14.9%: 95% CI Fuel for sterilisation (one or more of: kerosene/LPG/ 12.2-17.8] as compared to that in rural areas [8.2%: 95% coal/wood/electricity) was available in three fourths CI 6.8-9.6]. Also, such guidelines were available at a [75.6%: 95% CI 73.1-78.1] of the health facilities at the

- 3333 - Results Assessment of Injection Practices in India country level on the day that senior investigators went the injection/treatment tray at various health facilities for direct observation. Availability of fuel for in the country to assess their hygiene. sterilisation was similar in the rural [76.4%: 95% CI 72.4 - 80.3] and urban areas [73.6%: 95% CI 69.8-77.4] In order to analyse the results of these observations; a of the country. (Table 4.5.24) composite indicator was developed that reflected an unhygienic injection/treatment tray. The indicator Fuel availability was higher in the government health included a list of the presence of one or more of the facilities [90.3%: 95% CI 87.9-92.7] as compared to the following in the injection/treatment tray. private sector [69.8%: 95% CI 66.4 -73.2]. This was probably a reflection of the exclusive use of disposable 1 Open/soiled plastic syringes injection equipment in higher proportion at private 2 Soiled glass syringes health facilities as compared to that in the government 3 Disposable/metal needles lying open 4 Soiled swabs sector (Table 4.5.24). 5 Open multi-dose vials Awareness of Sterilisation Process among Prescribers Prescribers were asked about the steps they took for Health facilities where any of these articles were sterilising injection equipment at their health facility. noticed in the injection tray were deemed to have an It was disturbing to note that at the country level, more ‘unhygienic injection environment’. than half [55.6%: 95% CI 51.7-59.5] of the prescribers reported incorrect sterilisation procedures (i.e., Injection/ Treatment Tray: Direct Observation duration of sterilisation depends on the number of Two thirds [69.5%: 95% CI 66.9-72.1] of health facilities patients/only syringes are autoclaved/only needles at the country level, the injection environment was are autoclaved/boiling without specification/no need unhygienic. The injection environment was unhygienic to boil/cleaning or flushing with clean water or spirit at nearly three fourths [73.6%: 95% CI 70.2-77.0] of is acceptable). (Table 4.5.25) health facilities in the rural areas compared to 58.9 percent (95% CI 54.1-63.8) health facilities in the urban A higher proportion of prescribers in the private sector areas (p=0.000). (Table 4.5.26) (61.2%: 95%CI 55.5-67.0) had incorrect knowledge about the sterilisation process as compared to the Also, there were significant differences in the injection prescribers managing government health facilities. environment at various types of health facilities in the There were no rural-urban differences in the level of country. In the private sector, the injection appropriate knowledge. This information assumed environment was unhygienic at two thirds [66.6%: 95% greater importance in the context that a larger number CI 63.2-69.9] of the health facilities. The situation in of prescribers (19.2%) in the private sector were the government sector was worse where at three directly involved in the sterilisation process in their fourths of the government health facilities [76.4%: 95% clinics as compared to only 2.4 percent prescribers at CI 73.4-79.5] and immunisation clinics [75.7%: 95% CI the government health facilities. 72.5-78.9] the injection environment could be labelled as unhygienic (Table 4.5.26). The lack of availability of written guidelines for sterilisation (available at only 10.1% health facilities It would be relevant to mention that an unhygienic at the country level) combined with poor levels of environment and the quantum of unsafe injections (as awareness of the correct sterilisation process among assessed through direct observation - discussed in the prescribers, despite the availability of functional section 4.4 on Safety of injections) appeared to go hand- sterilisation equipment along with fuel, could be in-hand. Where overall 62.9 percent injections were among the various reasons for poor safety of injections found unsafe at the country level, the injection administered with glass syringes as seen in the environment was found unhygienic at 69.5 percent previous section on safety of injections. health facilities.

4.5.3 Injection Environment Injection Environment: Direct Observation – Ratio of One of the important factors affecting the safety of an Needles to Syringes injection is the hygiene of the treatment/injection tray. As part of the observation process of the contents of Senior investigators directly observed the contents of the injection/treatment tray, the investigators also

Results - 3434 - Assessment of Injection Practices in India closely examined the injection equipment present in study. This involved exploration of the perceptions of these trays. Ideally, the number of syringes and needles doctors and the community on injection related waste should be the same in an injection tray. The presence disposal through interviews and direct observation of of more needles than syringes or vice versa is an injection related waste disposal at health facilities. indicator of the reuse of either the syringes or the needles. 4.6.1 Guidelines for Waste Disposal Written guidelines for injection related waste disposal At the country level, at nearly half (45.4%) of the health were available only at 14.2 percent (95% CI 12.6-15.7) facilities, the number of syringes in the injection tray of the health facilities. Guidelines were available at a differed from the number of needles in it; at 41.5 larger proportion of health facilities in the urban areas percent (95% CI 38.8-44.2) of the health facilities [25.9%: 95% CI 22.6-29.1] as compared to those in the needles were in excess of syringes. (Table 4.5.27) rural areas [9.6%: 95% CI 8.0-11.2] (p=0.000). Similarly, a larger proportion of facilities in the government The presence of more needles than syringes in the sector had written guidelines on injection waste injection tray was observed more often at health disposal [25.6%: 95% CI 22.6-28.6] than their facilities in rural areas [44.3%: 95% CI 40.9-47.7] than counterparts in the private sector [10.3%: 95% CI 8.6- in the urban areas [34.1%: 95% CI 30.5-37.8]. 11.9] (p=0.000). (Table 4.6.1)

At half of the health facilities in the government sector 4.6.2 Waste Disposal at Health Facilities [49.6%: 95% CI 46.1-53.2] and immunisation clinics Senior investigators observed the manner in which [50.4%: 95% CI 46.8-54.1] the injection trays had more plastic syringes and needles were collected after use needles than syringes as compared to 37.9 percent (95% at various health facilities. To analyse the results of CI 34.3-41.4) of health facilities in the private sector. these observations, the disposal was characterised as (Table 4.5.27). ‘satisfactory’ / ‘unsatisfactory’ based on a composite variable, which was derived as follows: 4.6 Waste Disposal ‘Satisfactory disposal’ of plastic syringes at health facility level (if disposed in any one of the following Medical waste disposal is an issue that has attracted a ways). lot of attention and concern because of the detrimental effects of improper medical waste disposal on the environment. Keeping in view the huge burden of 1. Put in a jar containing hypochlorite solution 2. Collected in a dustbin injections in the country and the large proportion of 3. Broke the syringe and threw away into dustbin injections given with plastic syringes, injection related waste has significant implications for environmental safety. 'Unsatisfactory disposal' of plastic syringes at health facility level (if disposed in any one of the following Injection waste disposal has to be seen at two levels – ways) the health facility and the terminal level, because both have different requirements in terms of the systems 1. Thrown on the floor/littered set in place as well as training of concerned personnel 2. Put in a tray/placed on a table to manage the system. 3. Put in a pan of water/boiler/steriliser

While health facility level disposal requires a greater focus on training of health providers to dispose waste Waste Disposal at Health Facilities - Direct safely at their individual facilities, terminal disposal Observation demands a much wider system. It requires the At the all India level, plastic syringes were disposed involvement of health providers on the one hand and off in a satisfactory manner at 61.3 percent (95% CI the municipal system on the other and has a much 58.2-64.3) of health facilities. Satisfactory disposal was larger impact on the environment. observed at a higher proportion of urban health facilities [69.6%: 95% CI 66.0-73.1] at the country level, A detailed assessment of various issues related to compared to those in the rural areas [57.9%: 95% CI injection waste management was done during the 53.8-62.0] (Table 4.6.2).

- 3535 - Results Assessment of Injection Practices in India

While the estimates were quite similar for government Figure 4.6.2 health facilities [60.5%: 95% CI 56.7-64.2] and private health facilities [62.3%: 95% CI 58.6-65.9], satisfactory disposal of plastic syringes was least at the immunisation clinics [50.9%: 95% CI 46.7-55.2] (Table 4.6.2). Figure 4.6.1

Zone 1 Chandigarh, Delhi, Zone 3 Bihar & Punjab, Himachal Jharkhand Pradesh, J&K and Haryana Zone 10 Orissa Zone 11 Maharashtra and Goa Health facility level disposal of used plastic syringes Zone 15 Kerala Zone 13 Karnataka was consistently better in the urban areas of the country as compared to their rural counterparts in all 4.6.3 Terminal Waste Disposal sectors: government [rural: 59.3% vs. urban: 63.4%], In addition to the observation of injection related waste immunisation clinics [rural: 48.6%; urban 56.2%] and disposal at the health facility level, the manner of private [rural: 58.1% vs. urban 72.6%]. (Table 4.6.2) disposal of injection waste from the health facilities (Fig. 4.6.1) was also examined in detail. Terminal waste disposal was studied both by direct observation and through Waste Disposal at Health Facilities – Zonal in depth interviews of prescribers and the community. Variations Significant variations at the health facility level waste Segregation of Waste at the Health Facility disposal were observed between different Zones. Segregation of medical waste in appropriate categories Satisfactory disposal of used plastic syringes was at the health facility level is not merely a step towards observed at more than three fourths of the health its correct disposal; it is an indicator of efforts to put facilities in Zone 1 (Delhi, Punjab, Haryana, Himachal in place a system of waste disposal. Prescribers were Pradesh and J&K) [85.3%: 95% CI 78.7-91.9], Zone 10 asked about waste segregation at their health facilities (Orissa) [77.7%: 95% CI 68.8-86.7] and Zone 15 (Kerala) using colour-coded plastic bags. [79.7%: 95% CI 71.3-88.0]. It was noted that as per the prescribers’ views, waste The least satisfactory disposal was in Zone 3 (Bihar, was being segregated at only 6.2 percent (95% CI 4.5- Jharkhand) [45.5%: 95% CI 33.5-57.6], Zone 11 7.8) of health facilities at the country level. Waste (Maharashtra, Goa) [49.8%: 95% CI 41.6-57.9] and Zone segregation was done at the same proportion of health 13 (Karnataka) [36.5%: 95% CI 27.9-45.1]. (Fig. 4.6.2) facilities in the rural [6.2%; 95% CI 4.1-8.3] as well as (Table 4.6.2). in the urban areas [6.1%: 95% CI 4.5-7.8]. Similarly, there were no significant differences in the proportion It was interesting to note that for waste disposal, all of health facilities segregating waste in the government sectors of health care worked similarly in a particular sector [7.6%: 95% CI 5.5-9.8] and the private sector zone. (Figure 4.6.2). This type of consistency regarding [5.7%: 95% CI 3.7-7.6] (Table 4.6.3). waste disposal at the Zonal level suggested two things. Firstly, there are states where some kind of mechanism Seen together with the small number of facilities (14.2 had been evolved for waste disposal and secondly, percent facilities at the country level) where written waste disposal was an issue that was reflected in all guidelines for waste disposal were available; the the sectors in a Zone. disappointingly small proportion of health facilities

Results - 3636 - Assessment of Injection Practices in India where waste was segregated, indicated that current Satisfactory terminal disposal was observed at the efforts at proper waste management were grossly highest proportion of health facilities in Zone 1 (Delhi, inadequate. Punjab, Haryana, Himachal Pradesh and J&K) [62.9%: 95% CI 54.6-71.1] and Zone 15 (Kerala) [74.9%: 95% Terminal Disposal of Injection Waste CI 66.5-83.3] (Table 4.6.4). Similar to the disposal of plastic syringes/needles at the health facility level, the investigators also observed Satisfactory terminal disposal was observed at the the manner in which this waste was disposed off from lowest proportion of health facilities in Zone10 (Orissa) the health facility. [26.8%: 95% CI 16.2-37.3] and Zone 6 (Manipur, Nagaland, Mizoram) [29.9%; 95% CI 20.4-39.4]. ‘Satisfactory’ terminal disposal was characterised as disposal of used syringes/needles at the health facility Sale of Medical Waste to Rag Pickers by one of the following methods: One of the areas of prime concern regarding injection safety is the recycling of plastic syringes/needles. One 1. Buried in a pit of the principal mechanisms of recycling is the sale of 2. Carried away by municipality/Panchayat workers plastic syringes/needles by health facilities to waste- 3. Sent to incinerators pickers who in-turn sell it to recyclers. Prescribers were interviewed to determine the proportion of health 'Unsatisfactory' terminal disposal was characterised facilities where used plastic syringes/needles were as disposal using one of the following methods: being sold to waste-pickers.

At the country level, at 9.7 percent (95% CI 7.7-11.8) 1. Thrown out of health facility on road/lane/drain of health facilities, used plastic syringes/needles were 2. Dumped in a regular dustbin along road/ lane being sold off to waste-pickers. Waste was sold at a 3. Sold/given away to waste pickers/kabadiwallas slightly larger proportion of health facilities in the rural areas [10.6%: 95% CI 7.9-13.4] than in urban areas Terminal Disposal at Health Facility Level: Direct [7.5%: 95% CI 5.3-9.7] (Table 4.6.5). Observation At the country level, satisfactory terminal disposal of Selling of used plastic syringes/needles was mostly injection waste was observed in less than half of the done in the private sector where prescribers at 12.0 health facilities [44.8%: 95% CI 41.9-47.7]. Terminal percent [95% CI 9.3-14.8] of health facilities admitted disposal was better at health facilities in the urban that used plastic syringes/needles were sold off, areas [51.2%: 95% CI 46.9-55.5] than those in the rural compared to just 2.7 percent of health facilities in the areas [42.2%: 95% CI 38.5-45.9]. (Table 4.6.4) government sector (95% CI 1.7-3.8). (Table 4.6.5)

Overall, terminal disposal in the government health Direct observation of the terminal disposal of injection facilities, immunisation clinics and private sector waste from the health facilities corroborated what the health facilities required major improvement (Table prescribers had said about the sale of injection waste. 4.6.4). At the all India level, at 11.5 percent (95% CI 9.5-13.6) health facilities, it was observed that used plastic For all types of health facilities (government, private syringes/needles were being sold. The sale of injection and immunisation clinics), satisfactory terminal waste was seen more in the private sector [15.2 percent disposal was poorer in the rural areas as compared to (95% CI 12.3-17.9)] than in government health facilities the corresponding facilities in the urban areas, the - 3.2 percent (95% CI 1.9-4.5). difference being most significant at the immunisation clinics [rural: 43.6%; 95% CI 38.5-48.7; urban: 61.9%: Health Facility and Terminal Level Disposal 95% CI 57.2-66.6] (Table 4.6.4). As shown in Figure 4.6.3, terminal disposal was consistently less satisfactory than health facility level Terminal Waste Disposal – Zonal Differences disposal across all sectors. This pattern was true across As was the case with health facility level injection all the Zones. waste disposal, there were prominent Zonal differences in the terminal level disposal also. Considering that terminal disposal had a much larger

- 3737 - Results Assessment of Injection Practices in India impact on the environment on a larger scale and that areas [72.8%: 95% CI 69.2-76.4] reported that they had a huge amount of waste was generated on account of satisfactory terminal disposal methods in their health the use of plastic syringes in the country, there was an facilities as compared to prescribers in the rural areas urgent need to establish systems for safe terminal [56.1%: 95% CI 51.9-60.4]. disposal of injection waste. Similarly, a higher proportion of prescribers at Figure 4.6.3 government health facilities [69.6%: 95% CI 66.1-73.0] Satisfactory Health Facility Level and Treatment Level claimed to have satisfactory terminal waste disposal Injection Waste Disposal (Director Observation) methods as compared to their counterparts at private health facilities [57.9%: 95% CI 54.2-61.6] (Table 4.6.6). Health Facility and Terminal Level Disposal - Direct Observation vs. Prescriber Perspectives (Figure 4.6.4) A significant difference existed between the observed status of waste disposal methods and those claimed by the prescribers working in these health facilities. Clearly, a wide gap existed between the current knowledge level of prescribers and their practices to achieve satisfactory waste disposal. Data also 4.6.4 Stakeholders’ Perspectives on Injection Waste indicated that steps were necessary to improve In addition to direct observation of the disposal of prescriber knowledge particularly related to terminal injection waste both at the health facility and terminal waste disposal and put mechanisms in place to ensure translation of prescriber knowledge to practice. (Fig. level, perceptions of prescribers as well as the 4.6.4) community were explored to understand their views regarding injection waste. Figure 4.6.4

Waste Disposal at Health Facilities - Prescriber Perspectives At the country level, 87.3 percent (95% CI 85.3-89.4) prescribers described the manner of disposal of plastic syringes at their facilities, which could be termed as satisfactory. There were no major differences in the proportion of prescribers in both the rural as well as urban areas and also in the government as well as in the private sector, who could enumerate ‘satisfactory’ methods of waste disposal [government sector 90.1 percent (95% CI 87.8-92.5), private sector 86.4 percent (95% CI 83.9-88.9); rural areas 85.5 percent (95% CI

82.8-88.3), urban areas 92.0 percent (95% CI 89.9-94.1)]. Prescriber perspective was not obtained at Immunization Clinics (Table 4.6.6) Stakeholders' Perception of Dangers of Improper Injection Waste Disposal Since the observations and interviews were conducted Prescribers, clients coming out of health facilities and at the same health facilities it was noticed that while respondents in the community were asked about the proportion of prescribers having knowledge of problems that could occur in the community if used correct injection waste disposal was as high as 87.3 syringes/needles were thrown in drains/garbage percent at the country level, satisfactory disposal was dumps/along the roads. actually observed at only 61.3 percent health facilities. According to both the clients [58.6%: 95% CI 56.9-60.2] Terminal Disposal – Prescriber Perspective as well as the prescribers [93.6%: 95% CI 92.4-94.8] the Overall, 60.8 percent (95% CI 57.8-63.7) prescribers at most common complications that could occur due to the country level claimed that there was satisfactory improper injection waste disposal were physical injury terminal waste disposal at their health facilities. A and/or spread of disease/infection. (Fig. 4.6.5) (Table much higher proportion of prescribers in the urban 4.6.7).

Results - 3838 - Assessment of Injection Practices in India

Figure 4.6.5 4.7.1 Profile of Complaints Presented at Outpatient Clinics Dangers of Improper Disposal of Used Syringes / Needles - Prescriber and Community Perceptions* Patients with symptoms of fever, cough and diarrhoea constituted over half [53.3%: 95% CI 51.7-54.9] of all patients attending the outpatient departments of public and private health facilities. The other major category of patients had a mixture of symptoms for other types of infections, injuries, swellings, etc. [45.5%: 95% CI 43.9-47.2]. A very small proportion of patients [1.1%: 95% CI 0.9-1.4] had non-specific symptoms only viz. weakness, restlessness, etc. There were no major differences in the profile of patients attending private or public sector outpatients and in rural or urban areas. (Table 4.7.1)

It was noted that only about one fourth [26.2%: 95% 4.7.2 Reasons for Receiving Last Injection During the field survey, the community and patients CI 23.8-28.5] of the prescribers were aware of the coming out of government and private health facilities danger of waste handlers picking up and reusing were asked about the symptoms for which the last syringes that were thrown away in dumps/on the injection was prescribed. road. Very few respondents [5.0%: 95% CI 4.4-5.5] from the community and patient group seemed to be aware The community survey as well as data from exit of this danger. interviews indicated that half [51.7%: 95% CI 49.8-53.7 - Community survey; 51.1%: 95% CI 48.9-53.3 - Exit interviews] of the curative injections at the all India level Environmental pollution/risk to animals were were prescribed for symptoms like fever/cough/ perceived as problems arising out of improper diarrhoea. It is important to emphasise that all these injection waste disposal by a small proportion of symptoms were being managed on an outpatient basis. respondents in the community [16.6 percent: 95% CI (Table 4.7.2 ; Table 4.7.3 and Table 4.7.4 ) 15.4-17.8] as well as by prescribers. [21.5%: 95% CI 19.1- Both in community data and exit interviews there were 23.9] (Table 4.6.7). no major state/Zonal variations in the reasons given for injection prescriptions. The perceptions about dangers of unsatisfactory disposal were similar among those respondents in the Patients with other symptoms like swelling, injuries, community who had received injections in the last and symptoms of other infections received the remaining half [44.4 percent according to community three months and those who had not and the clients surveys; 47.7 percent according to exit interviews] of all exiting the health facilities. injections. A small proportion of injections were prescribed for patients with symptoms of weakness 4.7 Determinants of Injection Prescription or restlessness.

No significant differences in the prescriptions for A very large number of injections are administered in injections according to the symptoms were noted India and over 80 percent of these are given for between urban and rural areas and between curative reasons. An important study question was to government and private health facilities. assess the rationality of these injection prescriptions, particularly for indicator conditions viz. fever, cough Injection Prescription as a Function of Presenting and diarrhoea. It was equally important to capture the Symptoms It was interesting to note that irrespective of the type dynamics of client-prescriber interaction and identify of symptom(s), the possibility of a client receiving an the determinants of injection prescription. injection for his/her symptoms was approximately 50

- 3939 - Results Assessment of Injection Practices in India percent [community survey: fever/cough/diarrhoea Reasons for Receiving Last Injection: Age Related – 53.0% (95% CI 50.5-55.3); weakness – 48.3% (95% CI Differences 45.0-51.6); other symptoms – 51.7% (95% CI 49.8-53.7)] Of all the curative injections given to children below (Table 4.7.5). Information obtained during exit one year of age, 85.4 percent (95% CI 79.1-91.7) were interviews was similar. (Fig. 4.7.1) (Table 4.7.6). administered for complaints of fever/cough/ Figure 4.7.1 diarrhoea. Injection Prescription as a Function of Presenting Symptoms: Exit Interview of Clients at Health Facilities In contrast, individuals older than one year were receiving almost an equal proportion of injections for fever/cough/diarrhoea [50.2%: 95% CI 48.3-52.2] and other symptoms [46.5%: 95% CI 44.5-48.5]. (Fig. 4.7.3) (Table 4.7.7) Figure 4.7.3 Age Related Differences in Reasons for Injection

Overall, 48.1 percent of clients (95% CI 46.3-49.9) attending any outpatient clinic in the country were likely to receive an injection; injections were prescribed more in the private sector [50.6%: 95% CI 48.5-52.7] Clients >1yr old than in the government sector [40.7%: 95% CI 38.6- 42.9] (p=0.000).

There were Zonal variations in the injection prescription rates for indicator conditions like fever/ cough/diarrhoea (Fig. 4.7.2). Figure 4.7.2

Figures represent proportions Other Factors that Influenced Prescription of Injections In multivariate analysis, factors like receiving oral drugs before coming to the present health facility (OR = 0.7); previous injections for current illness (OR=2.1); illness severe enough to cause loss of wages or missing school (OR=1.4); type of practitioner (ISM practitioner - OR=1.5; informal practitioner - OR=1.9 with allopathic practitioner as base) were independent predictors for receiving injections during their current visit to the health facility. It was interesting to note that those who had received oral drugs before were Zone 4 West Bengal & Zone 9 Madhya Pradesh 30 percent less likely to receive injections during this A&N Islands & Chattisgarh visit. Zone 15 Kerala Zone 1 Chandigarh, Delhi, Punjab, Himachal Pradesh, J&K & Haryana 4.7.3 Decision about Injection Prescription Zone 6 Manipur, Nagaland, Zone 7 Rajasthan Mizoram & Tripura To understand the dynamics of decision making about injections, the interactions between the prescriber and

Results - 4040 - Assessment of Injection Practices in India

communication between prescriber and client was the Independent Odds 95% p value Variables Ratio CI miniscule proportion of cases [3.9%: 95% CI 95% CI 3.0-4.9] in which the prescriber discussed the cost of Previous Oral Drug 0.71 0.63-0.79 0.00 injection and medicines with the client before writing Previous Injection 2.13 1.79-2.58 0.00 Missed School/Work 1.40 1.23-1.58 0.00 the prescription. Informal Practitioner 1.89 1.48-2.29 0.00 ISM Practitioner 1.49 1.22-1.82 0.00 Contrary to the popularly held belief that large numbers of clients receive injections because they client were observed by the senior investigators. This demand injections; the direct observations of client – interaction could be seen as a continuum of the prescriber interaction revealed that in only one fifth perceptions of both the prescriber’s and client’s need of cases [19.2%: 95% CI 17.2-21.2] the clients had asked for injectables and oral drugs during the illness. for an injection. There was consistency in the proportion of client demand for injections across Client Prescriber Interaction – Direct Observation To understand the dynamics of decision making about settings. It was observed that a similar proportion of prescribing/receiving an injection, the interaction clients in rural [19.3%; 95% CI 16.8-21.8] and urban between clients and prescribers were directly observed [18.8%; 95% CI 15.5-22.1] areas as well as in by senior investigators (Fig.4.7.4). In 41.5 percent (95% government [19.5%: 95% CI 17.0-21.9] and private CI 38.7-44.3) cases, clients had been prescribed [19.1%: 95% CI 16.8-21.4] health facilities, demanded injections without the prescriber discussing it with injections. them. This lack of proper communication with the client about his prescription was observed more in the Client Prescriber Interaction – Exit Interview government health facilities [48.1%: 95% CI 44.4-51.8] In addition to the direct observation of client prescriber as compared to private health facilities [39.6%: 95% interaction, clients coming out of health facilities were CI 36.4-42.8] (p=0.000) (Table 4.7.8). asked about their interactions with the doctor and how the decision had been arrived at for the injection they Figure 4.7.4 had received during their current visit to the health facility. Thus, two sources of information were used to triangulate the process of injection prescription at health facilities.

An overwhelming majority of respondents [92.2%: 95% CI 90.9-93.4] said that the prescriber had decided on prescribing the injection. Correspondingly, only 7.9 percent (95% CI 6.7-9.1) clients at the country level (who had received an injection on their current visit), said that they had requested/expected to receive an injection during their visit. The estimates for client In another 29.1 percent (95% CI 26.6-31.6) of prescriber- client interactions, doctors were observed to be driven injections were similar in rural and urban areas insisting/encouraging the patient to receive an as well as in government and private sector health injection for his/her current illness (Table 4.7.8). Thus, facilities. injections were predominantly decided by the prescriber [70.5%: 95% CI 68.0-73.1]. Interestingly, the The data clearly showed that in most of the country, proportion of prescriber driven injections was nearly the prescriber made the decision about the injections the same in rural areas [70.6%: 95% CI 67.5-73.8] and [direct observation: 70.5 percent; exit interview: 92.2 the urban areas [70.3%: 95% CI 66.6-74.1] and also in percent]. Contrary to widely held belief, the government health facilities [71.9%: 95% CI 68.9-74.8] proportion of clients demanding injections was much and private health facilities [70.2%: 95% CI 67.3-73.2]. lower [exit interview: 7.9 percent; direct observation: 19.6 Perhaps a telling comment on the quality of percent].

- 4141 - Results Assessment of Injection Practices in India

4.7.4 Determinants of Injection – Stakeholders’ A range of answers was available that could be broadly Perception categorised into two major domains: A) situations Observations of the client-prescriber interactions and where doctors primarily decided and clients accepted interviews of client at exit indicated that prescribers and B) irrational medical reasons, which could be were the predominant decision makers regarding broadly termed as expectations from injections. Under injections. However, it was still not clear why doctors each category, there were sub-domains explaining the chose to prescribe injections to so many of these major domains (table below). patients. Injection Prescription – Injection Preference: A Vicious The study explored the perceptions of key stakeholders Cycle i.e., the prescribers and clients regarding their Clients perceived several benefits (e.g. quick relief, preference to prescribe/receive injections. Prescribers more effective) of the injections along with and respondents in the community were asked about psychological relief due to injections. Almost three the perceived preference for injections, when equally fourths of the clients [73.8%: 95% CI 72.5-75.1] cited effective oral drugs were available. these as the reasons for their preference for injections. These were irrational medical reasons, but probably In addition, the prescribers were asked about reflected client expectations from injections. A vast situations when they preferred to prescribe injections. majority of clinicians (88.6%) across the country

Determinants of Injections: Stakeholders' Perspective: (Why Prescribers/Clients Prefer Injections?)

Results - 4242 - Assessment of Injection Practices in India understood these expectations of their patients; clients accepted it. Enquiries with clients also revealed psychological relief to patients (53.8%) was given that a significant proportion of clients [44.1%; 95% CI particular importance in the dynamics of the 42.7-45.6] accepted the doctor’s decision even when prescriber-client relationship by their doctors (Table they perceived the injection as unnecessary [16.2%: 4.7.9). 95% CI 15.0-17.4].

An overwhelming majority [92.6%: 95% CI 91.2-94.0] Thus overall it appeared that a vicious cycle existed of prescribers across the health facilities claimed to between clients and prescribers regarding injections. adopt rational reasons for prescribing injections. Prescribers appeared to be fulfilling client expectations However, along with these responses, one third by prescribing more injections. In India, almost every [32.8%: 95% 30.0-35.6] of the prescribers also accepted second individual attending an outpatient clinic was that they were influenced by the client’s expectations. prescribed an injection. This high volume of injections It appeared that at least some of them may have was likely to further reinforce client misgivings about misgivings about reasons like quick relief and higher effectiveness and quick relief of any type of symptoms effectiveness of the injections [18.1%: 95% CI 15.7-20.5]. by injections.

Observation of client-prescriber interactions and later To break this vicious cycle, appropriate interventions interviews with patients coming out of the health and behaviour change communication strategies are facilities indicated that most of the times (70.6% to required. Data showed that clients and prescribers will 92.2%), doctors took the decision regarding the require different messages and strategies of prescription including prescribing injections and the communication to be effective.

- 4343 - Results Assessment of Injection Practices in India

5. Discussion

In India injections are frequently administered and percent for the three months recall period. According there are major safety concerns about the procedure. to the two-week recall period, the proportion of infants The observations made in this study have to be (<1yr old) receiving injections was twice the number interpreted and discussed in the light of their larger (23%) as compared to those older than one year (10%). public health relevance and policy implications. The The total burden of injection was estimated by results from the study hold relevance for new policy calculating the total number of injections received per guidelines or modification of existing programmes and person per year. Overall 5.8 injections were received practices related to injections administered in India. per person per year in the country according to two Notwithstanding these perceptions, policy and weeks recall. The corresponding figure based on three programme related decisions could only be made on month's recall was 2.9 injections per person per year. the basis of evidence generated from all parts of the The large variation in the figures for the two periods country. was probably due to respondents recall bias. Another reason could be the cohort effect, a proportion of IndiaCLEN Programme Evaluation Network on behalf population was more likely to get injections repeatedly of the Ministry of Health, Government of India, and (Table 5.1.1). World Bank undertook 'Assessment of Injection Practices in India'. The whole country was divided into Thus in a population of little over 100 crore, almost 15 Zones and investigators from 69 medical colleges, 300 crore (according to three months recall) injections nine health sector NGO's and six state health were administered in a year. institutions participated in this study. Based on the observations made in the study regarding the location of these injections (public sector 30% vs. 5.1 Burden of Injections private sector 70%), type of injections (curative 83% vs. preventive injection 17%) and distribution of preventive The study results showed that a large proportion of injections in two age groups (<1yr old- 35% vs. >1 yr the population was receiving injections at any point old individuals 65%) a model was developed. of time. Two recall periods were used for estimating According to data, 63 percent of all the injections the burden of injections in the country: two weeks and administered in India were unsafe; 60 percent of those three months recall prior to the time of interview with given in the private sector were unsafe, while this community members. In two weeks prior to the proportion was 70 percent in the government sector survey, 10.8 percent of the population in India had (government health facilities and immunisation received injections. This proportion increased to 27.1 clinics). Based on calculations on the three months

Table 5.1.1: Burden of Injections in India

Age Category

< 1 year ≥ 1 year Total

No. of injections / person / year Rural 5.3 2.9 3.0 (based on three month recall) Urban 6.3 2.7 2.9 Total 5.6 2.8 2.9 No. of injections / person / year Rural 8.4 6.0 6.1 (based on 2 week recall) Urban 9.3 4.6 4.9 Total 8.7 5.6 5.8 Proportion of injections as Rural 60.9 11.1 15.9 vaccines in past three months Urban 68.0 15.1 21.6 Total 63.2 12.2 17.5

Discussion - 4444 - Assessment of Injection Practices in India recall period, i.e., 300 crore injections, per year, the conditions do not recommend injections for ambulatory distribution of injections according to the sector and patients. type of injections is provided in the Table 5.1.2. Clearly a sizeable proportion of the injections currently Table 5.1.2: Annual Burden of Injections in India prescribed could be labelled as ‘unnecessary’. An (Modelling Estimates Based on Three Months' Recall) important study question was to assess the determinants of injections. The study explored the Type of Public Private Total Injections Sector Sector perceptions of key stakeholders i.e., the prescribers and clients regarding their preference to prescribe or receive Curative 58 191 249 injections.

Vaccines <1 yr 14 4 18 Almost three fourths of the clients (73.8%) perceived ≥1yr 18 15 33 several benefits (e.g. quick relief, more effective way Total @ 90 210 300 of treatment of illness) of the injections along with (Unsafe) (63) (126) (189) psychological relief. These were irrational medical *All numbers in Crore/year. reasons, but probably reflected client expectations from @ Overall 63% injections were unsafe, 70% in public sector and 60% injections. A vast majority of clinicians (88.6%) across in private sector the country understood these expectations of their patients and perceived that injections gave In addition to the enormous burden of injections, the psychological relief to the patients (53.8%). model also suggested that: a) Besides government sector, private sector will An overwhelming majority (92.6%) of prescribers also be an important stakeholder to address across the health facilities claimed to adopt rational all issues related to injections and their safety. reasons for prescribing the injections. However, one b) Immunisations particularly those given to third of the prescribers also accepted that they were children below one year are absolutely influenced by the client’s expectations. Data also essential and all of these must be administered suggested that several of them may have the in a safe manner. These injections assume misconception that injections provide quick relief and additional significance in view of the findings are more effective (18.1%), but the majority (53.8%) that 74% injections at immunization clinics thought that injections merely gave psychological relief were administered in unsafe manner. to patients. c) The huge quantum of unsafe injections (189 crore) can potentially be associated with major Direct observation of client-prescriber interactions and public health problems. later interviews with patients coming out of the health facilities indicated that in most cases (70.6% to 92.2%), Determinants of Injection Prescription doctors made the decision regarding prescriptions and this was accepted by clients. When questioned, clients At the country level, almost every second patient also revealed that a significant proportion of them (48.1%) coming out of a health facility had received an (44.1%) accepted the doctor’s decision to administer injection for his/her illness; clients coming out of injections even when these were perceived to be private health facilities (50.6%) were more likely to unnecessary. The dynamics of the relationship between receive an injection compared to that from government doctors and their patients rests on the premise that health facilities (40.7%). It was interesting to note that doctors prescribe the most appropriate and effective irrespective of the type of symptoms, the possibility of medicine that will give ‘quick relief’. Overall it a client receiving an injection for her/his symptoms appeared that though medical reasons might be an was approximately 50 percent. Almost all of these important consideration for prescribers to write for patients were ambulatory. Three symptoms viz. fever, injections, these practices were also influenced by cough and diarrhoea were taken as indicator conditions attempts to fulfil client expectations. To certain extent to assess the rationality of injections. Almost half of clients accept the prescription laid out by their ‘doctor’ these patients (community survey - 53%; exit interview - and might not be able to adequately differentiate 46.1%) had received injections. The standard treatment between ‘necessary’ and ‘unnecessary’ injections. Thus guidelines by WHO and other organisations for these in the current context of a high volume of prescriptions

- 4545 - Discussion Assessment of Injection Practices in India for injections, prescribers might actually be reinforcing necessary for reaching both prescribers and client misconceptions about their effectiveness and communities in every part of the country. Prescribers rapidity of action, irrespective of symptoms and need to adopt rational prescribing practices keeping underlying illness. This would particularly become in mind that clients respect as well as accept their important in an environment wherein most of the decisions as appropriate. clients or patients did not understand the full implications of unsafe injections, particularly in Misplaced and exaggerated benefits about injections relation to their potential for spreading blood borne need to be clarified among our communities and they virus infections and causing local infections or need to understand the dangers of unsafe injections reactions. at the individual as well as community levels. This will facilitate better understanding among the Thus the dynamics of injection prescription – injection providers as well as the recipients and lead to preference appeared to trigger a vicious cycle (Figure preference of rational therapeutic practices, under 5.1.1). To break this cycle, an effective communication which only injections considered essential are strategy needs to be developed, addressing both the prescribed. communities and the prescribers separately, in order to reduce the burden of injections in this country. The 5.2 Safety of Injections communication strategy with a behavioural change component will have to be evolved at the national as Several factors combine to make an injection safe. well as regional levels. Prevalent socio-cultural beliefs These factors were studied in detail through direct and misconceptions about injections should be observation of the process of administering injections incorporated in this strategic communication program. (including the type of injection equipment used for All channels of communication are important and administering injection) by senior investigators. A

Figure 5.1.1: Injection Preference & Prescription: A Hypothetical Model for Client and Prescriber Behaviour

Discussion - 4646 - Assessment of Injection Practices in India checklist for safe/ unsafe injections was developed by effects of the two above-mentioned parameters. Of all the Central Coordinating Team (CCT) on the basis of the injections administered in India, one third [31.6%; various criteria given by WHO, SIGN, PATH. For the 95% CI 29.4-33.0] carried a potential risk of transmitting purpose of this study an injection was considered blood borne viruses. Unsafe injections on account of unsafe if: faulty injection technique were observed in 53.1 percent (i) It had the potential to transmit blood borne [95% CI 50.8-55.4] of injections. Together, these two viruses (HIV, HBV, HCV). This risk was likely factors made nearly two thirds (62.9%; 95% CI 60.7- to occur if the injection was administered with 65.0) of the injections unsafe at the country level [Table an inadequately sterilised syringe/ needle 5.2.1]. and/ or if syringe/ needle were reused for another patient. The number of unsafe injections was the highest at (ii) It was administered using faulty technique immunisation clinics (74.0%; 95% CI 71.4-76.6) followed (and could cause local infection and/ or by government health facilities (68.7%; 95% CI 66.1- reaction). 71.3) and private health facilities (59.9%; 95% CI 56.9- 62.8) [Table 5.2.2]. The purpose of such a classification of an unsafe injection was to delineate public health actions for the The type of injection equipment (glass or plastic two types of risks. To avoid and minimise the risk of syringe) had a profound effect on the injection safety, transmitting blood borne virus the interventions have be it potential risk of blood borne viruses transmission to address issues related to sterilisation of glass syringes (glass 70.7% vs. plastic 18.2%), faulty injection and metal needles and prevent the reuse of disposable technique (glass 73.0% vs. plastic 46.2%) or overall syringes and needles. While such interventions will unsafe injections (glass 90.8% vs. plastic 53.3%). In fact, take care of the transmission risk of blood borne virus regression analysis (Figures 5.2.1 to 5.2.3) showed that when administering an injection but other steps in there was a linear but inverse relationship between the administering injections may still be faulty. quantum of plastic syringe use in a Zone and overall prevalence of unsafe injection as well as potential blood It will require major efforts to train injection borne virus risk of infection irrespective of the type of administrators across the country in improved injection health facility. Thus, frequent use of glass syringes techniques. Hence, the interventions will be (48%) appeared to be the most important reason for qualitatively different if this aspect of unsafe injections the highest proportion of unsafe injections at is to be addressed. immunisation clinics.

Injections with the potential risk to transmit blood It was interesting to note that for a particular type of borne viruses have a major public health impact. syringe, the number of unsafe injections remained very Different mathematical models have been developed similar at all types of health facilities (Figure 5.2.4). to predict the proportion of HIV, HBV and HCV infections in the community due to such unsafe In multivariate logistic analysis, the use of glass injections. The present study assessed the burden of syringes consistently emerged as the highest risk for unsafe injections with the potential to transmit blood unsafe injections (OR=8.4 for overall unsafe injection; borne viruses, but not the impact of these injections on OR =12.2 for risk of blood borne virus transmission and the prevalence of blood borne viral infection in the OR=3.0 for unsafe injections due to faulty techniques). community. The type of health facility (OR=0.9-1.3) did not The overall unsafe injections were due to the combined influence unsafe injections as much as the type of

Table 5.2.1: Characteristics of Unsafe Injections (% of all Injections) in India

Characteristics Percentage of Unsafe Injections with Unsafe Injections with Total Injections Plastic Syringe (%) Glass Syringe (%) Overall Unsafe 62.9 53.3 90.8 Potential Risk of BBV Transmission 31.6 18.2 70.7 Faulty Technique 53.1 46.2 73.0

- 4747 - Discussion Assessment of Injection Practices in India syringe used. The number of unsafe injections was trained prescribers) was almost one and half times marginally lower in urban areas (OR=0.7-0.9) as (OR=1.3-1.9) more as compared to that with allopathic compared to rural areas. It was interesting to observe that the risk of unsafe injections when administered prescribers. at non-allopathic health facilities (ISM and informally Appropriate sterilisation of glass syringes depended

Table 5.2.2: Profile of Unsafe Injections in relation to Type of Health Facility and Type of Syringe Use

Type of Health Overall Unsafe Injections with Injections Carrying Potential Risk Facility Injections Plastic Syringe (%) of BBV Transmission (As % of total) Overall With Plastic With Glass Syringe Syringe

Government Health 68.7 62.7 35.4 18.5 63.7 Facilities Private Health Facilities 59.9 80.7 30.1 18.1 80.1 Immunisation Clinics 74.0 52.3 33.5 18.0 50.5 All India 62.9 74.6 31.6 18.2 70.7

Figure 5.2.1. Figure 5.2.3. Immunization Clinics Private Health Facilities % of all Injections

Figure 5.2.4. Figure 5.2.2 Unsafety of Injections - Glass vs. Plastic Syringes Government Health Facilities

Relationship of Unsafe Injections and Potential Risk of BBV Transmission with use of Plastic Syringe

Discussion - 4848 - Assessment of Injection Practices in India upon a variety of factors - the type of personnel virus (70.7%) with glass syringes despite availability involved in the sterilisation process and their training, of functional sterilisation equipment and its fuel at over in addition to the availability and functional status of two-third of the health facilities. Issues related to the sterilisation equipment. Written guidelines for difficulties in accomplishing proper sterilisation in sterilisation were available at only 10.1 percent of all crowded outpatient departments have already been health facilities across the country. It was disturbing to discussed. To overcome these handicaps, one option is note that more than half (55.6%) of the prescribers to encourage the use of pre-sterilised injection reported an incorrect sterilisation process. At the equipment. country level, sterilisation equipment was available at 84.2 percent of government health facilities, 76.9 Disposable syringes and needles were used extensively percent of immunisation clinics and 57.7 percent (74.5% of injections) in all health sectors and in rural as private health facilities. Over three fourths (75.9%) of well as in urban areas of the country. However, use of the available sterilisation equipment was functional. disposable injection equipment does not ensure safety. Direct observation revealed that sterilisation was Although the risk of transmitting blood borne virus primarily done by paramedics in government health with plastic syringes (18.2%) was almost one fourth of facilities (58.2%) and immunisation clinics (59.8%) and that with glass syringes (70.7%), overall, 53.3% by a mix of prescribers (19.1%), paramedics (14.9%) and injections administered with plastic syringes were helpers (14.1%) at private health facilities. At all health unsafe. The persistence of a large component of unsafe facilities, attendants or helpers were involved in the injections even with disposable injection equipment sterilisation process, albeit to a variable extent. All these was largely due to faulty injection techniques. observations pointed towards the variable quality of sterilisation at health facilities across the country. It also Thus, the use of currently available plastic syringes and appeared that injection administrators were more needles only partially addresses the problems of blood callous while using glass syringes (73.0% times faulty borne virus transmission and overall unsafe injections. technique) as compared to that with plastic syringes The prevention of the reuse of disposable injection (46.2%). equipment will be of paramount importance to achieve further reduction in the risks of transmitting dangerous In addition to the above factors, coupled with the extra infections like HBV, HCV and HIV through injections. effort and patience required to properly sterilise the Policy makers and programme managers at various glass syringes particularly in the wake of crowded out levels along with professional organisations need to patient settings, it was not surprising to observe that develop a joint feasible plan/option for increasing the most of the injections administered through glass safety of injections in the country. Economic syringes were unsafe (90.7%) with potential risk of implications of such decisions/ interventions must be blood borne virus transmission (70.7%). worked out in the context of societal good and the overall health sector scenario in India. The huge quantum of unsafe injections in India has major public health implications and hence, is Improvement in the injection techniques and unacceptable. Careful deliberations are necessary to environment is the other intervention that will be consider different options for improving injection necessary for decreasing unsafe injections in this safety in our country. Injections associated with risks country. No figures are available, but rough estimates of transmitting blood borne virus have major public from various sources indicated that 20-30 lakh injection health significance. Issues related to spread of blood administrators may be working in both the formal and borne virus infection could be addressed by ensuring informal sectors in various villages, towns and cities the use of appropriately sterilised syringes and needles. of India. A huge challenge is to be able to reach them. Data clearly showed that improvement in the Certainly no short-term plans will be able to address sterilisation practices for glass syringes and metal this dimension of unsafe injections. A campaign to needles will be required. The feasibility of this option improve injection practices will have to be launched has to be considered in the context of existing ground with the participation of all stakeholders and using all realities - high overall percentage of unsafe injections possible channels to reach the maximum number of (90.8%) and potential risk of transmitting blood borne injection administrators in India.

- 4949 - Discussion Assessment of Injection Practices in India

5.3 Waste Disposal A significant difference existed between the observed status of waste disposal methods at the health facilities Biomedical waste disposal has attracted a lot of and terminal level versus that claimed by the attention and concern, because of the detrimental prescribers working in these health facilities (Figure effects improper waste disposal has on the 5.3.1). Thus, a wide gap existed between the current environment, communities and also on the medical knowledge level of prescribers and their practice in personnel. The study brought into focus the urgent achieving satisfactory waste disposal. The data also need to appropriately handle the waste generated by indicated that steps were necessary to improve the widespread use of plastic syringes. prescriber knowledge particularly related to terminal waste disposal and put a mechanism in place to ensure At the all India level, three fourths of all injections translation of prescriber knowledge to practice. (74.6%; 95% CI 72.6-76.6) were administered with plastic syringes. Plastic syringes were used extensively One of the prime concerns regarding injection safety in both rural (72.2%) and urban (80.8%) areas. The use is the recycling of plastic syringes/needles. One of the of plastic syringes was much higher in the private principle mechanisms of re-cycling is the selling of sector (80.7%) as compared to that in government used plastic syringes and needles to waste pickers who health facilities (62.7%) and in immunisation clinics in turn sell it to re-cyclers. Direct observation at health (52.3%). This shows that the country predominantly facilities revealed that selling of used plastic syringes/ uses plastic syringes and highlights the importance of needles to kabadiwala’s was more from private health handling the large volume of injection related waste facilities (15.2%) as compared to that from government generated across the country in all types of health health facilities (3.2%). facilities and outreach services of the public sector. Considering that terminal disposal had a much greater Injection waste disposal needs to be viewed at two impact on the environment and communities and that levels - health facilities and terminal level. Both have a huge amount of waste was already being generated different types of requirement in terms of setting up due to plastic use in the country, there is an urgent of systems as well as training of concerned personnel need to establish a system for safe terminal disposal to manage the waste. While health facility level of injection waste at the state, regional and national disposal requires a greater focus on the training of levels. National regulatory agencies like Central health providers to dispose off waste safely at their Pollution Control Board should be involved in individual facilities, terminal disposal demands a developing guidelines to manage injection related much broader vision. It requires the involvement of waste and ensuring their implementation. health providers and the establishment of a proper system for collection and terminal disposal including Figure 5.3.1 shredding and re-cycling of plastic material. This requires the coordinated involvement of the health department, Pollution Control Board and local municipal authorities.

Similar to sterilisation guidelines, guidelines for waste handling were available at only 14.2 percent of health facilities. Satisfactory disposal of plastic syringes and disposable needles was observed at 61.3 percent of health facilities and was found to be the least at immunisation clinics (50.9%). Waste segregation was being done only at 6.2 percent of health facilities at the country level. Satisfactory terminal disposal of Prescriber perspective was not obtained at Immunization Clinics injection waste was observed in less than half the health facilities (44.8%) and was found to be the least 5.4 Rural Urban Differences at private health facilities (41.5%). The problem of unsatisfactory waste disposal was more in rural areas Contrary to the general belief, large numbers of than at health facilities located in urban areas. injections were being administered in both urban and

Discussion - 5050 - Assessment of Injection Practices in India rural areas. According to the two-week recall period, At government health facilities, over 90 percent of individuals residing in rural areas received 6.1 injection givers were trained paramedics in both rural injections per person per year vs. 4.9 injections per and urban areas, whereas in the private sector, over person per year in urban areas. However, for the three- half of the injection administrators in villages were month recall period estimates were similar for rural trained on the job. (3.0 injections per person per year) and urban areas (2.9 injections per person per year). Direct observation Appropriate waste disposal was consistently a bigger of client and prescriber at health facilities did reveal problem at health facilities located in villages. Health that the proportion of clients prescribed injections was facility level disposal of plastic syringes was better in higher in rural areas (46.6%) as compared to those in urban areas (69.6%) of the country as compared to their urban areas (37.6%). Thus, the quantum of injections rural (57.9%) counterparts in all sectors. Similarly, was higher in rural areas mostly due to the larger satisfactory terminal disposal was more in urban health proportion of population along with marginally higher facilities (51.2%) as compared to that of health facilities injection rates at the individual level. Overall, vaccines in rural areas (42.2%). were prescribed more often to those residing in urban areas (21.6%) as compared to the communities in rural Although basic issues related to burden of injection, areas (15.9%) (p<0.001). safety and waste disposal remain the same for rural and urban areas; the magnitude of these problems in The proportion of unsafe injections was approximately rural areas appeared to be higher than in urban areas. ten percent higher in villages (65.9%) as compared to those in cities (54.9%). This difference was maintained A huge challenge will be managing injection related when data was stratified according to type of health waste generated in remote villages and outreach clinics. facilities and type of health providers. The proportion of injections carrying potential risk of spread of blood 5.5 Zonal Variations borne virus was also somewhat higher in villages (33.4%) as compared to that in urban areas (26.6%). Burden of injections was higher in Zone 12 (Andhra These differences in injection safety could be explained Pradesh), Zone 13 (Karnataka) and Zone 14 (Tamil by the higher use of glass syringes in rural areas, Nadu) as compared to the national average for both difference in the profile of prescribers and their safety periods of recall (two week and three month recalls). records, and training of injection givers. Availability The data from several sources e.g. observation of client- and functional status of sterilisation equipment was prescriber interaction and exit interviews of patients similar in the two settings. also indicated higher injection rates in these Zones.

Use of plastic syringes was widely prevalent as 72.2 5.6 Quality Assurance and Hawthorne Effect percent injections in rural areas and 80.8 percent injections in urban areas were given with plastic Source and method triangulations were incorporated syringes. into study design at several steps. It was heartening to note that there was consistency in data obtained from There were marked rural-urban differences in the direct observations and stakeholder interviews. The profile of injection prescribers in the country. Allopathic results repeatedly pointed inference in the same prescribers provided a larger proportion of injections direction. in urban areas as (61.6%) compared to that in rural areas (46.9%). On the other hand, informally trained The data from direct observations must be considered practitioners were writing prescriptions for 17.6 percent in the context of concomitantly operating Hawthorne injections in villages as compared to 4.9 percent in the Effect. Data for injection safety and injection urban areas - a four fold higher proportion in rural prescription habits was obtained through direct areas. The number of overall unsafe injections was observation as well as from the interviews with highest in clinics run by informally trained practitioners prescribers managing these health facilities. We were followed by ISM doctors and allopathic practitioners, likely to get the best estimates of the safety of injections respectively.

- 5151 - Discussion Assessment of Injection Practices in India through direct observation of the injection process by 5.7 Summary senior investigators in the present study. While overall In summary, there is an enormous burden of injections unsafe injections were 62.9 percent, injection (approximately 300-600 crore injections annually) in environment was unsatisfactory at 69.5 percent of India. A very large proportion of these injections health facilities. At only 17.5 percent of health facilities, (62.9%) were administered in an unsafe manner. One all the observed injections were administered in a safe third of all injections were associated with potential manner. Direct observations revealed the reuse of risk of transmitting blood borne viruses like HIV, HBV syringes and needles for nearly one fourth (23.5%) of and HCV. Over half of all the injections were all injections at country level. On the other hand, at administered with faulty techniques. Incidence of nearly half (45.4%) of the health facilities, the number unsafe injections was the highest at immunisation of syringes in the injection tray was either less (41.5%) clinics. There was a linear but inverse relationship or more (3.9%) than the needles in it. This suggested between unsafe injection practices and use of plastic syringes. Use of glass syringes was consistently the possibility of higher reuse rates, particularly of associated with the highest risk of unsafe injections syringes, than recorded during direct observation. across the different types of health facilities. Almost Similarly 44.1 percent clients were prescribed three fourths of the injections in the country were injections during direct observation of client-prescriber administered with plastic syringes. Handling of interaction while 48.1 percent clients coming out of injection related waste at health facilities and its these health facilities had a prescription for an terminal disposal was unsatisfactory at a majority of injection. The two observations were made at different health facilities. The challenges of burden, safety and time periods. The data therefore suggested that waste disposal of injections were generally more in Hawthorne Effect was operating. Thus, the safety rural areas as compared to that in urban areas. Issues profile of injections in the usual circumstances will related to unsafe injections were of particular concern certainly not be better than what was reported in this when non-allopathic practitioners administered study. injections.

Discussion - 5252 - Assessment of Injection Practices in India

6. Recommendations

Recommendations formulated on the basis of the
results from the study are aimed at improving injection Ensure availability of sterilisation guide- safety in India. Injections appear to be a popular mode lines, functional sterilisation equipment at of therapy for significant proportions of the all health facilities where glass syringes/ community. Consequently, injections are administered metal needles are used in almost every village, hamlet, remote inhabitation
Ensure adequate quantities of syringes/ and other rural as well as urban areas of India. A wide needles according to requirement variety of formally and informally trained personnel
Discourage use of inadequately sterilised prescribes and administers injections. Also a variety glass syringes/metal needles or the reuse of injection equipment (plastic syringe/needles, glass of disposable syringes/needles through syringe/metal needles and a combination of glass closer supervision at all levels of healthcare syringe with disposable needles) is used to administer injections. • All public and private sector health facilities Against this backdrop, the task of improving injection must adhere to the guidelines for injection practices will require collaborative efforts from all waste management framed by the Central stakeholders viz. political leadership, programme Pollution Control Board. managers, professionals and professional organisations, pharmaceutical and injection - All district/municipal bodies should equipment manufacturing industry and the evolve locally workable waste community. management systems conforming to these guidelines. The recommendations are grouped under three - Waste management guidelines should be headings: policy and programme, training and made available at all health facilities and communication. these should be prominently displayed at these facilities. 6.1 Policy and Programme - Special logistical needs of rural and remote areas should be addressed. • Encourage the universal use of ‘pre-sterilised syringes/needles with a mechanism for 6.2 Training and Capacity Building prevention of reuse’ – for administering injections. • Institutionalise the process of training of injection prescribers and administrators. • Need for immediate steps to make all injections given under the Government of - Incorporate the subject of injection safety India’s Universal Immunisation Programme in medical and nursing curricula. (UIP) safe. - Set up Model Injection Corners in teaching and tertiary care hospitals. These • Avoid the common practice of use of the same would serve as centres for pre- and in- syringe with different needles. Based on the service training of health professionals experience with the use of auto-disabled (AD) from all sectors. syringes in national immunization program, - Professional bodies like IMA, IAP, FOGSI, currently available disposable syringes may etc. should make injection safety a part of be modified to have fixed needles so that the their CME programmes and are syringe (plunger-piston) could not be reused encouraged to disseminate guidelines with another needle. among their members. These should also include education on: Drug/ • In the interim Injection therapy.

--- 535252 -- Recommendations Assessment of Injection Practices in India

6.3 Communication for Behaviour Change experts, agencies and government will need to establish partnerships for this To achieve a reduction in the large burden of injections purpose in the country, different messages and strategies of communication for both health professionals and the 6.4 Follow up studies community would be required. • To assess the economic aspect of prevailing - The model of determinants of injection injection practices and of interventions to proposed by the study could serve as a improve them guide for developing a communication • To estimate the contribution of unsafe strategy for prescribers and community injections to the burden of blood borne viral - Communication messages should reach infections in the community injection prescribers and administrators • To set up a monitoring mechanism to study in all sectors (including informally trained the impact of interventions for improving personnel) injection safety on the prevalence/incidence - Community should be sensitised to the of Hepatitis-B, Hepatitis-C and HIV in the harmful effects of injections community - Rational use of injections should be a key • To establish periodic evaluation system in the thrust area country to assess the impact of different - Teaching institutions, professional bodies, interventions on injection practices NGO’s, communication and media

Recommendations -- 5454 -- Annexure – 1

Map Showing Study Sites

y (Quantitative Component)
Central Coordinating •Srinagar Office ♦ Zonal Center Amritsar Kangra Chandigarh• ♦• Partner Institution
Dehradun • Rohtak• •Ghaziabad Jodhpur♦ • Aligarh Gangtok Jaipur • Agra Muzaffarpur• Barmer • • Lucknow Guwahati ♦Dibrugarh(2) Ajmer • Kohima Udaipur• • Chittorgarh ♦ • Darbhanga Shillong• • Gwalior• Gaya♦Patna• • • • • ♦ Varanasi• ♦Imphal Zone 1 Bhuj Rajkot Ranchi• Agartala Aizwal •♦ Bhopal Jabalpur •Burdwan • • Zone 2 Jamnagar• Baroda • Raipur• ♦Kolkata(4) • ♦ • Cuttack Zone 3 • Nagpur •Bilaspur• Bhavanagar • Sambhalpur♦Bhubaneshwar Zone 4 Surat • Berhampur • Zone 5 Mumbai Pune Hyderabad(2) • Visakhapatnam Zone 6 • • •Kakinada ♦GulbargaVijayawada• • Zone 7 Panaji • •Bijapur •Belgaum •Kurnool Zone 8 Zone 9 Manipal Bangalore♦Chennai • Vellore Zone 10 Calicut • • Kannur• Coimbatore Zone 11 Thrissur• • Madurai • •Thirunelveli Kottayam♦• • Zone 12 Thiruvananthapuram Zone 13 Zone 14 Zone 15

A-1 Annexure – 2

Zone Wise List of Clusters

Assessment of Injection Practices in India, 2002-2003: An IndiaCLEN Program Evaluation Network Study

ZONE 1

States Rural Clusters

Haryana Aterna Baganwala Balu Bhangu Denarpur Dhirpur Dodhai Gandhra Khera khemawati Mohabatpur Narnaul Sarhol Sersa Waisar

Himachal Pradesh Deotha Kudal Buhli Nalag Sainj Sanohu

Punjab Badra Bhaloor Bhang Wan Bhudan Boor majra Dhani pind Hussian pur Islampur Khadiala Mahi nangal Nangal Sohal Rai pura Saraba Talwandi nepalan Udho Nangal

Chandigarh Dadumajra

Delhi Hastsal

Urban Clusters

Haryana Ambala (M.C) -VI- ward 15 Bahadurgarh (M.C)-VIII- ward 9 Panipat (M.C)-II- ward 25 Portion of Fca-I- ward 18 Rewari (M.C)-III- ward 1 Thanesar (M.C)-III- ward 9 Tohana (M.C)-IV- ward 3

Punjab Amritsar M.Corporation- ward 21 Barnala (M.C.)- ward 7 Bhikiwind (C.T)*- ward 1 Chandigarh E.O.- ward 30 Jalandhar (M.CORP.)- ward 37 Ludhiana (M.CORP.)- ward 2 Ludhiana (M.CORP.)- ward 23 Moga (M.C.)- ward 12 Nawanshahr (M.C.)- ward 6 Pathankot (M.C.)- ward 14 Patiala (M.C.)- ward 27 Rupnagar (M.C.)- ward 4

Delhi A.N.D.M.C (MC)- ward 5 C.D.M.C. (M.Corp.)- ward 104 C.D.M.C. (M.Corp.)- ward 110 C.D.M.C. (M.Corp.)- ward 12 C.D.M.C. (M.Corp.)- ward 22 C.D.M.C. (M.Corp.)- ward 3 C.D.M.C. (M.Corp.)- ward 36 C.D.M.C. (M.Corp.)- ward 45 C.D.M.C. (M.Corp.)- ward 56 C.D.M.C. (M.Corp.)- ward 62 C.D.M.C. (M.Corp.)- ward 7 C.D.M.C. (M.Corp.)- ward 70 C.D.M.C. (M.Corp.)- ward 77 C.D.M.C. (M.Corp.)- ward 83 C.D.M.C. (M.Corp.)- ward 91 C.D.M.C. (M.Corp.)- ward 97 N.Nasir Pur (C.T.) **- ward 1

A-2 ZONE 2

State Rural Clusters

Uttar Pradesh Akora Antapur Basaba Kheri Bayepur Begamabad Devipur Dibai Dihwa Dudhawaniya Buzurg Garhi Udairaj Haibatpurkatra Hardoulee Jagdishpur urf Mahi Jaman Wala Kalonda Kundroop Kursauli Yadav Laxmipur Loyan Maharajpur Mahrana Mohiuddeenpur Khas Mubarakpur Muradpur Nagla Tarau Parsau Mundehra Rajapur Saiguwan Salawa Samapur Samari Shahwazpur Shivajot Sisend Stiswa Sukai Parsia Udatho Umari Bdgamganj Zafarapur

Urban Clusters

Uttar Pradesh Agra Cantt. - ward 4 Agra M.C.- ward 11 Aligarh M.B.- ward 10 Allahabad M.C.- ward 3 Allahabad M.C.- ward 39 Babina Cantt. - ward 5 Baraut M.B.- ward 4 Bareilly M.C.- ward 18 Bazpur M.B.- ward 6 Budaun M.B.- ward 11 Chandausi M.B.- ward 15 Chitbaragaon T.A.- ward 11 Etawah M.B.- ward 21 Fatehpur T.A.- ward 1 Ganga Ghat M.B.**- ward 6 Ganj Dundwara M.B.- ward 2 Ghaziabad M.B.- ward 35 Gorakhpur M.C.- ward 24 Gulaothi M.B.- ward 1 Kanpur M.C.- ward 29 Kanpur M.C.- ward 48 Kanpur M.C.- ward 8 Katra T.A.- ward 3 Lucknow M.C.- ward 18 Lucknow M.C.- ward 32 Mahoba M.B.- ward 7 Maunath Bhanjan M.B.- ward 20 Meerut M.C.- ward 12 Modinagar M.B.- ward 6 Mussoorie M.B.- ward 1 Nagina M.B.- ward 18 Rae Bareli M.B.- ward 10 Saharanpur M.B.- ward 0 Saiyad Raja T.A.- ward 7 Sambhal M.B.- ward 6 Shamli M.B.- ward 4 Sitapur M.B.- ward 1 Tetri Bazar T.A.- ward 12 Varanasi M.C.- ward 17 Vrindaban M.B.- ward 8

A-3 ZONE 3

States Rural Clusters

Bihar Amodei Anrer Bagesara Jharkhand Bali Bagraul Bangaon Baranjhula Bhagwanganj Biddupur Budhaura Chakhni Chalkari Chand Khap Dharmubandh Digharia Dumra Goapara Ijrahia Jamua Jharia Kailkha Kanaila Kant Kashidih Khagaur Khajuhatti Khanapur Kishunpur Ratwara Laylam Mahmuda Mau Dhaneshpurd Pakri Parasbana Pataundha Pharhabari Milik Phularh Rampur Dayal Sadipur Samhuti Singhani Telia

Urban Clusters

Bihar Bagaha (M)- ward 16 Bagbera (CT) $- ward 8 Jharkhand Banmankhi Bazar (NA)- ward 6 Bhagalpur (M. Corp.) $- ward 10 Bikramganj (NA)- ward 1 Bokaro Steel City (CT) $3- ward 77 Bundu (NA)- ward 1 Buxar (M)- ward 12 Darbhanga (M Corp.)- ward 30 Deorikalan (CT) *- ward 2 Dhanbad (M) $2- ward 32 Digha & Mainpura (OG) * $- ward 2 Dinapur Nizamat (M) $- ward 2 Forbesganj (M)- ward 4 Gaya (M. Corp.) $- ward 13 Ghatshila (CT)- ward 12 Giridih (M)- ward 11 Godda (NA)- ward 3 Hajipur (M)- ward 4 Jamadoba (CT) $2- ward 3 Jamshedpur (NA) $- ward 91 Jharia (NA) $2- ward 2 Lakhisarai (M)- ward 6 Loiya (CT) ** $2- ward 2 Madhupur (M)- ward 3 Motihari (M) $- ward 12 Munger (M)- ward 7 Muzaffarpur (M Corp.)- ward 3 Nawada (M)- ward 9 Pataliputra Housing Colony Patna (M.Corp.) $- ward 12 Patna (M.Corp.) $- ward 3 Rafigang (NA)- ward 1 Ranchi (M.Corp) $2- ward 21 Ranchi (M.Corp) $2- ward 4 Revelganj (M)- ward 6 Saharsa (M)- ward 10 Samastipur (M)- ward 10 Silao (NA) *- ward 4 Tenudam-cum-Kathhara (CT)$2- ward2

A-4 ZONE 4

State Rural Clusters

West Bengal Adrahti Palla Asraf pur Bayra Bhaudi Bholadanga Chausal Dakshin kathulia Gumki Habaspur Hariharpur Hastabud Kasal Danga Hatsimla Haur Hijal Indas Jarisa Jirakpur Jyram purr Kaksaha Kuli Lakshya Lalua Mahish nala Mallik pur Manta dari Mirzapur Murali Nandanpur Palasi Panch baria Patta bong tea garden Purbba srirampur Purbbapamal Rajib pur Rangamati Sahabhita Sankharipur Sulanggari Tanginayada

Urban Clusters

West Bengal Aistala (NM)** ward 1 Asansol (M) ward 4 Balurghat (M) ward 4 Bandra (NM) ward 1 Bankura (M) ward 5 Baranagar (M) ward 15 Barasat (M) ward 12 Barddhaman (M) ward 27 Basirhat (M) ward 10 Benagarya (OG) ward 1 Calcutta ward 114 Calcutta ward 135 Calcutta ward 17 Calcutta ward 2 Calcutta ward 34 Calcutta ward 53 Calcutta ward 65 Calcutta ward 78 Calcutta ward 93 Dakshin jhapardaha (NM) ward 1 Durgapur (NA) ward 5 Haora (MC) ward 1 Haora (MC) ward 29 Hugli-chinsurah (M) ward 20 Jangipur (M) ward 1 Krishna nagar (M) ward 11 Madrail fingapara (NM) ward 1 Mainaguri (NM) ward 1 Medinipur (M) ward 12 Nabagram colony (NM) ward 1 Naihati (M) ward 11 New Barrackpur (M) ward 1 Port blair M.B. ward 11 Pujali (NM)* ward 1 Raniganj (M) ward 6 Sadpur (NM)* ward 1 Siliguri (M) ward 7 Titagarh (M) ward 9 Uluberia (M) ward 8 Uttarpara kotrung (M) ward 12

A-5 ZONE 5

States Rural Clusters

Arunachal Pradesh Agia pt-ii Aloicherra pt I Bakhasal pt.iii Assam Balijan t.e Banbari Basantapur Bogdo Charagaon Charaihabi gaon no.1 Chekhaimukh borghuli Dhauliguri Dhulabari Doria grant Fata simulugaon Gandari para Ginjia t.e Golapara west pt-iii Goriaka wai-mari Hariabeel Hatichungi kamar gaon Japusabari pt_ii Jarangdisha Karertal Khudra makhibaha Kuwaritol Langsuwal t.e. 109/112 Nichimpur Niz harisinga No 2 dija pathar Panbari no.1 Puroni goraibari Raidangia na-kachari Sarthe rongpher Suapota-ii Tara nath pur ii Topatali gaon

Meghalaya Bikonggiri Mawryngkhong Umsaitmuit

Sikkim Upper tat

Urban Clusters

Assam Along town- ward 1 Badarpur t.c. - ward 3 Bongaigaon m.b. - Ward 9 Chengeligaon o.k. - ward 1 Dhubri m.b. - Ward 16 Dibrugarh m.b. - ward 21 Dibrugarh m.b. - ward 6 Diphu t.c. - ward 1 Doom dooma t.c.- ward 4 Gauripur t.c. - Ward 1 Goalpara m.b. - Ward 7 Guwahati city (m.corp.)- Ward 1 Guwahati city (m.corp.)- Ward 11 Guwahati city (m.corp.)- Ward 15 Guwahati city (m.corp.)- Ward 21 Guwahati city (m.corp.)- Ward 27 Guwahati city (m.corp.)- Ward 31 Guwahati city (m.corp.)- Ward 33 Guwahati city (m.corp.)- ward 34 Guwahati city (m.corp.)- Ward 7 Haflong t.c.- ward 7 Jorhat m.b.- ward 1 Lumding rly.colony c.t.- ward 3 Mankachar c.t. - Ward 5 Nagaon m.b.- ward 6 North lakhimpur m.b.- ward 14 Raha c.t.- ward 1 Rangapara t.c.- ward 1 Rangia m.b. - Ward 1 Sarthebari t.c. - Ward 4 Sibsagar m.b.- ward 11 Silchar m.b.- ward 28 Silchar m.b.- ward 7 Tezpur m.b.- ward 15 Tinsukia m.b.- ward 3

Meghalaya Nongthymmai- ward 1, Shillong municipality- ward 22, Shillong municipality- ward 7, William nagar **- ward 3

Sikkim Gangtok (n.t.a.c)- ward 4

A-6 ZONE 6

States Rural Clusters

Manipur Bajirungpa veng Chhingchhip Dolang Khuainoi Lalpani Lungsen Maibam konjin Mao pundung Phayeng Sagang Sagolmang Tingkhai khunou Wabagai

Nagaland Chiechama Chimonger Khekiye Longkhum Mopongchukit Siethekema Tening Thephutsami Yangzitong Yannyu

Tripura Anandanagar Bagma Bilashpur Choumohani Dalajhari Halahali Jirania Joychandrapur Kathalchhara Krishnapur Paschim jalefa Paschim singichhara Purba manpai Sanichhara Sonachhara Sutamura Taranagar

Sikkim Upper tat

Urban Clusters

Manipur Churachandpur (CT)- ward 9 Imphal (M)- ward 15 Imphal (M)- ward 20 I Imphal (M)- ward 4 Imphal (M)- ward 9 Jiribam (M) **- ward 6 Imphal (M)- ward 25 Lilong (Imphal West)(NAC) **- ward 7 Nambol (PART)(M)- ward 9 Ningthoukhong (NAC) **- ward 4 Sugnu (NAC) **- ward 1 Thoubal (M)- ward 6 Wangjing (NAC) **- ward 5

Mizoram Aizawl - ward 17 Aizawl - ward 3 Aizawl - ward 32 Aizawl - ward 43 Aizawl - ward 52 Champhai **- ward 11 Kolasib **- ward 5 Lunglei - ward 13 Saitual *- ward 1

Nagaland Dimapur - ward 14 Dimapur - ward 7 Kohima - ward 13 Kohima - ward 2 Mokokchung- ward 2 Tuensang**- ward 6 Zunheboto**- ward 3

Tripura Agartala (M)- ward 1 Agartala (M)- ward 11 Agartala (M)- ward 5 Agartala (M)- ward 8 Amarpur N.A. **- ward 1 Badharghat C.T. *- ward 1 Dharmanagar N.A. *- ward 1 Jogendranagar C.T. *- ward 1 Kumarghat N.A. *- ward 1 Singarbil C.T. *- ward 1 Teliamura N.A. *- ward 1

A-7 ZONE 7

State Rural Clusters

Rajasthan Anupgarh Bagdunda Barh doli Barli Bassi Beslaniyon ka tala Bhaola Chak kothiya Dhanga Genta Gotha chhoti Gudabari Hanumangarh Jat baroda Jheengar chhoti Kehariyon ki basti Khanri Khata kheri Khejariyali Khera Kherli Khetawas Kolasar Kurar Machar khani Madanpura Mahasinghji ka khera Malar Mandasi Masooda Nadauli Narwalan Neenor Peepaliya Sankhana Sarnawara Teemera khurd Thana Thikariya Ujoli

Urban Clusters

Rajasthan Abu Road M- ward 10 Ajmer MCL- ward 1 Ajmer MCL- ward 28 Alwar M.Cl- ward 35 Barmer MCL- ward 17 Bharatpur MCL- ward 17 Bhilwara MCL- ward 25 Bhiwadi CT- ward 9 Bikaner M.CL- ward 24 Chaksu M- ward 1 Chhabra M- ward 10 Chhapar M- ward 7 Fatehpur M- ward 17 Hanumangarh M.CL- ward 11 Hindaun M- ward 1 Jaipur MCL- ward 14 Jaipur MCL- ward 22 Jaipur MCL- ward 29 Jaipur MCL- ward 35 Jaipur MCL- ward 44 Jaipur MCL- ward 5 Jhunjhunu M- ward 23 Jodhpur MCL- ward 13 Jodhpur MCL- ward 31 Jodhpur MCL- ward 50 Kaprain M- ward 1 Kota MCL- ward 23 Kota MCL- ward 42 Kuchaman City (M)- ward 4 Niwai M- ward 7 Nokha M- ward 1 Pilibanga M- ward 2 Pipar City M- ward 11 Pratapgarh M- ward 2 Rajgarh M- ward 1 Rewa Talai CT- ward 9 Sahunagar Cement Fact. OG- ward 1 Sikar MCL- ward 24 Sumerpur M- ward 11 Udaipur MCL- ward 37

A-8 ZONE 8

State Rural Clusters

Gujarat Abhlod Aslali Bhandariya Bharatpur Charada Devaliya Devli Dhanturiya Ganva Gothada Gungawada Halenda Isdar Jhiliya Vasana Kachrol Kadegi Kalai Kamli Kera Khaladi Kherap Kholeshwar Mahadeviya Mahelav Modvadar Mota Sarnaiya Padal Parali Pati-Bandhara Pipalgabhan Pransli Rampar Pati Ranat Sakhwaniya Samarpada Surajpura Surana Toda Vatadra Zinzari

Urban Clusters

Gujarat Ahmadabad (MC)- ward 14 Ahmadabad (MC)- ward 17 Ahmadabad (MC)- ward 22 Ahmadabad (MC)- ward 27 Ahmadabad (MC)- ward 31 Ahmadabad (MC)- ward 36 Ahmadabad (MC)- ward 39 Ahmadabad (MC)- ward 5 Amod (NP)- ward 5 Bhachau (NP)- ward 2 Bhagdawada (OG)- ward 12 Bhavnagar (MC)- ward 11 Bodakdev (OG)- ward 55 Dabhoi (M)- ward 5 Dhari (NP)- ward 12 Godhra (M)- ward 7 Jamnagar (MC)- ward 10 Kadi (M)- ward 8 Mahuva (OG)- ward 7 Mavdi (OG)- ward 25 Navsari (M)- ward 11 Patan (M)- ward 3 Petlad (M)- ward 2 Radhanpur (NP)- ward 2 Rajkot (MC)- ward 11 Ranavav (NP)- ward 2 Sola (VP)- ward 1 Surajkaradi (VP)- ward 3 Surat (MC)- ward 29 Surat (MC)- ward 38 Surat (MC)- ward 46 Surat (MC)- ward 6 Surat (MC)- ward 60 Upleta (M)- ward 11 Vadodara (MC)- ward 2 Vadodara (MC)- ward 6 Vadodara (MC)- ward 9 Vaso (NP)- ward 3 Vijapur Rural (PART)(OG)- ward 5 Wadhwan (M)- ward 6

A-9 ZONE 9

State Rural Clusters

Madhya Pradesh Ajmain Amaniya Badbeli Badlipada Banskhedi Gugal Bilda Borgaon Chakchandokhar Chirula Deem Deoraha Dhanora Digoda Dorana Ghota Gondri Halka Hathkera Kachhayagura Kadar Kanharbahara Kerwara Khadi Kotara Mohasa Nanakhedi Nayagaon Pakhnar Pipalya Rampur Ratikarar Kalan Sanga Selud Semrikalan Silawati Singhaura Surajpura Temala Tongapani Umariya

Urban Clusters

Madhya Pradesh Baidhan (NM)*- ward 14 Balod (M)- ward 12 Bhilai Nagar (N.M.)- ward 14 Bhopal (M.C)- ward 29 Bhopal (M.C)- ward 45 Bhopal (M.C)- ward 8 Budni (M)*- ward 2 Champa (M)- ward 15 Chhindwara (M)- ward 10 Dabra (M)- ward 6 Deori (M)- ward 5 Dewas (M.C)- ward 28 Dhamnod (M)**- ward 2 Gadarwara (M)- ward 3 Goriyaband (N.M.)*- ward 2 Guna (M)- ward 6 Gwalior (M.C.)- ward 1 Gwalior (M.C.)- ward 27 Harda (NM)- ward 1 Indore (M.C.)- ward 11 Indore (M.C.)- ward 33 Indore (M.C.)- ward 55 Jabalpur (MC)- ward 38 Jabalpur (MC)- ward 7 Jaora (M)- ward 15 Khachrod (M)- ward 13 Khandwa (M.C)- ward 35 Khurai (M)- ward 17 Korba (N.M.)- ward 33 Koria Block (N.M)*- ward 17 Laundi (M)- ward 4 Maheshwar (NM)- ward 9 Morena (M)- ward 35 Murwara (Katni) (M.C)- ward 13 Nagod (M)- ward 9 Narsingarh (M)- ward 8 Raipur (MC)- ward 18 Rajnandgaon (M.C.)- ward 38 Ujjain (M.C.)- ward 43 Nowrozabad (Khodargama) (M)- ward 1

A-10 ZONE 10

State Rural Clusters

Orissa Andeisahi Asada Badabhundu Baradihi Baunsenmura Beheradihi Bhataida Birakisorpur Dhatukimal Fatamunda Ganipur Ganjapara Garhnayar chhada Ghatiguda Hansatuli Jafar pur Kaima Bara Kandulguda Khajuridihi krushna nagarpatna Kusuma Mahaling Nalakani Namachira Nuagada Nuhanala Odasingi Padmapur Parsaile Phukjodi Rajiba Salajharia Sanankaria Saubhagyadeipur Similisahi Singarpur Suanga Telnati Tenkar Tilatinga

Urban Clusters

Orissa Aurkela [S.T] (N.A.C.)- ward 25 Aurkela [S.T] (N.A.C.)- ward 6 Balagoda [bolani] (C.T.)- ward 1 Balangir (M)- ward 2 Baleshwar (M)- ward 5 Baudh (NAC)- ward 6 Bhadrak (M)- ward 11 Bhubaneswar (M)- ward 13 Bhubaneswar (M)- ward 23 Bhubaneswar (M)- ward 37 Bhubaneswar (M)- ward 4 Brahmapur [M]- ward 22 Brahmapur [M]- ward 7 Burla (NAC)- ward 4 Chandili (C.T.)- ward 1 Charibatia (CT)- ward 1 Choudwar (M)- ward 8 Cuttack (M)- ward 19 Cuttack (M)- ward 27 Cuttack (M)- ward 9 Dhenkanal (M)- ward 16 Harsuguda (M)- ward 16 Jajapur Road (N.A.C)- ward 16 Joda (NAC)- ward 2 Khariar Road (N.A.C.)- ward 15 Konark (NAC)- ward 11 Malkangiri (NAC)- ward 10 Nabarangapur (M)- ward 13 Paradip (NAC)- ward 7 Parlakhemundi [M]- ward 5 Pipili (NAC)- ward 8 Puri -Municipality- ward 22 Purusottampur [NAC]- ward 10 Rajagangapur [M]- ward 8 Rajarajnagar (M)- ward 2 Raurkela (M)- ward 21 Raurkela (M)- ward 4 Sambalpur (M)- ward 7 Sunabeda (NAC)- ward 12 Udala (NAC)- ward 3

A-11 ZONE 11

States Rural Clusters

Goa Armori Bebad Ohol Bhayale Maharashtra Borakhedi Chandrapur Chinchani Daund Degaon Deulwada Dhanoshi Gondbori Gondegaon Harli Kh. Kadus Kamlapur Kamtha Khadi Kolvan Khargaon Kumbharde Mangi Medsinga Halni Navalane Nipani Takali Pirla Rajewadi Regaon Rozode Salegaon Saokhed Bhoi Sarnobatwadi Sawargaon Met Shirala Takli Bk. Toli Vaduj Vaijali Vatakapada Wada Wanoda

Urban Clusters

Goa Akola (M)- ward 24 Ambejogai (M)- ward 10 Maharashtra Amravati (M.Corp.)- ward 50 Aurangabad (M.Corp.)- ward 9 Bhagur (M)- ward 15 Bhiwandi (M)- ward 29 Bhusawal (M)- ward 9 Dhule (M)- ward 25 Gondiya (M)- ward 26 Greater Bombay (M.Corp.)- ward 1600 Greater Bombay (M.Corp.)- ward 2700 Greater Bombay (M.Corp.)- ward 3200 Greater Bombay (M.Corp.)- ward 3600 Greater Bombay (M.Corp.)- ward 4500 Greater Bombay (M.Corp.)- ward 5200 Greater Bombay (M.Corp.)- ward 5700 Greater Bombay (M.Corp.)- ward 6400 Greater Bombay (M.Corp.)- ward 7000 Greater Bombay (M.Corp.)- ward 7800 Greater Bombay (M.Corp.)- ward 8000 Greater Bombay (M.Corp.)- ward 8400 Greater Bombay (M.Corp.)- ward 8700 Jalna (M)- ward 37 Kalyan (M.Corp.)- ward 37 Kolhapur (M.Corp.)- ward 1 Kudal (CT)*- ward 4 Latur (M)- ward 9 Nagpur (M.Corp.)- ward 23 Nagpur (M.Corp.)- ward 68 New Bombay (Thane) (CT)*- ward 9 Pimpri chinchwad (M.Corp.)- ward 50 Ponda (M.CL)- ward 4 Pune (M.Corp.)- ward 35 Pune (M.Corp.)- ward 39 Sangamner (M)- ward 11 Solapur (MC)- ward 20 Thane (M.Corp.)- ward 47 Ulhasnagar (M)- ward 16 Wai (M)- ward 23 Wardha (M)- ward 36

A-12 ZONE 12

State Rural Clusters

Andhra Pradesh Burja Kanchili Jarjapupeta Pakalapadu Kattupalem Kumarapuram Ravulapalem Dippakayalapadu Darsiparru Tirumalagiri Veeravalli Rentachintala Pedakakani Uppudi Ipuru palem Darakani padu Koduru - ii Dainadu Kotarvedu Moolapalle Polimerapalle Marpala Madakasira Holagunda Maddikera (east) Gaddeguda Bijjawaram Peddemul Shamnapur Kalvemula Bichkunda Kowtla buzurg Kistampet Pegadapalle Anthakkapeta Chinthapalle Peda midisileru chalk-iii Koya chalka Chinaraval Palle Mella chervu

Urban Clusters

Andhra Pradesh Bobbili (m)- ward 10 Bheemunipatnam (m)- ward 13 Visakhapatnam (mc)- ward 34 Gopalapatnam (p)- ward 8 Pithapuram (m)- ward 1 Rajahmundry (m)- ward 72 Kovvur (m)- ward 6 Eluru (m)- ward 20 Tiruvuru- ward 3 Vijayawada (mc)- ward 9 Vijayawada (mc)- ward 54 Phiramgipuram (p)- ward 14 Guntur (m)- ward 16 Kandukur (m)- ward 9 Kavali (m)- ward 8 Sirpur (p)- ward 4 Ramagundam (nac)- ward 6 Warangal (m)- ward 11 Yellandu (m)- ward 2 Nalgonda (m)- ward 3 Nellore (m)- ward 32 Tirupati (m)- ward 15 Cuddapah (m)- ward 5 Kadiri (m)- ward 7 Guntakal (m)- ward 14 Kurnool (m)- ward 26 Nandyal (m)- ward 26 Tandur (m)- ward 8 Malkajgiri (m)- ward 34 Kukatpally (m)- ward 3 Gaddiannaram [p]**- ward 6 Hyderabad (mc) (portion)- ward 3 Hyderabad (mc) (portion)- ward 8 Hyderabad (mc) (portion)- ward 13 Hyderabad (mc) (portion)- ward 17 Hyderabad (mc) (portion)- ward 19 Hyderabad (mc) (portion)- ward 29 Secunderabad cantonment- ward 1 Armur [p]- ward 1 Adilabad (m)- ward 3

A-13 ZONE 13

State Rural Clusters

Karnataka Honnenahalli Gantiganahalli Kakaramanahalli Ankali Yemakanmardi Alakhanur Rupanagudi Thippehalli Ghotala Anawal Siddapur Yaragalla Athigiri Mallasamudra Palavvanahalli Peruvai Uppunda Kuthyar Akki alur Haralapur Hulgur Chimmanchod Madna Hullahalli Hullahalli kaval Hudikeri Thondebhavi Palya H.kodihalli Govindavady Hanur Hemmaragala Uddihal Hire kotankal Arkeri Keladi Huliyar Kadagathur Dommanakuppe Hirehalli

Urban Clusters

Karnataka Dodda Bommasandra OG- ward 1 Laggere NMCT- ward 1 J.P. Nagar OG- ward 1 O M B R LAYOUT OG- ward 1 Bangalore MC- ward 3 Bangalore MC- ward 12 Bangalore MC- ward 24 Bangalore MCward 33 Bangalore MC- ward 45 Bangalore MC- ward 55 Bangalore MC- ward 64 Bangalore MC- ward 76 Bangalore MC- ward 87 Hoskote TMC- ward 5 Hukeri TMC- ward 2 Belgaum MC- ward 13 Kampli TMC- ward 3 Bellary CMC- ward 17 Bidar CMC- ward 10 Muddebihal TMC- ward 4 Sringeri MP- ward 3 Hiriyur TMC- ward 2 Pudu NMCT - ward 1 Mudbidri TMC- ward 2 Udipi TMC- ward 2 Ranibennur CMC- ward 4 Hubli-Dharwad MC- ward 21 Hubli-Dharwad MC- ward 56 Shorapur TMC- ward 3 Gulbarga MC- ward 10 Virajpet MP- ward 2 Mulbagal TMC- ward 2 Mandya CMC- ward 4 Gundlupet TMC- ward 4 Mysore MC- ward 4 Hatti Gold Mines NAC- ward 1 Raichur CMC- ward 10 Shimoga CMC- ward 1 Sira TMC- ward 3 Karwar CMC- ward 4

A-14 ZONE 14

State Rural Clusters

Tamil Nadu Ananderi Kolathuvancheri Pudupattu Arapakkam Vengatasamudram Gumlapuram Mottur Mittareddihalli Illupakunam Royandapuram Panamalai Nedumanur Sathippattu Alambadi Karukkalvadi Chinnamanayakanpalayam Attavanai Iraiyamangalam Pachampalayam Vadugapatti Kemmarampalayam Edayapalayam Kodaimangalam Kanavaipatti Thelur Kolakudi Pettavathalai Kadalangudi Kathur Mahadeva Pattinam Viriankottai Maramadakki Piramanur Periyakattalai Appakkarai Kollankondan Mandapam Tirumalapuram Udaiyarkulam Keezhkulam Neendakara

Urban Clusters

Tamil Nadu Madras (M.Corpn.)- ward 9 Madras (M.Corpn.)- ward 33 Madras (M.Corpn.)- ward 53 Madras (M.Corpn.)- ward 68 Madras (M.Corpn.)- ward 91 Madras (M.Corpn.)- ward 116 Madras (M.Corpn.)- ward 135 Madras (M.Corpn.)- ward 153 Sriperumbudur (TP)- ward 12 Tiruvottiyur (M)-ward 34 Tambaram (M)- ward 33 Valasaravakkam (TP)*- ward 12 Melvisharam (TP)- ward 11 Sattuvacheri (TP)- ward 2 Kaveripattinam (TP)- ward 7 Villupuram (M)- ward 36 Vriddhachalam (M)- ward 14 Salem (M)- ward 18 Attur (M)- ward 15 Gopichettipalaiyam (M)- ward 27 Nelliyalam (TP)- ward 9 Ashokapuram (VP)- ward 4 Coimbatore (M.Corpn.)- ward 40 Kuniyamuttur (TP)- ward 9 Pollachi (M)- ward 22 Dindigul (M)- ward 23 Kulittalai (TP)- ward 13 Ponmalai (M)- ward 23 Kumbakonam (M)- ward 19 Tiruvarur (M)- ward 27 Karaikkudi (M)- ward 8 Theni Allinagaram (M)- ward 14 Madurai (M.Corp)- ward 26 Madurai (M.Corp)- ward 68 Pallapatti (VP)**- ward 2 Mandapam (TP)- ward 1 Udangudi (TP)- ward 6 Tirunelveli (M)- ward 32 Kolachel (M)- ward 22 Ozhukarai (CP)- ward 9

A-15 ZONE 15

State Rural Clusters

Kerala Karadka Padne Kolacherry Kolavelloor Thomattuchal Ayancheri Ulliyeri Raroth Pallikkal Trikkalangode Valambur Nannambra Kattipparuthi Alamcode Thirumittacode Puduppariyaram Muthalamada Kaniyarkode Elavally Edathiruthy Kuttichira Kizhakkambalam Njarackal Kottappady Kattappana Peermade Vaikom Kurichy Thuravoor Thekku Kumarapuram Perungala Ranni Angadi Erathu Sooranad South Chakkuvarakkal Panayam Pulimath Koliyakode Venganoor Karode

Urban Clusters

Kerala Kanhangad (M)- ward 7 Taliparamba (M)- ward 6 Munderi (C.T.)- ward 6 Azhikode North (CT)- ward 1 Thottada (CT)- ward 8 Pattiom (CT)- ward 8 Thalassery (M)- ward 14 Vadakara (M)- ward 23 Kozhikode (C)- ward 7 Kozhikode (C)- ward 30 Elathur (OG)- ward 12 Cheruvannur (CT)- ward 8 Malappuram (M)- ward 16 Tirur (M)- ward 17 Mannarkad (M)- ward 13 Marutharode (CT)- ward 5 Paluvai (CT)- ward 3 Poonkunnam O.G- ward 1 Edakkunny (CT)- ward 2 Chalakudy (M)- ward 27 Vadakkekara (CT)- ward 2 Varapuzha (CT)- ward 3 Kochi (C)- ward 14 Kochi (C)- ward 28 Kochi (C)- ward 44 Vazhakkala (CT)- ward 2 Koothattukulam (M)- ward 4 Kottayam (M)- ward 18 Kanjirappally (M)- ward 5 Thanneermukkam (CT)- ward 10 Alappuzha (M)- ward 32 Chengannur (M)- ward 13 Neendakara (O.G)- ward 5 Kollam (M)- ward 28 Vadakkevila (C.T)- ward 12 Thiruvananthapuram (C)- ward 1 Thiruvananthapuram (C)- ward 18 Thiruvananthapuram (C)- ward 37 Sreekariyam (O.G.)- ward 2 Nemom (C.T.)- ward 4

A-16 Annexure – 3

Interview Schedule log sheet for Team Leaders

Assessment of Injection Practices in India, 2002-2003: An IndiaCLEN Program Evaluation Network Study

Please Note: (i) Format to be filled by the senior investigator of each team after completing each cluster. (ii) Original of this format to be sent to CCO, New Delhi, along with original copy of the completed schedules at the end of each cluster. (iii) Copy of this format to be submitted along with the xerox copy of the schedules to the zonal coordinator towards the end of the study. (iv) Return the rejected / unused schedules also to the CCO, New Delhi.

Zone Name:...... Date:...... Cluster Address: ...... Cluster No:...... Team: ......

Category of Interviews / Observations Completed

A. Health Facility Activities Government Generic Observations Specific Observations Prescriber Interview Exit Interview Private Generic Observations Specific Observations Prescriber Interview Exit Interview Immunization Generic Observations Specific Observations

B. Client Interviews Less than 1 year ...... M ...... F 1 - 14 years ...... M ...... F 15 years or more ...... M ...... F

Total ...... Out of expected (38)

2. Blank / rejected schedules sent to CCO (enter unique number of the schedule) Exit Interview: Male Clients: Female Clients:

3. Date of Dispatch to CCO, New Delhi: ......

4. Problems encountered, if any:

Signature of the Senior Investigator:...... Date: ......

A-17 Annexure – 4

Log Sheet for Households Surveyed in Each Cluster

Assessment of Injection Practices in India, 2002-2003: An IndiaCLEN Program Evaluation Network Study

Please Note: 1. To be maintained by research assistants 2. Give details of the households visited for selecting respondents 3. To be submitted along with the original interview schedules to CCO, New Delhi

Zone No: ______Cluster No. and Details ______

S. No. Name - Head of family Remarks*

* Should include comments like: Interviewed; door locked; no one in the eligible age group available at home; individuals available but busy with (household) work; refused to be interviewed; no privacy; etc.

Signature of Research Assistant______

Date______

A-18 Annexure – 5

List of Team Members who Conducted Cluster Survey in 15 Zones of the Country

Assessment of Injection Practices in India: An IndiaCLEN Program Evaluation Network study

Zone No-1: Delhi, Haryana, Jammu & Kashmir, Punjab, Himachal Pradesh, Chandigarh Zonal Coordinator: Dr. Rajesh Kumar

Team 1 Team 6 Senior Investigator: 1 Dr. Muneer A Masoodi, Senior Investigator: 1 Dr. Amarjeet Singh 2 Dr. Safoora Bilques 2 Dr. S. Bandyopadhay Doctor: 3 Dr. S. Mohammad Khan Doctor: 3 Dr. Rubina 4 Dr. Anjim Fazil 4 Dr. K.S. Khatri Research Associate 5 Dr. Ashafaq A Bhat Research Associate: 5 Ms. Minakshi 6 Suhail Ahmed 6 Mr. Rajesh Kumar

Team 2 Team 7 Senior Investigator: 1 Dr. T.D. Sharma Senior Investigator: 1 Dr. J.S Thakuri 2 Ms. Swaran Lata 2 Dr. Sonu Goel Doctor: 3 Dr. G.L. Jaryal Doctor: 3 Dr. Harinder Kaur 4 Dr. K.L. Ghai 4 Dr. Harinder Singh Research Associate: 5 Mr. Bishan Dutt Research Associate: 5 Ms. Ruchi Chauhan 6 Mr. Rajiv Kumar 6 Mr. Naresh Sharma

Team 8 Team 3 Senior Investigator: 1 Dr. Jay Kishore Senior Investigator: 1 Dr. O. Raj. Goldia 2 Dr. Manoj Bhardwaj 2 Dr. Vikrant Prabhakar Doctor: 3 Dr. Lalit Doctor: 3 Dr. Kamal Deep Vashist 4 Dr. Anuj 4 Dr. Shashi Paul Research Associate: 5 Mr. Vinay Research Associate: 5 Mr. Rajneesh Arora 6 Mr. Ashish 6 Mr. Deepak Kumar Team 4 Team 9 Senior Investigator: 1 Dr. S.S. Deepti Senior Investigator: 1 Dr. Sanjay Atri 2 Dr. Kanwaljit Singh 2 Dr. Ashwini Goel Doctor: 3 Dr. Rajwinder Randhawa Doctor: 3 Dr. Ram R Sharma 4 Dr. Ramandeep Kahlon 4 Dr. Vikash Nizhawan Research Associate: 5 Dr. Naiya Bansal Research Associate: 5 Mr. Sandeep 6 Dr. Parminder S. Dhillon 6 Mr. Chandrakant

Team 5 Team 10 Senior Investigator: 1 Dr. Tejbir Singh Senior Investigator: 1 Dr. K.C. Sharma 2 Dr. Jasleem Kaur 2 Dr. Purshottam Doctor: 3 Dr. Nidhi Doctor: 3 Dr. Kapil Sharma 4 Dr. Nitasha Sehgal 4 Dr. Manish Bansal Research Associate: 5 Dr. Nidhi Sood Research Associate: 5 Mr. Hemant Garg 6 Dr. Rita Gaba 6 Mr. Raju Sharma

A-19 Zone No-2: Uttar Pradesh, Uttaranchal Zonal Coordinator: Dr. Ramesh C. Ahuja

Team 1 Team 6 Senior Investigator: 1 Dr. Vinod K. Srivastava Senior Investigator: 1 Dr. Gajendra Gupta 2 Dr. Ramesh Chandra 2 Dr. Sangeeta Kansal Doctor: 3 Dr. Ranjeev Gupta Doctor: 3 Dr. Ravindra Katiyar 4 Dr. Amarnath Gupta 4 Dr. Prachi Garg Research Associate: 5 Mrs. Ramka Saxena Research Associate: 5 Mr. Bhupendra Shishodia 6 Mr. AjaySrivastava 6 Mr. Sanjeev Pathak

Team 2 Team 7 Senior Investigator: 1 Dr. Deoki Nandan Senior Investigator: 1 Dr. Ramesh Chandra 2 Dr. S.C. Gupta 2 Dr. S. D. Kandpal Doctor: 3 Dr. Anand M. Dixit Doctor: 3 Dr. K. S. Negi 4 Dr. Pooja 4 Dr. Jayanti Semwal Research Associate: 5 Mr. Devendra Singh Research Associate: 5 Ms. Neelam Joshi 6 Ms. Mamta Pal 6 Mr. Bhagat Singh Rana

Team 3 Team 8 Senior Investigator: 1 Dr. S.K. Misra Senior Investigator: 1 Dr. V.K. Srivastava 2 Dr. B. B. Maheshwari 2 Dr. Yogesh Saxena Doctor: 3 Dr. Sadhna Awasthi Doctor: 3 Dr. Pravin Pratap 4 Dr. Manish Chaturvedi 4 Dr. Rajesh Paswan Research Associate: 5 Mr. Parag Dutt Sharma Research Associate: 5 Mr. Ajay Srivastava 6 Ms. Leena Singh 6 Ms. Sunita Srivastava

Team 4 Team 9 Senior Investigator: 1 Dr. S.C. Mohapatra Senior Investigator: 1 Dr. Azra Ahmed 2 Dr. V. M. Gupta 2 Dr. Syed Manazir Ali Doctor: 3 Dr. P. Mohapatra Doctor: 3 Dr. Abdul Siddiqui 4 Dr. V. Chaudhary 4 Dr. Ehtisham Ahmed Research Associate: 5 Dr. Sanjay Pandey Research Associate: 5 Dr. Shazia Afzal 6 Dr. Indrajeet Singh 6 Dr. Naseem Aktar

Team 5 Team 10 Senior Investigator: 1 Dr. Uday Mohan Senior Investigator: 1 Dr. S.P. Agnihotri 2 Dr. A. K. Shrivastava 2 Dr. S. N. Bhargawa Doctor: 3 Dr. Richa Singh Doctor: 3 Dr. Sovanan Singh 4 Dr. Shashi B. Kumar 4 Dr. M. Sharma Research Associate: 5 Mrs. Seema Saxena Research Associate: 5 Ms. Pratibha Pandey 6 Mr. Pateshwar Singh 6 Ms. Priyanka Verma

A-20 Zone No-3: Bihar, Jharkhand Zonal Coordinator: Dr. S.P. Srivastava

Team 1 Team 6 Senior Investigator: 1 Dr. N.P. Verma Senior Investigator: 1 Dr. Bijay K Singh 2 Dr. Manju Prasad 2 Dr. S.N. Sharma Doctor: 3 Dr. Prakash Kumar Doctor: 3 Dr. R.K. Bibhuti 4 Dr. Nawal Deepak 4 Dr. R.K. Chandal Research Associate: 5 Dr. Neeraj Kumar Research Associate: 5 Dr. Ashok K Singh 6 Mr. Ravindra Sharma 6 Mr. B.K. Chaudhary

Team 2 Team 7 Senior Investigator: 1 Dr. Arbind Kumar Senior Investigator: 1 Dr. K.N. Acharya 2 Dr. Manish Kumar 2 Dr. C.S. Sharma Doctor: 3 Dr. Sachin Singh Doctor: 3 Dr. B.K. Singh 4 Dr. Subodh Sharma 4 Dr. Binay Kr. Singh Research Associate: 5 Mrs. Neeta Verma Research Associate: 5 Mr. Anil Kumar 6 Mr. B.B. Pandey 6 Mr. Subhash V Sagar

Team 3 Team 8 Senior Investigator: 1 Dr. Hemant K Das Senior Investigator: 1 Dr. R.K. Sinha 2 Ms. Kalpana Das 2 Dr. K.K. Sinha Doctor: 3 Dr. Suraj Doctor: 3 Dr. Salami Horo 4 Dr. Ajit Kumar Srivastava 4 Dr. Md. Moiz Research Associate: 5 Mr. Abhishek Research Associate: 5 Dr. Prem Kumar 6 Mr. Ashish K Ranjan 6 Dr. A. Prabhkar

Team 4 Team 9 Senior Investigator: 1 Dr. Raja Ram Senior Investigator: 1 Dr. Arun K Sharma 2 Dr. Mala Sinha 2 Dr. J.P. Mishra Doctor: 3 Dr. Arun Prasad Doctor: 3 Dr. O.P. Bharti 4 Dr. Dharmendra Kumar 4 Dr. Sunil Kr. Chaudhary Research Associate: 5 Dr. Shilpi Sonkar Research Associate: 5 Dr. Dennis L. Khawlhring 6 Dr. Vinod Kumar 6 Mrs. Jyotimaya Mishra

Team 5 Team 10 Senior Investigator: 1 Dr. Ashok Kumar Senior Investigator: 1 Dr. Vivek Kashyap 2 Dr. Amita Varma 2 Dr. S.K. Singh Doctor: 3 Dr. Arun K Mishra Doctor: 3 Dr. Arindam Jha 4 Dr. Abhay Kumar 4 Dr. Ashutosh Research Associate: 5 Mr. Vinay K Singh Research Associate: 5 Mr. Amit Kumar 6 Mr. Ramanuj Acharya 6 Mr. Manish K Singh

A-21 Zone No-4: West Bengal, Andaman & Nicobar Zonal Coordinator: Dr. Sandip K. Ray

Team 1 Team 6 Senior Investigator: 1 Dr. Dipak Pal Senior Investigator: 1 Dr. Sarmila Mallik 2 Dr. Prasanta Karmakar 2 Dr. Biswajit Biswas Doctor: 3 Dr. Amitava Sarkar Doctor: 3 Dr. Debasish Manna 4 Dr. Ajay Kr. Chakraborty/ 4 Dr. Mira Das Dr. Tutul Chatterjee Research Associate: 5 Ms. Manisha Kar Research Associate: 5 Mr. Barun Kr. Ray 6 Dr. Arijit Ghosh 6 Mr. Nul Islam Mallick Team 7 Team 2 Senior Investigator: 1 Dr. Jayasri Mitra (Ghosh) Senior Investigator: 1 Dr. Nabendu Chaudhuri 2 Dr. Shyama Prasad Mitra 2 Dr. Nabanita Bhattacharyya Doctor: 3 Dr. Asim Kr. Munsi Doctor: 3 Dr. Biswanath Ray 4 Dr. Subhayan Mondal 4 Dr. Sanjit Kannakar Research Associate: 5 Smt. Ratna Dey Research Associate: 5 Dr. Bhubaneswar Bhattacharjee 6 Mr. Ranajit Kr Bhattacharjee 6 Mr. Mrinal Kanti Mandal Team 8 Team 3 Senior Investigator: 1 Dr. Madhumita Dobe Senior Investigator: 1 Dr. B.B. Mukhopadhyay 2 Mr. Ram Narayan Mandal 2 Prof. Bijoy Mukherjee Doctor: 3 Dr. Dibakar Haldar Doctor: 3 Dr. Anjan Roy 4 Dr. Rinta Mukhopadhyay 4 Dr. Nandini Bhattacharyya Research Associate: 5 Ms. Rekha Rani Dey Research Associate: 5 Dr. Chandan Mukherjee 6 Ms. Swapna Das 6 Mr. Ranjit Kumar Das

Team 4 Team 9 Senior Investigator: 1 Dr. Rabindra N Sinha Senior Investigator: 1 Dr. Ashok Kr. Mallick 2 Dr. Ramaprasad Roy 2 Mr. Suprakas Hazra Doctor: 3 Dr. Debasish Das Doctor: 3 Dr. Samir Kumar Ray 4 Dr. Suman Guha 4 Dr. Tarun K Sarkar Research Associate: 5 Mr. Kamal Kanti Mandal Research Associate: 5 Ms. Debolina Basu 6 Ms. Sukla Paul Chatterjee & 6 Ms. Mala Biswas & Mr. Tarun Chaudhuri Ms. Soma Sadhu

Team 5 Team 10 Senior Investigator: 1 Dr. Samir Das Gupta Senior Investigator: 1 Dr. Asoke Mondal 2 Dr. Nirmal K Mandal 2 Dr. N.C. Mondal Doctor: 3 Dr. Puspendu Das Doctor: 3 Dr. Nishi Kanta Halder 4 Dr. Palash Das 4 Dr. Himadra Paul Research Associate: 5 Mr. Tapan Kr. Dutta Research Associate: 5 Mr. Manoj Kanti De 6 Mr. Tusar Kanti Patra 6 Ms. Papia Maity

A-22 Zone No-5: Assam, Arunachal Pradesh, Sikkim, Meghalaya Zonal Coordinator: Dr. Faruque U. Ahmed

Team 1 Team 6 Senior Investigator: 1 Dr. Alak Barua Senior Investigator: 1 Dr. P.K. Bordoloi 2 Dr. Bobyjeet Goswami 2 Dr. P.J. Bhuyan Doctor: 3 Dr. Parth P Saikia Doctor: 3 Dr. Dibyajyoti Borah 4 Dr. Aman Hussain 4 Dr. Jayanta Dutta Research Associate: 5 Ms. Pallavi Bhuyan Research Associate: 5 Mr. Janardan Hazarika 6 Ms. Unmana Neog 6 Mr. Biplab Borah

Team 2 Team 7 Senior Investigator: 1 Dr. Swapna Kakoty Senior Investigator: 1 Mrs. Aloka Bhattacharjee 2 Dr. Giriraj Kurse 2 Dr. Saumyendra Sarma Doctor: 3 Dr. Deep Mahanata Doctor: 3 Dr. Mutikam Choudhury 4 Dr. Pranami Bordoloi 4 Dr. Sanjeeb Kr. Medhi Research Associate: 5 Ms. Nibedita Deka Research Associate: 5 Mr. Swarup Bhatta 6 Ms. Bhuban Bharali 6 Mrs. Jonali Das

Team 3 Team 8 Senior Investigator: 1 Dr. P. K. Dutta Senior Investigator: 1 Dr. Ajmal Hussain 2 Dr. S. P. Sinha 2 Ms. Minakshi Borah Doctor: 3 Dr. Vinayak Baruah Doctor: 3 Dr. Anup Dutta 4 Dr. Gautom Talukder 4 Dr. Monoj Sarma Research Associate: 5 Mr. Santanu Shome Research Associate: 5 Ms. Dipali Kakoty 6 Mr. Rituraj Biswas 6 Mr. Mridul Kr. Das

Team 4 Team 9 Senior Investigator: 1 Dr. Ganesh Ch. Baruah Senior Investigator: 1 Dr. Chiranjeeb Kakoty 2 Dr. Saurabh Borkatoki 2 Dr. Abdul Kalam Ajad Doctor: 3 Dr. Sidartha Baruah Doctor: 3 Dr. Muksedur Rahman 4 Dr. Lakhinandan Borah 4 Dr. M. Iftikar Ahmed Research Associate: 5 Mr. Randeep Gogoi Research Associate: 5 Ms. Falicita Lakra 6 Mr. Niranjan Phukan 6 Ms. Pankaja Nath

Team 5 Team 10 Senior Investigator: 1 Dr. Bijit Bhattacharya Senior Investigator: 1 Dr. C. Danaila 2 Dr. Jugadhar Changmai 2 Dr. A. Nongpiur Doctor: 3 Dr. Manas Nath Doctor: 3 Dr. Anisha Mowlong 4 Dr. Krishna Garodia 4 Ms. Bitalenwa Majaw Research Associate: 5 Mr. Debajit Saikia Research Associate: 5 Ms. M.L. Rythathiang 6 Mr. Bharat Rajkonwar Team 11 Senior Investigator: 1 Dr. B. B. Rai Doctor: 2 Dr. H. Lepcha Research Associate 3.Mr. Bhupal Rai

A-23 Zone No-6: Manipur, Tripura, Mizoram, Nagaland Zonal Coordinator: Dr. E. Yaima Singh

Team 1 Team 6 Senior Investigator: 1 Dr. L. Usharani Devi Senior Investigator: 1 Dr. K. Zoramthanga 2 Dr. Kh. Robindro Singh 2 Dr. F. Lallianhlira Doctor: 3 Dr. Surajkumar Singh Doctor: 3 Dr. Randolph Sailo 4 Dr. Ranjan Singh 4 Dr. Jeremy V. Pachuau Research Associate: 5 Ms. Manorama Devi Research Associate: 5 Dr. Vanlalruati Pachuau 6 Mr. David Singh 6 Mr. Lalsawma

Team 2 Team 7 Senior Investigator: 1 Dr. A.K. Brogen Senior Investigator: 1 Dr. B. Lalduhawma 2 Dr. Thoiba Henba 2 Dr. Vanlalrengpuia Doctor: 3 Dr. Surjit Singh Doctor: 3 Mr. Henry Lalmawizuala 4 Dr. Sanjeep Singh 4 Mr. Lalnunmawia Research Associate: 5 Mr. Nabachandra Singh Research Associate: 5 Ms. Lalthankimi 6 Mr. L. Amarjit Singh 6 Ms. Laltanpuli Team 3 Senior Investigator: 1 Dr. T. Gambir Singh Team 8 2 Dr. A. Naranbabu Singh Senior Investigator: 1 Dr. Subasish Deb Barma Doctor: 3 Dr. Somarendrro Singh 2 Dr. Saroj Kr. Das 4 Dr. Athui Gangmei Doctor: 3 Dr. Sambhunath Choudhary Research Associate: 5 Mr. M. Meghachandra 4 Dr. Bidhan Das 6 Ms. Y. Prabhabati Devi Research Associate: 5 Mr. Bimalendu Das 6 Mr. Jahar Deb Barma Team 4 Senior Investigator: 1 Dr. Kumini Kathipri Team 9 2 Dr. Tiasnup Senior Investigator: 1 Dr. Tapan Kr. Das Doctor: 3 Dr. Sentila 2 Dr. Jayanta Kr. Das 4 Dr. L.T Patton Doctor: 3 Dr. Amit Kr. Dutta Research Associate: 5 Ms. Narola 4 Mr. Jyotirmay Bhowmik 6 Ms. Tiawati Research Associate: 5 Mr. Ratan Dutta

Team 5 Team 10 Senior Investigator: 1 Dr. L. Yanthan Senior Investigator: 1 Dr. M.S. Choudhury 2 Dr. Limatula 2 Dr. Pranab Chatterjee Doctor: 3 Dr. Talitemsu Doctor: 3 Dr. Kamal Reang 4 Dr. John Murry 4 Mr. Subrata Mallik Research Associate: 5 Chenithung Yanthan Research Associate: 5 Mr. Parijat Dutta 6 Ms. Aienla

A-24 Zone No-7: Rajasthan Zonal Coordinator Dr. Balvir S. Tomar

Team 1 Team 6 Senior Investigator: 1 Dr. Shiv L. Solanki Senior Investigator: 1 Dr. Pavitra Mohan 2 Dr. B.L. Gupta 2 Dr. Sanjna Mohan Doctor: 3 Dr. Rajendra Tater Doctor: 3 Mr. Ezekil Samuel 4 Dr. Manjula Mittal 4 Ms. Kalpana Sen Research Associate: 5 Dr. U.C. Gupta Research Associate: 5 Mr. Ramesh Bunker 6 Mr. Shailendra Birsa/ 6 Mr. Manak Lal Chobisa Mrs. Tara Solanki Team 7 Team 2 Senior Investigator: 1 Dr. R.P. Yadav Senior Investigator: 1 Dr. Suman Bhansali 2 Mr. S.L. Nepalia 2 Dr. S. R. Negi Doctor: 3 Dr. R.C. Bora Doctor: 3 Dr. Savitri Sharma 4 Dr. G.L. Goyal 4 Dr. Surendra Rawat Research Associate: 5 Mr. Arvind Sharma Research Associate: 5 Dr. Usha Vyas 6 Mrs. Mamta Sharma 6 Mr. B.N. Mathur Team 8 Team 3 Senior Investigator: 1 Mr. Mahesh Panpalia Senior Investigator: 1 Dr. Anoop Tankha 2 Mr. Gaurav Bhargava 2 Dr. T.S. Broca Doctor: 3 Dr. Lokesh Gehlot Doctor: 3 Dr. R.V. Barar 4 Dr. Sirin Khan 4 Dr. Mahesh Keswani Research Associate: 5 Mr. Giriraj Jangir Research Associate: 5 Mr. Rajendra Kumar Garg 6 Ms. P. Sireesha 6 Mr. Suresh Chandra Dube Team 9 Team 4 Senior Investigator: 1 Dr. Suresh Chand Gaur Senior Investigator: 1 Dr. Narendra Gupta 2 Dr. S.L. Agarwal 2 Dr. Kanhaiya Lal Sanwaria Doctor: 3 Dr. Jai Singh Shekhawat Doctor: 3 Dr. Mahendra Singh 4 Dr. B.l. Prajapati 4 Dr. Mukesh Slavi Research Associate: 5 Ms. Asha Singh Research Associate: 5 Ms. Minakshi 6 Mr. Govind Singh Bisht 6 Ms. Vinita Team 10 Team 5 Senior Investigator: 1 Dr. S.C. Gupta Senior Investigator: 1 Dr. Veena Dwivedi 2 Dr. M.C. Poonia 2 Dr. Tej Ram Jat Doctor: 3 Dr. Kiran Sharma Doctor: 3 Dr. Vikas Agarwal 4 Dr. Mukesh Sharma 4 Dr. Arun Pancholi Research Associate: 5 Ms. Nasreen Bharti Research Associate: 5 Ms. Shweta Toshniwal 6 Mr. Parvendra Singh 6 Ms. Pushpa Lata

A-25 Zone No-8: Gujarat, Diu, Daman Zonal Coordinator: Dr. Bhadresh R. Vyas

Team 1 Team 6 Senior Investigator: 1 Dr. B.S. Bhavsar Senior Investigator: 1 Dr. K. N. Pandya 2 Dr. Geeta Kedia 2 Dr. Deepak Pande Doctor: 3 Dr. Minal Dadhvi Doctor: 3 Dr. Unadkat Sumit 4 Dr. Mihir Goswami 4 Dr. Tushar S. Vora Research Associate: 5 Mr. Paresh Patel Research Associate: 5 Dr. Vishal Patel 6 Mrs. Lata Banker 6 Dr. Paresh Deolakiya

Team 2 Team 7 Senior Investigator: 1 Dr. P.V. Kotecha Senior Investigator: 1 Dr. Yogesh Parikh 2 Dr. Sangeeta Patel 2 Dr. Umesh Patel Doctor: 3 Dr. Ashish Trivedi Doctor: 3 Dr. Chikitsa Amin 4 Dr. Ilesh Kotecha 4 Dr. R. H. Bhalara Research Associate: 5 Mrs. Usha Chauhan Research Associate: 5 Dr. Mehul J. Kansagra 6 Ms. Sheba Christian 6 Ms. Rekha Parmar

Team 3 Team 8 Senior Investigator: 1 Dr. V.S. Majumdar Senior Investigator: 1 Dr. R.K. Srivastava 2 Dr. J.R. Damar 2 Dr. Nipin Bagla Doctor: 3 Dr. Bharti Makwana Doctor: 3 Dr. Nayan Patel 4 Dr. Kaushik Patel 4 Dr. Brijesh Odedara Research Associate: 5 Dr. Rakesh Patel Research Associate: 5 Ms. Anjana Gamit 6 Ms. Renjaben Deval 6 Mr. Sunil Chaturvedi

Team 4 Team 9 Senior Investigator: 1 Dr. Hiren Deshi Senior Investigator: 1 Dr. Naresh Godara 2 Dr. Sunil Panjwani 2 Dr. Arvind Panwar Doctor: 3 Dr. Sonaiya Tushar Doctor: 3 Dr. Gaurav Patel 4 Dr. Gaurav Parmar 4 Dr. Viral Patel Research Associate: 5 Dr. Umesh Chaudhari Research Associate: 5 Ms. Jyotsna S. Patel 6 Dr. Jayesh Gajjan 6 Mr. Satish Patel

Team 5 Team 10 Senior Investigator: 1 Dr. Chetan Shah Senior Investigator: 1 Dr. Kamlesh Shah 2 Mr. Hemant J.S 2 Dr. Kinjal Baxi Doctor: 3 Dr. Rupal Morabia Doctor: 3 Dr. Gautam Kapadia 4 Dr. Nilesh Kshatriya 4 Dr. Deven Shah Research Associate: 5 Dr. Angela Vaidya Research Associate: 5 Ms. Payal Shah 6 Ms. Priti Gajjar 6 Ms. Maheshwari Jhala

A-26 Zone No-9: Madhya Pradesh, Chattisgarh Zonal Coordinator: Dr. Sheila S. Bhambal

Team 1 Team 6 Senior Investigator: 1 Dr. R.K.S. Kushawaha Senior Investigator: 1 Dr. Ashok Mishra 2 Dr. B. L. Sharma 2 Dr. Subodh Mishra Doctor: 3 Dr. Manish Virteare Doctor: 3 Dr. Pankaj Jain 4 Dr. Abhishek 4 Dr. Vasundhara Aras Research Associate: 5 Mr. M.L. Vishwakarma Research Associate: 5 Dr. Pramod Gautam 6 Mr. S. P. Mehra 6 Dr. R. S. Bhadouria

Team 2 Team 7 Senior Investigator: 1 Dr. S. Nandeshwar Senior Investigator: 1 Mr. Vijay Tiwari 2 Dr. R. Kakkar 2 Mr. Raj Kumar Raj Doctor: 3 Dr. Amit Sondhiya Doctor: 3 Dr. P.K. Srivastava 4 Dr. S. N. Gole 4 Dr. Naveen Agarwal Research Associate: 5 Dr. S. N. Manjhi Research Associate: 5 Ms. Archana Toppo 6 Dr. Prashant Verma 6 Ms. Divya Tirkey

Team 3 Team 8 Senior Investigator: 1 Dr. A. K. Upadhyay Senior Investigator: 1 Mr. Prakash Pradhan 2 Dr. Pradeep Tiwari 2 Mr. Rajendra Shukla Doctor: 3 Dr. Sagar Singhal Doctor: 3 Dr. Sharad Singh 4 Dr. Vishal Jamara 4 Dr. Pramod Jain Research Associate: 5 Mr. R. M. Gour Research Associate: 5 Mr. Rakesh Singh 6 Mr. Rakesh Shakya 6 Mr. Vikram Dhar Diwan

Team 4 Team 9 Senior Investigator: 1 Dr. U. K. Dube Senior Investigator: 1 Mr. Basant Kashyap 2 Dr. R. Kathal 2 Mr. Babu Lal Kashyap Doctor: 3 Dr. Ravi Tripathi Doctor: 3 Dr. Nita Shrivastava 4 Dr. Aditya Pathak 4 Dr. D. K. Gupta Research Associate: 5 Mr. R. K. Sahu Research Associate: 5 Ms. Namita Sahariya 6 Mr. Vivek Samadriya 6 Ms. Aakanchha Tiwari

Team 5 Team 10 Senior Investigator: 1 Dr. D. K. Pal Senior Investigator: 1 Dr. N.Gandhi 2 Dr. P.K. Kasar 2 Dr. M. Toppo Doctor: 3 Dr. Arvind Sharma Doctor: 3 Dr. Kamlesh Jain 4 Dr. T.R. Jadhav 4 Dr. Roshni Gaur Research Associate: 5 Dr. Abhinav Sinha Research Associate: 5 Dr. Ashish Mishra 6 Dr. H.B. Kalikoty 6 Dr. Brijesh Gole

A-27 Zone No-10: Orissa Zonal Coordinator: Dr. Bhagwati C. Das

Team 1 Team 6 Senior Investigator: 1 Dr. P. Bharati Senior Investigator: 1 Dr. D.M. Satapathy 2 Dr. J.M. Das 2 Dr. Archana Patnaik Doctor: 3 Dr. D. Shobha Mallini Doctor: 3 Dr. Kalapana Dalwi 4 Dr. Sanghamitra Pati 4 Dr. Pratap Kr. Sahoo Research Associate: 5 Mr. B. Behera Research Associate: 5 Dr. Debabrata Sabat 6 Ms. Kadambari Misra 6 Dr. A.K. Behera

Team 2 Team 7 Senior Investigator: 1 Dr. M.K. Panigrahy Senior Investigator: 1 Dr. O.P. Panigrahy 2 Dr. Nutan Panda 2 Dr. S.K. Misra Doctor: 3 Dr. Sandeep Mohpatra Doctor: 3 Dr. B.B. Singh 4 Dr. B. Mohanty 4 Dr. B. Pati Research Associate: 5 Mr. S.M. Mohpatra Research Associate: 5 Mrs. M. Dash 6 Mr. P.K. Pradhan 6 Dr. R.K. Padhi

Team 3 Team 8 Senior Investigator: 1 Dr. B.K. Behera Senior Investigator: 1 Dr. H.P. Acharya 2 Mr. G.S. Patnaik 2 Dr. A.K.Misra Doctor: 3 Dr. S.K. Subudhi Doctor: 3 Dr. Smitha Panda 4 Dr. A. Patra 4 Dr. L.P. Nayak Research Associate: 5 Mr. S.K. Patnaik Research Associate: 5 Dr. B. Dixit 6 Mr. R.N. Satua 6 Dr. S. Mishra

Team 4 Team 9 Senior Investigator: 1 Ms. G. Banalata Devi Senior Investigator: 1 Dr. B. Mahapatra 2 Dr. T. Karuna 2 Dr. K. Misra Doctor: 3 Dr. A.P. Patra Doctor: 3 Dr. S.S. Parida 4 Dr. Sagar Khadanga 4 Dr. M. Biswas Research Associate: 5 Mr. P.V. Sai Prasad Research Associate: 5 Dr. J.R. Jena 6 Mr. K.C. Mohapatra 6 Mr. S.K. Manipatra

Team 5 Senior Investigator: 1 Dr. T. Sahu 2 Dr. N.C. Sahani Doctor: 3 Dr. S. Panda 4 Dr. T.R. Behera Research Associate: 5 Dr. Hari Hana 6 Mr. M.M. Padhi

A-28 Zone No-11: Maharashtra, Goa Zonal Coordinator: Dr. Abhimanyu K. Niswade

Team 1 Team 6 Senior Investigator: 1 Dr. Sanjay Zodpey Senior Investigator: 1 Dr. P. A. Bluyar 2 Dr. S. G. Deshpande 2 Dr. B. S. Kamla Purkar Doctor: 3 Dr. Vidyanand Deshpande Doctor: 3 Dr. S. A. Bhuyar 4 Dr. Pankaj Chakradhare 4 Dr. P. D. Bhosale Research Associate: 5 Ms. Prashant Sonpipre Research Associate: 5 Mr. Shirish Naikare 6 Mrs. Daksha Satpute 6 Mr. Nitin Sawant

Team 2 Team 7 Senior Investigator: 1 Mr. Suresh Ughade Senior Investigator: 1 Dr. Unmesh Korde 2 Dr. A. V. Saoji 2 Dr. Leena Rasal Doctor: 3 Dr. Nisha Singh Doctor: 3 Dr. Alka Sonavane 4 Dr. A. P. Jamgade 4 Dr. Simantini Jog Research Associate: 5 Mr. Atul Nimbalkar Research Associate: 5 Dr. Vanita Korde 6 Ms. Rupali Mandvekar 6 Dr. Prakash Saroj

Team 3 Team 8 Senior Investigator: 1 Dr. Abhay Gaidhane Senior Investigator: 1 Dr. Violet Desa 2 Dr. S.Z. Quazi 2 Dr. Trupti Bodhare Doctor: 3 Dr. H. Deshmukh Doctor: 3 Dr. Digambar Kangule 4 Dr. N. Bawankule 4 Dr. Jayashri Bute Research Associate: 5 Mr. Vijay Panchdhane Research Associate: 5 Dr. Pragati Chavan 6 Ms. Kavita Godbole 6 Dr. Samir Bele

Team 4 Team 9 Senior Investigator: 1 Dr. D. D. Motghare Senior Investigator: 1 Dr. Lalit Sankhe 2 Dr. A. M. A. Ferrira 2 Dr. Sudhir Maknikar Doctor: 3 Dr. Nitin Dhupadale Doctor: 3 Dr. Chandra Shekhar Taklikar 4 Dr. Kumulkar 4 Dr. Priya Kulkarni Research Associate: 5 Mr. V. D. Souza Research Associate: 5 Ms. Sonali Ukey 6 Mr. Pandurang Gautankar 6 Mr. Sunil Shinde

Team 5 Team 10 Senior Investigator: 1 Dr. D. L. Ingole Senior Investigator: 1 Dr. Nishikant Rahate 2 Dr. J. S. Bhawalkar 2 Dr. Ranjit Mankeshwar Doctor: 3 Dr. Swapna Sonawane Doctor: 3 Dr. K.S. Vani 4 Dr. Prajakta Bangar 4 Dr. B.K. Jadhav Research Associate: 5 Ms. Vijaya R. Jori Research Associate: 5 Mr. Sanjay Bhonge 6 Mr. Uttam K. Sonawane 6 Mr. Avinash Humane

A-29 Zone No-12: Andhra Pradesh Zonal Coordinator: Dr. S. Narasimha Reddy

Team 1 Team 6 Senior Investigator: 1 Dr. A. Sanjeeva Rao Senior Investigator: 1 Dr. N. Ananthaiah Chetty 2 Dr. G. Krishnababu 2 Dr. G. Ravi Prabhu Doctor: 3 Dr. B. Devi Madhvi Doctor: 3 Dr. G. Usha Kumari 4 Dr. S. Appala Naidu 4 Dr. N. Parthasarathy Research Associate: 5 Dr. S. A. David Raju Research Associate: 5 Mr. P. Sreenivasulu 6 Dr. S. Sunitha 6 Ms. K. Mavitha

Team 2 Team 7 Senior Investigator: 1 Dr. M. Ravi Prasad Senior Investigator: 1 Dr. C. Niranjan Paul 2 Dr. K. V. S. Murthy 2 Dr. A. Sreedevi Doctor: 3 Dr. R. Pushpanjali Doctor: 3 Dr. S. Cynthia Subhaprada 4 Dr. M. L. Surya Prabha 4 Dr. B. Nirmala Devi Research Associate: 5 Dr. B. Sailaja Research Associate: 5 Mr. K. Joseph Rao 6 Mrs. B. Akkamma 6 Mr. K. M. Mallikarjunaiah

Team 3 Team 8 Senior Investigator: 1 Dr. V. Chandra Sekhar Senior Investigator: 1 Dr. C. Bala Krishna 2 Dr. G.S.S. Ganesh Babu 2 Dr. K. Ashok Reddy Doctor: 3 Dr. S. Shyam Doctor: 3 Dr. G. Sukhdas 4 Dr. Ch. Durga Kumar 4 Dr. A. Shravan Kumar Research Associate: 5 Dr. M. Sambha Siva Rao Research Associate: 5 Dr. K. Chandra Shekhar 6 Dr. T. Kamalakar Prasad 6 Dr. J. Anki Reddy

Team 4 Team 9 Senior Investigator: 1 Dr. T.S.R. Sai Senior Investigator: 1 Dr. B. Prithviraj 2 Dr. R. Nageswara Rao 2 Dr. G. Kasiram Doctor: 3 Dr. K. Laxman Rao Doctor: 3 Dr. Alpha Tej 4 Dr. Madhavi 4 Dr. C. Krishna Reddy Research Associate: 5 Dr. K. Ravindraiah Reddy Research Associate: 5 Dr. Sriniwas Babu 6 Mr. Nagwewara Rao 6 Mr. Yesu

Team 5 Team 10 Senior Investigator: 1 Dr. V. Subramanyam Senior Investigator: 1 Dr. G. Subrahmanyam 2 Dr. R. Sambasiva Rao 2 Dr. Venugopal Reddy Doctor: 3 Dr. S. Jagan Mohan Doctor: 3 Dr. P. Narsimha Reddy 4 Dr. S. Fathimunisha 4 Dr. S. Madhusudan Research Associate: 5 Ms. K. Madhavi Research Associate: 5 Mr. M. A. Qaiyyum 6 Ms. P. Durga Rao 6 Dr. Surya Prasad

A-30 Zone No-13: Karnataka Zonal Coordinator: Dr. B. Mallikarjun

Team 1 Team 6 Senior Investigator: 1 Dr. Shivananda Senior Investigator: 1 Dr. Ramachandra Kamath 2 Dr. H.M. Vishwanath 2 Dr. Avinash Shetty Doctor: 3 Dr. M.C.Mahesh Doctor: 3 Dr. Ganesh Kumar 4 Dr. R. Nita 4 Dr. Chandrashekar Research Associate: 5 Dr. Manjunath Research Associate: 5 Dr. Divakar 6 Dr. Supradha 6 Dr. Ashok

Team 2 Team 7 Senior Investigator: 1 Dr. Shivaprasad Senior Investigator: 1 Dr. R.S. Phaneendra Rao 2 Dr. S.C. Mogali 2 Dr. Vinod Batt Doctor: 3 Dr. Vikas N. Satwik Doctor: 3 Dr. Ankur Basua 4 Dr. Sai Kiran 4 Dr. Animesh Jain Research Associate: 5 Dr. G.D. Ranganatha Research Associate: 5 Mrs. Chitralekha 6 Dr. Jagadish Seth 6 Mrs. Leena Ashok

Team 3 Team 8 Senior Investigator: 1 Dr. G.B. Belvadi Senior Investigator: 1 Dr. A.S. Akki 2 Dr. Asha Benakappa 2 Dr. K.A. Masaki Doctor: 3 Dr. G.N. Sanjeeva Doctor: 3 Dr. T. Prashanth 4 Dr. B.O. Dinesh 4 Dr. Vasant Pawar Research Associate: 5 Dr. Nanjunda Research Associate: 5 Dr. K.S. Ravish 6 Dr. M. Rajani 6 Dr. Prabhusami Reddy

Team 4 Team 9 Senior Investigator: 1 Dr. V.D. Patil Senior Investigator: 1 Dr. Kapate Rajashekar 2 Dr. N.S. Mahantshetti 2 Dr. T. Prabhushetty Doctor: 3 Dr. Padmaja Walvekar Doctor: 3 Dr. K.G. Biradar 4 Dr. B.S. Prarthana 4 Dr. T.S. Anil Research Associate: 5 Dr. Roopa M. Bellad Research Associate: 5 Dr. T Girish 6 Dr. Durgappa 6 Dr. Anil Kumar

Team 5 Team 10 Senior Investigator: 1 Dr. A.S. Wantamutte Senior Investigator: 1 Dr. B.N. Patil 2 Dr. Suresh Sommannavar 2 Mr. Shrishail Ghooli Doctor: 3 Dr. Anilkumar S. Talikoti Doctor: 3 Dr. B. Rohit 4 Dr. Santosh Bagali 4 Dr. Sudhindra Research Associate: 5 Dr. Sanjay Kambar Research Associate: 5 Dr. Siddappa 6 Dr. K. Hemagiri 6 Dr. Arun

A-31 Zone No-14: Tamil Nadu, Pondicherry Zonal Coordinator: Dr. Manjula Datta

Team 1 Team 6 Senior Investigator: 1 Dr. N.C. Appavoo Senior Investigator: 1 Dr. K. N. Maithreyi 2 Dr. T. Sathyaprakash 2 Dr. S. Vijayalakshmi Doctor: 3 Dr. G.S.Vikram Doctor: 3 Dr. S. Sendhil Kumar 4 Dr. K. Senthil Kumaran 4 Dr. S. Jansi Banu Research Associate: 5 Dr. Jivarina Nayagam / Research Associate: 5 Mr. M.J. Titus Amanda Singh Dr. Subramaniam 6 Mr. M. Bilal Mohammed 6 Mr. M. Dhandapani Team 7 Team 2 Senior Investigator: 1 Dr. R. Sathianathan Senior Investigator: 1 Dr. K.R. John 2 Mr. R. K. Padmanabhan 2 Dr. V.M. Soma Sundaram Doctor: 3 Dr. Karthikeyan Doctor: 3 Dr. M. Thirumalai Velu 4 Dr. G. Srinivas 4 Dr. K. Santosh Kumar/ Research Associate: 5 Mr. A. Randeep Rajkumar Dr. K. Suresh Kumar 6 Mr. M. Stanley Vinoth Research Associate: 5 Mrs. Joyce Rajan 6 Dr. S. Kumaravel Team 8 Senior Investigator: 1 Dr. S. Shafee Ahmed Team 3 2 Mr. Edwin Amalraj Senior Investigator: 1 Dr. R. Meera Doctor: 3 Dr. P. S. Bharani Prasad 2 Dr. K. Bhuvaneswari 4 Dr. R. Govindrajan Doctor: 3 Dr. S. Venkatesh Research Associate: 5 Mr. J. Kumar 4 Dr. B. Vijayasekharan 6 Mr. S. Kumar Research Associate: 5 Ms. S. Saveetha 6 Mrs. R. Saratha Team 9 Senior Investigator: 1 Dr. C. Indira Priyadarsini Team 4 2 Dr. R. Napoleon Senior Investigator: 1 Dr. G. Sugunadevi Doctor: 3 Dr. S. Muthukumari 2 Dr. M. Seetharaman 4 Dr. E. Nirmala Devi Doctor: 3 Dr. M. Subramaniam Research Associate: 5 Mr. P. Saravanan 4 Dr. S. Srikumar 6 Mr. A.P. Arun Jude Research Associate: 5 Mr. N. Uthayakumar 6 Mr. R. Kumaravel Team 10 Senior Investigator: 1 Dr. K. Muthulakshmi Team 5 2 Dr. P. Gnanaguru Senior Investigator: 1 Dr. P.A. T. Jagadeeswary Doctor: 3 Dr. M.A. Ashika Bhegum 2 Dr. V. Dhanalakshmi 4 Dr. A. Martin Paniraj Doctor: 3 Dr. T. Manokaran Research Associate: 5 Mr. A. Syed Abuthahir 4 Dr. S. Sam Sarvapalli 6 Ms. S. Kala Research Associate: 5 Mr. V. Soundara Pandian 6 Mr. R. Kasiammal

A-32 Zone No-15: Kerala, Lakshwadeep Zonal Coordinator: Dr. Rema Devi

Team 1 Team 6 Senior Investigator: 1 Dr. Philomina Cardoz Senior Investigator: 1 Dr. P. K. Accamma 2 Dr. S. Prasanth Kumar 2 Dr. Nileena Koshy Doctor: 3 Dr. Shybin Usman Doctor: 3 Dr. V.J. Bimal 4 Dr. Sheeja Philip 4 Dr. C. Joman Raphael Research Associate: 5 Mr. K. Ratheesh Research Associate: 5 Dr. Dalvin Thomas 6 Mr. V. Sanath Kumar 6 Dr. V.K. Ajay Mohan

Team 2 Team 7 Senior Investigator: 1 Dr. M. Jayakumari Senior Investigator: 1 Dr. G. Syamala Kumari 2 Dr. S. Jayadevan 2 Mrs. C. G. Santha Doctor: 3 Dr. A. Shefeek Doctor: 3 Dr. Binu Areekal 4 Dr. K.M. Sajin 4 Dr. Anjum Susan Charian Research Associate: 5 Ms. K.V. Bindu Research Associate: 5 Dr. Jacob Varghase 6 Mr. K.V. Ramakrishnan 6 Dr. Shinoy Ansari

Team 3 Team 8 Senior Investigator: 1 Dr. M. Ramla Beegum Senior Investigator: 1 Dr. A. Sobha 2 Dr. T Jayakrishnan 2 Dr. M.G. Prasanna Doctor: 3 Dr. Joe Thomas Doctor: 3 Dr. S. Sajith Kumar 4 Dr. Jayakrishnan 4 Dr. Abraham Johnson Research Associate: 5 Dr. Ravi Prasad Varma Research Associate: 5 Dr. Thomas David 6 Dr. S. Kishore Kumar 6 Dr. M.D. Lalji

Team 4 Team 9 Senior Investigator: 1 Dr. Thomas Bina Senior Investigator: 1 Dr. C. Nirmala 2 Dr. T. Hymavathi 2 Dr. K. Sasikala Doctor: 3 Dr. Bindu Vasudevan Doctor: 3 Dr. A. Althaf 4 Dr. Usha Karunakaran 4 Dr. Sabu Mohammed Naina Research Associate: 5 Dr. K.K Omjith Research Associate: 5 Dr. Leena Sumaraj 6 Dr. T. Ranjith Kumar 6 Ms. Indu Mohan

Team 5 Team 10 Senior Investigator: 1 Dr. K.R. Leela Itty Amma Senior Investigator: 1 Dr. V. Suja 2 Dr. Lucy Rapheal 2 Dr. T. Unnikrishnan Doctor: 3 Dr. T.A. Jayaj Doctor: 3 Dr. K. N. Binoj Kumar 4 Dr. T. Unnikrishan 4 Dr. V. Sethumadhavan Research Associate: 5 Dr. S. Arun Sankar Research Associate: 5 Ms. Gowri G. V. 6 Dr. K. Deepak 6 Ms. Elizabeth Michael

A-33 A-34 A-35 A-36 A-37 A-38 A-39 Annexure - 12

Quality Assurance Visit by CCT Member

Assessment of Injection Practices in India, 2002-2003: An IndiaCLEN Program Evaluation Network Study

Name of CCT Member:...... Date:......

Zone:...... Team No:......

Cluster Description:......

Observation of interviewing technique i) Health Facility (Visit one HF) ii) Data Collection (Re-confirmed UNIQUE No.)

Clients 1. 2. 3. 4. iii) Interview / Observation Schedules / ICR Sheets

Total No. Scrutinized Remarks (Please scan all schedules completed till the day of your visit)

1. Generic Observations

2. Specific Observations

3. Prescriber schedules

4. Exit Schedules

5. Clients Schedules

A-40 A-41 Table 4.2.1 Burden of Injections in Community: Proportion of Population Receiving Injections in Last 2 Weeks and 3 Months

2 Weeks Recall 3 Months Recall

<1 yr ≥ 1yr Total <1 yr ≥ 1yr Total Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Esti 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, 31.8 19.6-43.9 0.1 11.3 8.6-13.9 2.6 12.4 9.8-15.1 2.4 78.7 67.9-89.5 0.1 23.3 20.0-26.6 2.2 26.3 23.3-29.4 1.8 Punjab, Himachal Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar 4.0 1.0-7.0 0.1 9.1 6.6-11.7 7.6 8.9 6.4-11.3 7.2 60.5 49.6-71.4 0.1 20.516.4-24.6 10.2 22.6 18.7-26.4 8.4 Pradesh)

Zone 3 (Bihar & Jharkhand) 19.0 6.8-31.2 0.1 9.5 6.5-12.5 6.3 10.1 7.0-13.1 6.4 51.8 34.8-68.8 0.2 21.9 16.5-27.3 10.4 23.6 18.1-29.1 10.4

Zone 4 (West Bengal & 21.2 11.0-31.4 0.1 4.4 2.9-5.9 2.2 5.3 3.9-6.8 1.8 70.6 59.6-81.6 0.1 15.6 13.2-17.9 1.9 18.5 15.9-21.0 1.9 Andaman & Nicobar Islands)

Zone 5 (Assam, Arunachal 11.0 3.6-18.5 0.03 3.9 2.8-5.1 0.6 4.3 3.1-5.5 0.6 51.3 35.2-67.5 0.1 14.9 11.9-17.8 1.2 16.8 13.7-19.8 1.2 Pradesh, Meghalaya & Sikkim)

Zone 6 (Manipur, Nagaland, 19.4 10.7-28.1 0.01 4.4 2.9-5.8 0.2 5.2 3.8-6.6 0.2 60.3 45.9-74.5 0.01 15.3 12.3-18.2 0.3 17.7 14.7-20.7 0.3 Mizoram & Tripura)

Zone 7 (Rajasthan) 31.3 19.7-42.9 0.1 9.3 6.5-12.2 3.0 10.5 7.7-13.4 2.7 80.3 71.3-89.3 0.04 23.5 19.3-27.8 3.2 26.7 22.6-30.8 2.8

Zone 8 (Gujarat & Daman & 9.1 2.9-15.2 0.03 7.6 5.7-9.5 1.5 7.7 5.8-9.5 1.4 60.8 48.6-72.9 0.1 23.5 20.3-26.7 1.6 25.5 22.4-28.5 1.4 Diu)

Zone 9 (Madhya Pradesh & 31.7 20.2-43.1 0.1 8.5 6.6-10.5 2.2 9.7 7.7-11.8 2.3 60.2 47.1-73.3 0.1 23.3 20.7-25.9 1.8 25.2 22.6-27.9 1.7 Chattisgarh)

Zone 10 (Orrisa) 46.3 31.8-60.9 0.1 15.7 11.7-19.7 2.5 17.4 13.2-21.6 2.6 83.3 74.0-92.6 0.04 27.7 23.4-32.0 1.9 30.8 26.4-35.1 1.9

Zone 11 (Maharashtra & Goa) 29.5 20.7-38.2 0.1 11.2 9.4-13.0 1.8 12.4 10.5-14.2 1.8 73.0 64.1-81.9 0.1 28.0 24.9-31.2 2.7 30.9 27.7-34.1 2.7

Zone 12 (Andhra Pradesh) 20.5 11.9-29.1 0.1 14.8 11.9-17.6 2.7 15.1 12.3-17.8 2.5 72.9 62.7-83.0 0.1 34.7 30.0-39.3 4.0 36.7 32.1-41.4 3.9

Zone 13 (Karnataka) 36.1 24.3-47.9 0.1 14.5 12.2-16.8 1.3 15.7 13.3-18.1 1.3 77.9 67.8-87.9 0.1 33.7 30.6-36.7 1.2 36.1 33.0-39.2 1.2

Zone 14 (Tamil Nadu & 39.7 27.4-52.1 0.1 16.6 13.7-19.5 2.2 17.9 17.9-20.9 2.1 88.9 81.9-95.9 0.1 41.9 36.5-47.2 4.3 44.5 39.2-49.9 4.2 Pondicherry)

Zone 15 (Kerala & 22.2 11.2-33.3 0.04 3.6 2.5-4.8 0.6 4.7 3.5-5.9 0.6 64.5 52.7-76.3 0.03 16.5 14.2-18.8 0.7 19.3 17.1-21.5 0.1 Lakshadweep Islands)

Cont…

Table 4.2.1 Burden of Injections in Community: Proportion of population receiving injections in Last 2 weeks and 3 Months

2 Weeks Recall 3 Months Recall

<1 yr >1yr Total <1 yr >1yr Total All India Est 95% Est 95% Est 95% Esti 95% Est 95% Est 95% Deff Deff Deff Deff Deff Deff (%) CI (%) CI (%) CI (%) CI (%) CI (%) CI

17.2- 9.7- 10.3- 60.0- 23.7- 25.9- Rural 21.3 0.1 10.5 2.9 11.1 2.8 65.2 0.1 24.9 3.5 27.1 3.1 25.3 11.3 11.9 70.3 26.2 28.4

23.7- 8.0- 9.1- 71.5- 22.8- 25.7- Urban 27.4 0.03 8.9 1.4 9.9 1.4 75.7 0.04 24.0 1.5 27.0 1.4 31.1 9.7 10.8 79.8 25.4 28.3

20.1- 9.3- 10.1- 64.7- 23.5- 25.9- Total 23.0 0.1 10.0 3.5 10.8 3.3 68.2 0.1 24.7 4.5 27.1 4.1 26.0 10.8 11.5 71.8 25.9 28.3

Table 4.2.2 Burden of Injections in Community: Estimated Number of Injections Received Per Person Per Year on 2 Weeks’ Recall

Zone Rural Urban Total Est 95% CI Deff Est 95 % CI Deff Est 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 6.4 3.9-8.8 1.6 7.6 4.8-10.4 0.7 6.8 4.9-8.7 1.1 Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 4.9 2.7-7.1 4.8 4.7 2.7-6.7 1.3 4.9 3.0-6.7 4.2 Zone 3 (Bihar & Jharkhand) 6.4 4.1-8.6 3.4 5.1 3.2-6.9 0.6 6.2 4.2-8.2 3.1 Zone 4 (West Bengal & Andaman & Nicobar Islands) 2.1 1.2-2.9 1.6 2.2 0.9-3.4 0.7 2.1 1.4-2.8 1.3 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 3.2 1.0-5.4 0.7 4.5 1.5-7.4 0.1 3.4 1.4-5.4 0.6 Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 2.3 1.1-3.4 0.3 4.7 2.2-7.1 0.1 2.8 1.8-3.9 0.2 Zone 7 (Rajasthan) 6.8 3.2-10.4 4.1 4.2 2.6-5.7 0.5 6.2 3.4-8.9 3.7 Zone 8 (Gujarat & Daman & Diu) 3.6 2.2-5.1 1.5 3.2 1.9-4.5 0.7 3.5 2.4-4.5 1.2 Zone 9 (Madhya Pradesh & Chattisgarh) 5.9 4.2-7.8 2.4 4.0 2.4-5.6 0.6 5.5 4.1-6.9 1.9 Zone 10 (Orrisa) 8.2 5.3-11.1 1.4 6.9 4.8-9.2 0.2 8.0 5.5-10.6 1.3 Zone 11 (Maharashtra & Goa) 6.2 4.9-7.6 1.2 3.9 2.7-5.2 1.7 4.9 3.9-5.8 1.5 Zone 12 (Andhra Pradesh) 10.9 7.5-14.3 2.3 6.9 4.4-9.5 0.8 9.8 7.2-12.4 2.1 Zone 13 (Karnataka) 7.9 6.2-9.7 0.9 4.9 3.9-5.8 0.3 6.9 5.7-8.2 0.9 Zone 14 (Tamil Nadu & Pondicherry) 11.1 7.9-14.3 1.0 7.7 5.5-9.8 0.8 9.9 7.7-12.1 1.0 Zone 15 (Kerala & Lakshadweep Island) 4.1 0.6-7.7 0.7 4.0 0.6-7.4 0.3 4.1 1.4-6.9 0.6 <1 yr 8.4 6.4-10.4 2.1 9.3 7.4-11.3 0.4 8.7 7.3-10.0 1.1 All India ≥1 yr 6.0 5.5-6.7 2.1 4.6 3.9-5.4 1.4 5.6 5.1-6.2 2.1 Total 6.1 5.5-6.8 2.1 4.9 4.2-5.6 1.4 5.8 5.3-6.3 2.1

Table 4.2.3 Burden of Injections in Community: Estimated Number of Injections Received Per Person Per Year on 3 Months’ Recall

Rural Urban Total Zone Est Est Est (%) 95% CI Deff 95 % CI Deff 95% CI Deff (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 2.8 2.0-3.5 1.4 2.6 1.9-3.4 0.8 2.7 2.2-3.3 1.1 Pradesh, Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 2.4 1.7-3.1 5.7 2.6 1.7-3.4 1.6 2.4 1.9-3.0 4.7 Zone 3 (Bihar & Jharkhand) 2.6 1.7-3.4 1.6 2.6 1.5-3.6 6.6 2.6 1.7-3.4 5.1 Zone 4 (West Bengal & Andaman & Nicobar Islands) 1.7 1.2-2.3 1.6 1.6 1.1-2.1 0.5 1.7 1.2-2.1 1.3 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 2.3 1.3-3.3 1.0 2.2 1.5-2.9 0.2 2.3 1.4-3.1 0.9 Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 1.6 1.1-2.1 0.2 1.8 1.3-2.2 0.1 1.6 1.2-2.0 0.2 Zone 7 (Rajasthan) 3.2 2.1-4.2 2.2 2.9 1.9-3.9 0.4 3.1 2.3-3.9 1.7 Zone 8 (Gujarat & Daman & Diu) 2.5 1.7-3.3 0.9 1.6 1.1-2.1 1.2 2.2 1.6-2.8 0.9 Zone 9 (Madhya Pradesh & Chattisgarh) 2.7 2.1-3.4 2.7 3.3 1.8-4.9 0.9 2.9 2.2-3.5 1.7 Zone 10 (Orrisa) 2.9 2.0-3.7 1.5 2.2 1.7-2.8 0.2 2.8 2.0-3.5 1.4 Zone 11 (Maharashtra & Goa) 2.8 2.2-3.3 1.4 2.8 1.7-3.9 1.8 2.8 2.1-3.5 1.7 Zone 12 (Andhra Pradesh) 4.8 3.7-5.9 2.5 5.3 3.7-6.9 1.2 4.9 4.0-5.8 2.0 Zone 13 (Karnataka) 4.3 3.1-5.4 1.1 2.9 2.3-3.6 0.7 3.9 3.0-4.7 1.1 Zone 14 (Tamil Nadu & Pondicherry) 5.9 4.5-7.5 2.4 4.8 3.7-5.9 1.1 5.6 4.5-6.6 2.1 Zone 15 (Kerala & Lakshadweep Island) 3.1 1.7-4.4 0.6 3.2 1.7-4.6 0.2 3.1 2.0-4.2 0.5 <1 yr 5.3 4.6-6.0 2.0 6.3 5.6-7.1 0.6 5.6 5.0-6.2 1.6 All India ≥ yr 2.9 2.6-3.1 1.9 2.7 2.4-3.1 1.3 2.8 2.6-3.0 2.0 Total 3.0 2.8-3.2 1.9 2.9 2.6-3.3 1.4 2.9 2.8-3.2 2.1

Table 4.2.4 Burden of Injections in Community: Vaccination Injections as a Proportion of Total Injections Received (Based on 3 Months Recall)

<1 yr ≥ 1 yr Total Zone Est 95%CI Deff Est 95%CI Deff Est 95%CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 75.0 60.5-89.6 0.1 11.2 7.6-14.7 1.4 17.4 12.5-22.2 1.3 Pradesh, Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 50.6 24.8-76.3 0.2 10.5 7.6-13.5 2.4 14.9 11.3-18.6 2.3 Zone 3 (Bihar & Jharkhand) 67.0 48.2-85.8 0.2 13.9 8.9-19.1 2.9 18.7 12.1-25.3 3.3 Zone 4 (West Bengal & Andaman & Nicobar Islands) 65.4 41.0-89.7 0.1 34.5 22.2-46.8 2.0 40.9 29.2-52.7 1.6 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 85.9 63.2-108.5 0.05 15.1 7.7-22.6 1.0 21.0 11.7-30.4 0.9 Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 66.0 44.2-87.9 0.01 28.9 15.9-41.9 0.4 34.9 22.5-47.2 0.3 Zone 7 (Rajasthan) 55.2 33.8-76.6 0.1 10.0 6.4-13.7 1.3 15.8 10.8-20.7 1.3 Zone 8 (Gujarat & Daman & Diu) 64.7 36.6-92.8 0.1 19.5 12.7-26.4 1.3 24.1 16.7-31.5 1.1 Zone 9 (Madhya Pradesh & Chattisgarh) 53.1 39.3-66.9 0.1 9.9 5.9-13.9 2.4 14.5 10.0-18.9 1.7 Zone 10 (Orrisa) 68.4 49.8-87.0 0.1 21.6 14.2-29.1 1.3 27.5 19.5-35.5 1.2 Zone 11 (Maharashtra & Goa) 80.9 71.4-90.5 0.1 18.9 11.9-25.8 2.4 26.4 18.2-34.6 2.1 Zone 12 (Andhra Pradesh) 56.7 38.3-75.2 0.1 5.1 3.4-6.8 1.7 8.9 6.8-11.1 1.2 Zone 13 (Karnataka) 69.4 51.1-87.8 0.1 9.6 5.5-13.7 1.3 14.9 9.7-20.3 1.3 Zone 14 (Tamil Nadu & Pondicherry) 59.7 46.8-72.7 0.1 7.0 4.7-9.4 1.7 11.7 8.4-14.9 1.8 Zone 15 (Kerala & Lakshadweep Island) 70.8 45.9-95.6 .01 10.9 6.0-15.9 0.7 16.8 10.7-22.9 0.5 Rural 60.9 52.6-69.3 2.1 11.1 9.7-12.6 2.2 15.9 14.3-17.6 1.9 All India Urban 68.0 60.2-75.9 7.6 15.1 12.7-17.5 1.1 21.6 18.9-24.4 1.0 Total 63.2 56.8-69.6 1.8 12.2 10.9-13.4 1.7 17.5 16.0-18.9 1.8

Table 4.2.5 Site of Preventive & Curative Injections in India

Preventive Injections Curative Injections Type of Health < 1 yr ≥ 1 yr Total < 1 yr ≥ 1 yr Total Facility Est 95% Deff Est 95% Deff Est 95% Deff Est 95% Deff Est 95% Deff Est 95% Deff (%) CI (%) CI (%) CI (%) CI (%) CI (%) CI

78.8- 57.9- 67.2- 16.4- 21.3- 21.4- Rural 84.2 2.6 64.1 2.9 72.2 3.7 25.8 1.4 23.8 2.7 23.9 2.6 89.6 70.3 77.3 35.2 26.4 26.4

Govern- 59.3- 38.6- 48.3- 12.1- 18.2- 18.3- Urban 66.0 1.2 44.7 1.2 53.3 1.4 22.1 0.8 20.2 0.7 20.3 0.7 ment 72.8 50.7 58.3 32.1 22.3 22.4

74.2- 52.9- 62.5- 17.4- 20.9- 20.9- Total 78.3 1.7 57.7 2.4 66.0 2.5 24.7 1.3 22.9 2.4 22.9 2.4 82.3 62.4 69.6 31.9 24.9 24.9

Rural 10.9- 30.8- 23.7- 64.8- 73.6- 73.6- 16.7 2.6 37.2 2.8 29.0 3.7 74.2 1.4 76.2 2.7 76.1 2.6 22.5 43.5 34.3 83.6 78.7 78.6

Urban 28.6- 51.1- 43.6- 67.9- 77.7- 77.6- Private 35.9 1.2 57.4 1.3 48.8 1.5 77.9 0.8 79.8 0.7 79.7 0.7 43.1 63.7 54.1 87.9 81.8 81.7

Total 18.8- 38.9- 31.8- 68.1- 75.1- 75.1- 22.9 1.7 43.8 2.5 35.5 2.5 75.3 1.3 77.1 2.4 77.0 2.4 27.2 48.8 39.2 82.6 79.1 79.0

Table 4.2.6 Prescription Containing Injections: Proportion of Clients Prescribed Injection [Direct observation of Prescriber Client Interactions]

Government Health facilities Private Health Facilities Total Zone Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff Zone 1(Chandigarh, Delhi, Punjab, Himachal Pradesh, 21.5 17.2-25.8 1.0 30.9 25.4-36.6 1.1 28.6 24.0-33.1 1.5 Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 36.7 30.6-42.9 3.2 46.5 41.0-51.9 3.3 44.0 39.5-48.6 4.0 Zone 3 (Bihar & Jharkhand) 23.9 19.6-28.2 2.3 40.8 34.4-47.3 2.5 36.5 31.2-41.7 3.5 Zone 4 (West Bengal & Andaman & Nicobar Islands) 24.1 20.4-27.8 1.3 25.9 21.8-30.0 1.5 25.5 21.9-28.9 2.2 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 27.9 22.4-33.3 0.7 33.6 29.4-37.8 0.7 32.1 28.7-35.6 0.8 Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 20.6 16.0-25.1 0.2 28.3 23.8-32.8 0.1 26.3 22.6-30.1 0.2 Zone 7 (Rajasthan) 40.4 35.3-45.5 1.1 50.9 44.7-57.0 1.1 48.2 42.8-53.7 1.7 Zone 8 (Gujarat & Daman & Diu) 24.4 19.6-29.2 0.9 31.4 25.7-37.1 0.9 29.6 24.8-34.4 1.3 Zone 9 (Madhya Pradesh & Chattisgarh) 48.4 42.3-54.6 1.6 47.1 40.9-53.3 1.6 47.5 42.3-52.6 2.2 Zone 10 (Orrisa) 39.5 33.9-45.0 0.8 47.2 40.1-54.2 0.8 45.2 39.4-51.0 1.2 Zone 11 (Maharashtra & Goa) 39.9 33.2-46.6 1.5 47.0 40.6-53.5 1.2 45.2 39.7-50.8 1.9 Zone 12 (Andhra Pradesh) 63.8 56.5-71.1 1.3 66.6 60.2-72.9 1.2 65.8 60.7-71.0 1.5 Zone 13 (Karnataka) 60.5 54.7-66.2 0.8 66.8 61.6-72.0 0.8 65.2 60.9-69.6 1.0 Zone 14 (Tamil Nadu & Pondicherry) 69.6 62.6-76.5 0.9 73.6 67.5-79.7 0.9 72.6 67.4-77.8 1.3 Zone 15 (Kerala & Lakshadweep Island) 15.3 12.1-18.6 0.6 27.4 21.8-32.9 0.6 24.3 20.1-28.6 0.8 Rural 40.3 38.1-42.6 1.5 48.7 46.7-50.7 1.2 46.6 44.8-48.4 1.9 ALL INDIA Urban 33.7 30.7-36.7 0.9 38.9 36.1-41.7 0.9 37.6 35.1-39.9 1.3 Total 38.5 36.7-40.3 1.3 45.9 44.2-47.7 1.3 44.1 42.6-45.6 1.8

Table 4.2.7 Prescriptions Containing Injections: Proportion of Clients Prescribed Injections [Exit Interviews]

Government Health Private Health Facilities Total facilities Zone Est % 95% CI Deff Est % 95% CI Deff Est % 95% CI Deff Zone 1 (Chandigarh, Delhi, Punjab, Himachal 25.9 20.2-31.8 1.7 36.2 29.8-42.7 1.8 33.7 28.7-38.7 2.2 Pradesh, Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 31.3 23.6-38.9 7.1 50.8 43.5-58.1 5.5 45.9 39.7-51.9 7.9 Zone 3 (Bihar & Jharkhand) 23.6 16.7-30.4 4.3 41.7 35.0-48.3 2.9 37.1 31.4-42.7 4.4 Zone 4 (West Bengal & Andaman & Nicobar Islands) 33.0 27.5-38.6 1.6 28.4 23.2-33.6 1.6 29.6 25.6-33.6 1.9 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 27.6 21.2-34.1 0.9 25.5 20.1-30.9 0.7 26.1 21.5-30.7 0.9 Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 23.9 19.3-28.6 0.2 26.8 21.3-32.3 0.2 26.1 21.8-30.4 0.2 Zone 7 (Rajasthan) 57.3 48.8-65.9 2.5 64.9 57.5-72.3 2.0 63.0 55.9-70.1 3.6 Zone 8 (Gujarat & Daman & Diu) 28.8 22.1-35.5 1.7 46.4 38.6-54.1 1.9 41.9 35.6-48.3 2.5 Zone 9 (Madhya Pradesh & Chattisgarh) 51.7 44.9-58.4 2.2 60.5 52.5-68.5 3.2 58.3 52.1-64.4 3.7 Zone 10 (Orrisa) 41.7 34.9-48.4 0.9 46.8 38.5-55.2 1.5 45.5 38.2-52.8 2.3 Zone 11 (Maharashtra & Goa) 36.7 29.8-43.7 3.1 48.9 42.7-55.3 2.4 45.9 40.5-51.3 3.5 Zone 12 (Andhra Pradesh) 71.0 63.9-78.2 2.8 70.8 63.5-78.0 2.9 70.8 64.8-76.8 3.9 Zone 13 (Karnataka) 61.7 55.5-67.9 1.3 68.8 63.3-74.2 1.1 66.9 62.1-71.8 1.7 Zone 14 (Tamil Nadu & Pondicherry) 72.6 64.9-80.3 2.8 72.5 65.9-78.9 1.9 72.5 66.6-78.4 3.3 Zone 15 (Kerala & Lakshadweep Island) 22.1 16.7-27.4 0.8 39.8 32.8-46.7 0.9 35.3 30.1-40.4 1.1 Rural 41.6 38.9-44.3 3.2 52.8 50.4-55.3 2.6 50.0 47.9-52.1 3.7 All India Urban 38.3 34.9-41.8 2.1 44.8 41.5-48.1 1.9 43.2 40.4-45.9 2.7 Total 40.7 38.6-42.9 3.0 50.6 48.5-52.7 2.7 48.1 46.3-49.9 3.9

Table 4.2.8 Prescriptions Containing Injection(s) (According to Type of Prescriber): Proportion of Clients Prescribed Injection

Direct Observation Type of Rural Urban Total Prescriber Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff Allopathic 42.5 40.0-45.0 1.9 37.0 34.4-39.3 1.1 40.5 38.8-42.1 1.4 ISM 50.8 47.0-54.6 2.2 39.2 33.0-45.2 1.6 48.2 45.0-51.4 2.0 Informal 53.0 48.6- 57.6 3.0 43.6 30.6-56.5 1.3 52.3 48.1-56.7 2.8 All India 46.6 44.8-48.4 1.9 37.6 35.1-39.9 1.3 44.1 42.6-45.6 1.8

Type of Prescriber Exit Interview Rural Urban Total Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff Allopathic 43.4 41.1-45.8 3.5 40.8 37.8-43.7 2.7 42.6 40.7-44.4 3.2 ISM 54.9 49.7-60.2 3.4 43.8 37.1-50.4 1.5 52.2 48.2-56.8 3.0 Informal 57.6 52.3-63.0 4.0 56.3 46.8-65.8 1.0 57.5 52.6-62.4 3.7 All India 50.0 47.9-52.1 3.7 43.2 40.4-46.0 2.7 48.1 46.3-49.9 3.9

Table 4.3.1 Plastic Syringe Use – As a Proportion of Total Injections Observed [Direct Observation]

Government Health Private Health Facilities Immunization Clinic Total Zone Facilities Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu & Kashmir 81.6 74.1-89.1 3.7 86.5 79.6-93.5 4.1 60.0 50.3-69.7 3.9 83.6 78.7-88.5 5.3 & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 70.8 61.3-80.3 11.4 84.7 76.4-93.0 14.0 45.8 34.0-57.6 14.6 78.8 72.3-85.3 19.8

Zone 3 (Bihar & Jharkhand) 87.1 79.2-94.9 8.2 87.2 78.5-95.9 10.4 85.9 77.5-94.2 8.5 87.1 80.2-93.9 18.9

Zone 4 (West Bengal & Andaman & 35.2 25.0-45.4 5.5 86.4 79.2-93.6 5.3 20.3 12.3-28.2 4.7 69.9 63.8-76.0 6.4 Nicobar Islands)

Zone 5 (Assam, Arunchal Pradesh, 49.2 36.5-62.0 2.9 67.3 54.5-80.1 3.3 35.2 22.9-47.5 3.0 60.8 50.3-71.3 6.1 Meghalaya & Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & 64.6 54.2-75.1 0.6 90.1 83.8-96.5 0.6 53.4 42.9-63.9 0.6 81.6 75.4-87.8 0.9 Tripura)

Zone 7 (Rajasthan) 88.6 81.1-96.2 4.8 80.2 71.8-88.7 3.8 76.3 67.4-85.3 3.8 81.9 75.5-88.4 7.1

Zone 8 (Gujarat & Daman & Diu) 80.8 72.8-88.8 3.0 78.6 69.6-87.5 3.6 78.6 69.6-87.5 3.6 77.1 70.4-83.9 5.8

Zone 9 (Madhya Pradesh & Chattisgarh) 63.1 52.5-73.7 5.9 58.9 47.5-70.2 6.4 71.4 61.9-80.8 5.3 60.7 51.8-69.6 12.1

Zone 10 (Orrisa) 90.8 84.2-97.4 2.9 88.4 82.2-94.6 1.9 78.0 67.7-88.4 3.4 88.3 83.9-92.6 2.9

Zone 11 (Maharashtra & Goa) 53.9 44.9-62.9 4.8 89.0 83.2-94.9 5.1 40.4 30.9-49.8 5.5 77.3 72.4-82.3 6.0

Zone 12 (Andhra Pradesh) 38.1 27.7-48.5 5.1 68.0 58.3-77.8 4.9 61.3 49.5-73.1 6.2 60.6 52.7-68.5 8.7

Zone 13 (Karnataka) 57.2 47.2-67.3 3.3 83.1 74.9-91.2 3.7 57.8 47.3-68.4 3.6 75.2 68.7-81.8 5.4

Zone 14 (Tamil Nadu & Pondicherry) 15.8 9.9-21.7 2.5 69.6 60.3-78.9 3.9 20.8 14.4-27.2 2.4 53.8 46.9-60.6 5.3

Zone 15 (Kerala & Lakshadweep Island) 63.3 52.2-74.5 2.6 95.5 91.2-99.9 2.2 18.3 9.3-27.3 2.6 82.8 77.9-87.6 2.3

Rural 59.8 56.5-63.1 4.9 78.5 75.1-81.9 7.5 50.4 47.0-53.7 4.9 72.2 69.5-74.9 12.1

ALL INDIA Urban 70.3 66.3-74.2 3.2 86.7 83.5-89.8 3.5 57.3 53.2-61.3 2.8 80.8 78.3-83.3 4.9

Total 62.7 59.8-65.5 5.3 80.7 78.2-83.2 6.3 52.3 49.1-55.5 6.2 74.6 72.6-76.6 9.8

Table 4.3.2 Proportion of Health Facilities Using Only Plastic Syringes [Direct Observation]

Government Health Private Health Facilities Immunization Clinic Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 66.9 56.1-77.7 1.0 75.9 66.1-85.7 1.0 46.4 35.6-57.2 0.9 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 49.8 36.9-62.7 3.5 75.5 64.2-86.8 3.7 35.0 22.7-47.4 3.5

Zone 3 (Bihar & Jharkhand) 78.9 67.0-90.7 2.6 79.6 67.8-91.5 2.7 75.4 62.8-88.0 2.6

Zone 4 (West Bengal & Andaman & Nicobar Islands) 23.2 12.8-33.6 1.5 76.8 66.4-87.2 1.5 13.6 6.3-20.9 1.1

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 40.3 26.5-54.0 0.7 60.4 46.5-74.4 0.7 23.8 11.6-36.1 0.8

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 50.5 37.7-63.3 0.2 78.9 68.5-89.3 0.2 31.4 19.7-42.9 0.2

Zone 7 (Rajasthan) 85.0 75.9-94.1 1.1 66.3 54.1-78.6 1.1 58.8 46.3-71.4 1.1

Zone 8 (Gujarat & Daman & Diu) 69.1 58.0-80.2 0.9 72.5 62.0-82.9 0.8 32.3 21.3-43.3 0.8

Zone 9 (Madhya Pradesh & Chattisgarh) 43.7 31.1-56.3 1.6 49.7 37.1-62.3 1.6 52.5 39.8-65.2 1.6

Zone 10 (Orrisa) 80.7 69.5-91.8 0.9 73.5 61.1-85.9 0.9 67.5 54.4-80.6 0.9

Zone 11 (Maharashtra & Goa) 45.5 35.6-55.5 1.2 77.2 67.7-86.6 1.5 30.5 20.5-40.5 1.4

Zone 12 (Andhra Pradesh) 27.2 16.4-37.9 1.3 49.9 37.8-62.2 1.3 54.4 41.8-67.0 1.3

Zone 13 (Karnataka) 40.6 29.1-52.1 0.9 75.0 64.6-85.4 0.9 45.7 33.8-57.6 0.9

Zone 14 (Tamil Nadu & Pondicherry) 9.4 3.8-15.1 0.7 54.5 43.1-66.0 1.0 12.0 6.0-18.1 0.7

Zone 15 (Kerala & Lakshadweep Island) 53.1 40.8-65.4 0.6 90.1 82.6-97.5 0.6 14.9 6.1-23.7 0.6

Table 4.3.3 Pattern of Syringes Used for Injections [Direct Observation]

Only Plastic Syringe Only glass Syringe Both Glass / Plastic Syringe

Type of Health Facility Estimate Estimate Estimate 95% CI Deff 95% CI Deff 95% CI Deff (%) (%) (%)

Rural 46.3 41.7-50.9 1.9 26.5 22.8-30.1 1.6 27.2 22.9-31.6 2.2

Government Urban 59.8 55.0-64.5 0.8 19.0 15.2-22.9 0.8 21.1 17.2-25.0 0.8

Total 50.0 46.5-53.6 1.6 24.4 21.6-27.2 1.3 25.5 22.2-28.9 1.8

Rural 67.2 62.9-71.5 1.9 12.7 9.7-15.8 1.9 20.0 16.4-23.8 1.9

Private Urban 78.2 74.1-82.2 0.8 7.4 4.9-9.9 0.8 14.4 10.9-17.9 0.8

Total 70.2 66.9-73.5 1.6 11.3 8.9-13.6 1.7 18.5 15.7-21.4 1.7

Rural 39.2 34.7-43.7 1.9 38.4 33.9-42.8 1.8 22.5 18.5-26.5 2.0

Immunization Urban 45.5 40.5-50.5 0.9 30.9 26.3-35.5 0.9 23.6 19.3-27.8 0.8 Clinic

Total 40.9 37.4-44.4 1.6 36.3 32.9-39.7 1.5 22.8 19.7-25.9 1.7

Rural 60.4 57.0-63.8 3.2 17.7 15.2-20.1 2.8 21.9 19.0-24.7 3.2

Total Urban 71.7 68.4-74.8 1.2 11.7 9.7-13.7 1.0 16.6 14.0-19.1 1.25

Total 63.5 60.9-66.1 2.7 16.0 14.2-17.9 2.3 20.4 18.3-22.7 2.7

Table 4.3.4 Proportion of Health Facilities Using both Plastic & Glass Syringes [Direct Observation]

Zone Government Health Facilities Private Health Facilities Immunization Clinic

Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 25.0 15.0-35.1 1.1 15.6 7.1-24.1 1.1 27.1 16.8-37.3 1.1 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 39.7 26.7-52.6 3.7 15.0 5.6-24.4 3.6 24.0 12.9-35.0 3.5

Zone 3 (Bihar & Jharkhand) 17.7 6.5-28.9 2.7 15.6 4.9-26.1 2.6 18.5 7.0-29.9 2.6

Zone 4 (West Bengal & Andaman & Nicobar Islands) 29.7 18.8-40.7 1.4 14.3 5.5-23.1 1.5 16.8 7.5-26.2 1.5

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 23.9 11.6-36.2 0.8 11.9 2.6-21.3 0.8 23.7 11.8-35.5 0.7

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 29.7 17.8-41.7 0.2 17.2 7.8-26.6 0.2 40.8 28.1-53.6 0.2

Zone 7 (Rajasthan) 8.7 1.8-15.6 1.0 26.7 15.1-38.4 1.2 28.1 16.6-39.5 1.1

Zone 8 (Gujarat & Daman & Diu) 21.3 11.4-31.3 0.9 12.5 4.7-20.3 0.8 32.1 21.1-43.2 0.9

Zone 9 (Madhya Pradesh & Chattisgarh) 31.8 20.0-43.5 1.6 22.5 11.9-33.1 1.6 31.9 19.9-43.8 1.6

Zone 10 (Orrisa) 15.0 5.0-24.9 0.9 23.3 11.3-35.4 0.9 18.8 8.2-29.5 0.8

Zone 11 (Maharashtra & Goa) 17.5 9.1-25.9 1.4 16.7 8.4-25.1 1.5 21.9 12.6-31.4 1.5

Zone 12 (Andhra Pradesh) 28.1 16.9-39.4 1.4 33.0 21.2-44.8 1.4 13.2 5.5-20.9 1.1

Zone 13 (Karnataka) 33.5 22.1-44.9 0.9 14.1 5.9-22.2 0.9 23.3 13.2-33.4 0.9

Zone 14 (Tamil Nadu & Pondicherry) 18.6 10.0-27.1 0.9 28.9 18.1-39.7 1.1 23.4 13.5-33.3 1.0

Zone 15 (Kerala & Lakshadweep Island) 17.3 7.6-26.9 0.6 8.1 1.5-14.7 0.6 8.8 2.0-15.5 0.5

Table 4.3.5 Pattern of Syringe Use for Injections [Direct Observation]

Only Plastic Syringe Only glass Syringe Both Glass / Plastic Syringe Zone Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 71.8 64.5-79.2 1.6 9.6 4.9-14.3 1.5 18.6 12.1-25.0 1.6 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 66.8 57.9-75.5 5.4 11.9 6.2-17.5 4.8 21.4 13.9-28.8 5.2

Zone 3 (Bihar & Jharkhand) 79.2 70.2-88.1 4.5 4.6 -0.3-9.4 5.0 16.3 7.9-24.5 4.6

Zone 4 (West Bengal & Andaman & Nicobar Islands) 59.9 51.6-68.3 2.1 21.9 15.8-27.9 1.6 18.1 11.2-25.1 2.4

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 53.3 41.7-64.8 1.5 31.2 20.9-41.6 1.4 15.5 7.5-23.5 1.3

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 69.0 60.0-78.1 0.3 9.2 4.1-14.4 0.2 21.7 14.1-29.4 0.3

Zone 7 (Rajasthan) 70.2 61.1-79.4 2.0 7.2 1.8-12.6 2.2 22.6 14.1-31.1 2.1

Zone 8 (Gujarat & Daman & Diu) 69.0 61.1-77.0 1.4 15.1 8.8-21.4 1.4 15.8 10.2-21.5 1.1

Zone 9 (Madhya Pradesh & Chattisgarh) 48.5 39.1-57.9 2.6 26.2 16.7-35.8 3.4 25.3 17.5-33.1 2.3

Zone 10 (Orrisa) 74.8 65.8-83.7 1.4 4.1 0.8-7.5 0.9 21.1 12.2-29.9 1.6

Zone 11 (Maharashtra & Goa) 66.5 58.9-74.0 2.2 16.2 11.5-20.9 1.5 17.3 11.2-23.3 2.2

Zone 12 (Andhra Pradesh) 44.9 35.9-53.9 2.2 24.5 16.3-32.6 2.4 30.6 22.2-39.0 2.2

Zone 13 (Karnataka) 64.9 57.0-72.9 1.3 15.8 9.2-22.3 1.5 19.3 12.7-25.9 1.3

Zone 14 (Tamil Nadu & Pondicherry) 41.1 32.9-49.2 1.5 32.8 25.9-39.7 1.2 26.1 18.3-33.9 1.8

Zone 15 (Kerala & Lakshadweep Island) 76.3 69.6-83.1 0.7 13.4 9.1-17.7 0.5 10.3 5.4-15.2 0.8

Table 4.3.6 Proportion of Health Facilities Using Only Plastic Syringes – Prescriber Perspective

Government Health Facilities Private Health Facilities Total Zone Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 53.6 42.8-64.3 0.9 77.6 67.9-87.3 1.1 71.4 63.3-79.6 1.3 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 36.0 23.5 -48.6 3.6 58.5 45.5-71.5 3.6 52.8 42.8-62.9 4.2

Zone 3 (Bihar & Jharkhand) 60.7 46.9-74.4 2.6 68.6 55.3-81.9 2.7 66.6 55.6-77.6 3.5

Zone 4 (West Bengal & Andaman & Nicobar Islands) 9.5 2.7-16.4 1.3 71.1 59.6-82.5 1.5 55.6 46.8-64.3 1.5

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 29.6 16.7-42.5 0.7 62.2 48.2-76.1 0.8 54.2 42.5-65.9 1.0 Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 51.6 38.7-64.5 0.2 86.8 78.8-94.8 0.1 77.9 70.8-85.2 0.2

Zone 7 (Rajasthan) 60.4 48.2-72.6 1.1 84.5 74.8-94.2 1.2 78.2 70.1-86.4 1.3

Zone 8 (Gujarat & Daman & Diu) 55.1 43.4-66.8 0.8 72.6 62.1-83.2 0.9 68.2 59.9-76.5 0.9

Zone 9 (Madhya Pradesh & Chattisgarh) 24.3 13.5-35.0 1.5 45.3 32.8-57.8 1.5 40.0 30.2-49.9 1.9

Zone 10 (Orrisa) 93.0 85.8-100.2 0.9 90.4 81.9-98.9 0.9 91.1 84.7-97.5 1.1

Zone 11 (Maharashtra & Goa) 34.0 24.3-43.8 1.2 75.5 65.7-85.3 1.5 65.1 56.9-73.2 1.7

Zone 12 (Andhra Pradesh) 14.5 6.1-22.9 1.3 66.6 54.8-78.4 1.4 53.5 44.1-62.8 1.6

Zone 13 (Karnataka) 24.9 14.7-35.1 0.9 75.8 65.7-85.9 0.9 62.9 54.8-71.2 0.9

Zone 14 (Tamil Nadu & Pondicherry) 4.3 0.7-7.9 0.6 68.7 57.7-79.6 1.0 52.5 44.3-60.6 1.0

Zone 15 (Kerala & Lakshadweep Island) 26.4 16.2-36.6 0.5 82.2 72.3-92.0 0.6 68.2 60.0-76.3 0.6

Rural 33.3 29.5-37.2 1.5 64.3 59.7-68.8 1.9 56.4 52.9-59.9 2.2

ALL INDIA Urban 44.7 40.7-48.7 0.5 80.8 76.5-85.0 0.9 71.7 68.2-75.2 0.9

Total 36.5 33.1-39.9 1.5 68.9 65.4-72.4 1.8 60.7 57.9-63.5 2.1

Table 4.3.7 Proportion of Health Facilities Using Both Plastic & Glass Syringes – Prescriber Perspective

Government Health Facilities Private Health Facilities Total Zone Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal 42.5 31.7-53.2 0.9 19.3 10.1-28.6 1.1 25.3 17.3-33.3 1.3 Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 55.5 42.4-68.6 3.6 38.5 25.6-51.4 3.6 42.8 32.7-52.9 4.3

Zone 3 (Bihar & Jharkhand) 34.0 20.7-47.4 2.6 31.1 17.8-44.3 2.7 31.8 20.6-42.9 3.8

Zone 4 (West Bengal & Andaman & Nicobar Islands) 71.8 60.7-82.9 1.5 28.3 16.9-39.7 1.5 39.2 30.4-48.1 1.6

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 58.2 44.1-72.3 0.7 17.8 6.7-28.9 0.8 27.7 18.4-36.9 0.8 Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 40.5 27.7-53.3 0.2 8.3 2.2-14.3 0.1 16.3 10.1-22.5 0.1

Zone 7 (Rajasthan) 37.7 25.6-49.9 1.1 13.5 4.4-22.7 1.2 19.8 11.8-27.8 1.4

Zone 8 (Gujarat & Daman & Diu) 41.5 29.9-53.1 0.8 22.4 12.5-32.3 0.9 27.2 19.6-34.8 0.9

Zone 9 (Madhya Pradesh & Chattisgarh) 63.8 51.6-76.0 1.6 37.5 25.2-49.8 1.6 44.1 33.8-54.5 2.1

Zone 10 (Orrisa) 6.9 -0.2-14.2 0.9 7.0 -0.5-14.5 0.9 7.0 1.3-12.7 1.1

Zone 11 (Maharashtra & Goa) 36.5 25.5-47.4 1.5 17.5 8.8-26.2 1.6 22.3 14.9-29.7 1.9

Zone 12 (Andhra Pradesh) 55.5 43.2-67.7 1.4 27.9 16.7-39.2 1.4 34.9 25.9-43.9 1.6

Zone 13 (Karnataka) 56.5 44.6-68.4 0.9 19.2 9.9-28.5 0.9 28.6 20.9-36.3 0.9

Zone 14 (Tamil Nadu & Pondicherry) 45.9 34.3-57.6 1.0 24.8 14.5-35.1 1.1 30.1 21.9-38.3 1.2

Zone 15 (Kerala & Lakshadweep Island) 52.7 40.3-65.0 0.6 17.8 7.9-27.7 0.6 26.6 18.5-34.7 0.6

Rural 49.9 45.5-54.3 1.7 29.8 25.0-34.6 2.3 34.9 31.2-38.5 2.6

ALL INDIA Urban 44.1 39.2-48.9 0.8 16.5 12.2-20.8 1.1 23.4 20.0-26.9 1.1

Total 48.3 44.7-51.9 1.6 26.1 22.6-29.5 1.9 31.7 28.9-34.5 2.2

Table 4.3.8 Categorization of Health Facilities According to Patterns of Syringe Use – Prescriber Perspective

Government Health Facility Private Health Facility Total Pattern of Syringe

Use Estimate 95% CI Deff Estimate (%) 95% CI Deff Estimate (%) 95% CI Deff (%)

Rural 33.3 29.5-37.2 1.5 64.3 59.7-68.8 1.9 56.4 52.9-59.9 2.2

Exclusive Plastic Urban 44.7 40.7-48.7 0.5 80.8 76.5-85.0 0.9 71.7 68.2-75.2 0.9

Total 36.5 33.1-39.9 1.5 68.9 65.4-72.4 1.8 60.7 57.9-63.5 2.1

Rural 16.2 13.2-19.2 1.4 5.1 3.2-6.9 1.5 7.9 6.2-9.6 1.8

Exclusive Glass Urban 10.5 7.3-13.6 0.9 2.2 0.7-3.7 0.9 4.3 2.9-5.6 0.8

Total 14.6 12.2-17.0 1.4 4.3 2.8-5.7 1.5 6.9 5.6-8.2 1.7

Rural 49.9 45.5-54.3 1.7 29.8 25.0-34.6 2.3 34.9 31.2-38.5 2.6

Both Glass & Urban 44.1 39.2-48.9 0.8 16.5 12.2-20.8 1.1 23.4 20.0-26.9 1.1 Plastic

Total 48.3 44.7-51.9 1.6 26.1 22.6-29.5 1.9 31.7 28.9-34.5 2.2

Table 4.3.9 Plastic Syringe Use for Last Injection: Respondents’ Recall [Community Survey]

Rural Urban Total Zone Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal 71.7 62.6-80.9 2.3 87.4 82.9-91.8 0.7 78.4 72.5-84.3 1.9 Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 50.6 41.3-59.9 6.0 79.3 73.8-84.8 0.8 56.3 48.6-63.9 5.2

Zone 3 (Bihar & Jharkhand) 70.6 60.0-81.1 6.6 77.7 69.3-86.0 0.7 71.5 62.3-80.7 5.9

Zone 4 (West Bengal & Andaman & Nicobar 53.1 43.5-62.8 2.3 78.9 71.4-86.5 0.7 59.7 52.3-67.2 1.9 Islands)

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 56.0 43.2-68.8 1.6 68.3 57.5-79.2 0.2 57.6 46.5-68.8 1.4 Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 66.4 55.5-77.4 0.4 83.2 74.4-91.9 0.1 69.9 60.9-78.8 0.3

Zone 7 (Rajasthan) 70.8 62.2-79.5 2.4 81.6 74.7-88.4 0.5 73.0 66.0-79.9 2.1

Zone 8 (Gujarat & Daman & Diu) 59.5 49.1-69.9 2.3 73.6 64.4-82.8 0.9 63.7 55.9-71.5 1.9

Zone 9 (Madhya Pradesh & Chattisgarh) 42.9 34.1-51.7 2.8 68.4 60.1-76.8 0.8 48.3 40.9-55.6 2.4

Zone 10 (Orrisa) 84.9 78.5-91.3 1.7 86.6 82.4-90.8 0.1 85.1 79.4-90.7 1.5

Zone 11 (Maharashtra & Goa) 55.6 47.9-63.3 1.8 70.9 63.8-78.2 2.3 64.1 58.7-69.5 2.2

Zone 12 (Andhra Pradesh) 71.1 62.9-79.2 3.6 71.1 64.2-78.2 0.9 71.1 64.9-77.3 2.9

Zone 13 (Karnataka) 61.4 55.7-67.1 1.0 72.1 64.6-79.6 0.9 64.5 59.9-69.1 0.9

Zone 14 (Tamil Nadu & Pondicherry) 57.9 50.3-65.7 2.5 74.2 69.1-79.3 0.7 63.6 58.2-69.1 2.0

Zone 15 (Kerala & Lakshadweep Island) 54.2 45.9-62.5 0.7 54.9 45.4-64.4 0.3 54.4 47.7-61.1 0.6

ALL INDIA 60.9 57.9-63.9 4.2 74.9 72.7-77.3 1.2 64.9 62.7-67.0 3.2

Table 4.3.10 Use of Disposable Syringe for Injection- Direct Observation

Government Health Facilities Private Health Facilities Immunization Clinic Total

All India

Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Rural 75.3 71.9-78.7 6.7 95.6 94.1-97.0 5.6 62.8 59.3-66.2 5.5 88.6 87.2-90.1 6.9

Urban 84.7 81.6-87.8 2.9 98.2 97.2-99.3 2.5 73.3 69.8-76.8 2.6 93.4 92.3-94.4 2.2

Total 77.9 75.4-80.5 5.9 96.3 95.2-97.4 5.2 65.7 62.6-68.8 6.6 89.9 88.9-90.9 5.6

Table 4.3.11 Proportion Health Facilities Using Only Disposable Needles – Prescriber Perspective

Government Health Facilities Private Health Facilities Total Zone Est(%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal 71.9 61.7-82.0 1.0 94.9 89.8-100.0 1.0 88.9 84.5-93.5 0.8 Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 40.0 27.3-52.8 3.5 88.0 79.4-96.6 3.7 75.9 68.4-83.5 3.2

Zone 3 (Bihar & Jharkhand) 72.5 59.9-85.0 2.6 83.8 73.2-94.4 2.7 80.9 72.4-89.5 3.1

Zone 4 (West Bengal & Andaman & Nicobar Islands) 19.2 10.5-27.9 1.2 83.2 73.8-92.5 1.5 67.1 59.8-74.4 1.2

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 25.7 13.6-37.8 0.7 65.3 51.7-78.9 0.8 55.7 43.9-67.4 1.0 Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 52.2 39.3-65.1 0.2 86.8 78.8-94.8 0.1 78.1 70.9-85.4 0.2

Zone 7 (Rajasthan) 67.9 55.8-80.0 1.2 89.0 80.6-97.4 1.2 83.5 76.9-90.2 1.1

Zone 8 (Gujarat & Daman & Diu) 65.9 54.7-77.1 0.8 94.1 88.7-99.5 0.8 87.0 82.4-91.6 0.6

Zone 9 (Madhya Pradesh & Chattisgarh) 46.2 33.5-58.9 1.6 76.8 65.8-87.7 1.6 69.1 59.7-78.4 1.9

Zone 10 (Orrisa) 92.7 85.5-99.9 0.9 86.3 76.2-96.4 0.9 87.9 80.0-95.9 1.3

Zone 11 (Maharashtra & Goa) 34.5 24.4-44.6 1.3 91.5 85.8-97.2 1.2 77.2 72.3-82.0 0.8

Zone 12 (Andhra Pradesh) 58.4 46.2-70.6 1.4 91.6 85.6-97.6 1.1 83.2 77.7-88.7 0.9

Zone 13 (Karnataka) 44.1 32.2-55.9 0.9 89.2 81.9-96.5 0.9 77.8 72.3-83.4 0.6

Zone 14 (Tamil Nadu & Pondicherry) 13.6 6.3-20.9 0.9 86.6 78.7-94.6 1.0 68.2 61.9-74.5 0.7

Zone 15 (Kerala & Lakshadweep Island) 36.3 24.8-47.8 0.5 91.9 85.3-98.5 0.6 77.9 72.7-83.1 0.3

Rural 45.4 40.9-49.8 1.8 85.7 81.8-89.5 2.6 75.5 72.6-78.4 1.9

ALL INDIA Urban 55.6 51.9-59.2 0.4 90.5 87.9-93.0 0.6 81.7 79.7-83.7 0.4

Total 48.2 44.7-51.7 1.5 87.0 84.5-89.5 1.7 77.2 75.1-79.3 1.6

Table 4.3.12 Proportion of Health Facilities Using both Disposable and Steel Needles – Prescriber Perspective

Government Health Facilities Private Health Facilities Total Zone Est (%) 95% CI Deff Est(%) 95% CI Deff Est(%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal 24.7 14.9-34.4 1.0 4.1 -0.6-8.8 1.1 9.4 5.1-13.6 0.8 Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 53.5 40.4-66.6 3.6 9.5 1.7-17.3 3.7 20.6 13.5-27.6 3.2

Zone 3 (Bihar & Jharkhand) 25.3 13.2-37.5 2.5 14.0 4.1-23.9 2.7 16.9 8.6-25.2 3.2

Zone 4 (West Bengal & Andaman & Nicobar 67.1 55.9-78.4 1.4 14.3 5.5-23.1 1.5 27.6 20.3-34.9 1.3 Islands)

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 64.1 50.5-77.6 0.7 21.1 9.5-32.8 0.8 31.6 22.0-41.2 0.8 Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 41.9 29.1-54.8 0.2 8.8 2.7-14.9 0.1 17.1 10.9-23.3 0.1

Zone 7 (Rajasthan) 32.1 19.9-44.2 1.2 10.9 2.6-19.4 1.2 16.5 9.8-23.1 1.1

Zone 8 (Gujarat & Daman & Diu) 31.6 20.7-42.6 0.8 5.9 0.5-11.3 0.8 12.4 7.7-16.9 0.6

Zone 9 (Madhya Pradesh & Chattisgarh) 48.2 35.5-60.9 1.6 18.8 8.7-28.9 1.6 26.2 17.3-35.2 2.0

Zone 10 (Orrisa) 7.3 0.1-14.5 0.9 11.4 2.1-20.8 0.9 10.4 2.9-17.9 1.3

Zone 11 (Maharashtra & Goa) 44.5 33.1-55.9 1.5 7.5 2.1-12.9 1.3 16.8 11.9-21.7 0.9

Zone 12 (Andhra Pradesh) 35.9 23.9-47.9 1.4 2.7 0.1-5.3 0.6 11.1 7.6-14.6 0.6

Zone 13 (Karnataka) 50.9 38.9-62.9 0.9 10.8 3.5-18.1 0.9 20.9 15.2-26.6 0.6

Zone 14 (Tamil Nadu & Pondicherry) 45.1 33.4-56.8 1.0 13.4 5.4-21.3 1.0 21.4 15.4-27.3 0.8

Zone 15 (Kerala & Lakshadweep Island) 46.9 34.6-59.2 0.6 8.1 1.5-14.7 0.6 17.9 12.3-23.5 0.4

Rural 44.2 38.8-49.5 2.6 11.7 8.2-15.2 2.6 19.9 17.1-22.7 2.1

ALL INDIA Urban 37.9 33.6-42.1 0.6 8.0 5.7-10.3 0.6 15.5 13.5-17.6 0.5

Total 42.4 38.8-45.9 1.7 10.7 8.3-12.9 1.7 18.7 16.7-20.7 1.6

Table 4.3.13 Categorization of Health Facilities According to Patterns of Needle Use – Prescriber Perspective

Pattern of Needles Government Health Facilities Private Health Facilities Total

Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff (%) (%) (%)

Rural 45.4 40.9-49.8 1.8 85.7 81.8-89.5 2.6 75.5 72.6-78.4 1.9

Exclusive Urban 55.6 51.9-59.2 0.4 90.5 87.9-93.0 0.6 81.7 79.7-83.7 0.4 Disposable

Total 48.2 44.7-51.7 1.5 87.0 84.0-89.5 1.7 77.2 75.1-79.3 1.6

Rural 10.1 7.2-13.0 2.0 2.3 0.7-3.8 2.3 4.3 2.8-5.7 2.3

Exclusive Urban 6.4 4.1-8.7 0.8 1.5 0.3-2.7 0.8 2.7 1.5-3.9 0.9 Steel

Total 9.1 7.1-11.0 1.4 2.1 1.0-3.1 1.7 3.8 2.9-4.8 1.5

Rural 44.2 38.8-49.5 2.6 11.7 8.2-15.2 2.6 19.9 17.1-22.7 2.1

Steel & Urban 37.9 33.6-42.1 0.6 8.0 5.7-10.3 0.6 15.5 13.5-17.6 0.5 Disposable

Total 42.4 38.8-45.9 1.7 10.7 8.3-12.9 1.7 18.7 16.7-20.7 1.6

Table 4.3.14 Problems Faced in Procurement of Plastic Syringes at Health Facilities – Prescriber Perspective

Perceived Problem Government Health Facilities Private Health Facilities Total

Est (%) 95% CI Deff Est (%) 95% CI Deff Est(%) 95% CI Deff

Rural 91.9 87.8-96.1 2.0 54.4 36.6-72.2 1.8 79.9 73.3-86.5 2.7

Supply Urban 88.7 84.0-93.3 0.5 30.3 7.9-52.6 0.6 75.8 66.4-85.0 1.2

Total 91.2 87.9-94.6 1.6 50.8 34.7-66.9 1.7 79.0 73.3-84.7 2.6

Rural 11.1 6.5-15.7 1.8 23.3 6.6-39.9 2.1 15.0 9.1-20.9 2.8

Administrative Urban 10.7 5.6-15.8 0.7 36.5 10.3-62.7 0.7 16.4 8.9-23.9 1.0

Total 11.0 7.3-14.8 1.6 25.2 12.0-38.5 1.5 15.3 10.6-20.0 2.3

Rural 2.9 0.6-5.3 1.7 19.0 4.9-33.3 1.8 8.1 3.5-12.8 2.9

Financial Urban 3.6 1.0-6.2 0.5 33.2 10.9-55.4 0.5 10.2 4.8-15.5 0.8

Total 3.0 1.2-4.9 1.4 21.2 8.4-33.9 1.6 8.5 4.4-12.7 2.9

Table 4.3.15 Measures to Overcome Shortage of Syringes at Health Facilities – Prescriber Perspective

Proactive Efforts of Use of Existing Syringes in an Use of Glass Syringes with Change of Prescription (oral Procurement Unsafe Manner Proper Sterilization Drug/Referral) Type of Health Facility Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff Esti (%) 95% CI Deff

Rural 85.4 81.9-88.9 1.2 9.3 5.4-13.1 2.1 14.9 10.7-19.2 1.7 4.9 1.7-8.2 2.6

Government Urban 84.7 79.6-89.7 0.8 10.0 6.3-13.8 0.7 17.7 12.4-23.0 0.8 2.2 0.9-3.4 0.3

Total 85.2 81.9-88.5 1.4 9.5 6.9-11.9 1.2 15.7 12.4-18.9 1.4 4.2 2.2-6.3 1.7

Rural 63.7 54.3-72.9 2.5 17.9 10.5-25.4 2.5 18.9 11.8-26.0 2.2 10.6 5.4-15.7 1.8

Private Urban 78.1 68.9-87.3 0.8 11.5 4.5-18.4 0.8 8.5 2.8-14.3 0.7 9.4 2.0-16.8 1.1

Total 66.6 59.7-73.5 1.8 16.6 11.1-22.1 1.8 16.8 10.9-22.7 2.1 10.3 6.1-14.6 1.7

Rural 71.9 65.8-78.1 3.6 14.6 9.4-19.9 4.2 17.4 12.6-22.2 3.1 8.4 5.1-11.7 2.7

Total Urban 81.1 74.8-87.4 1.4 10.8 5.9-15.6 1.3 12.7 8.6-16.8 0.8 6.1 1.9-10.3 1.7

Total 73.9 69.4-78.5 2.7 13.8 10.2-17.3 2.7 16.4 12.5-20.3 2.8 7.9 5.2-10.6 2.5

Table 4.3.16 Purchase of Syringe for Injection by Clients Exiting Health Facilities

Government Health Facilities Private Health Facilities Total

Zone

Est (%) 95% CI Deff Est (%) 95% CI Deff Est (%) 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal 42.3 28.9-55.6 1.9 33.6 22.6-44.6 1.9 35.3 25.5-45.1 2.8 Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 55.3 41.4-69.2 6.4 39.2 26.1-52.3 9.5 41.9 29.9-53.9 14.0

Zone 3 (Bihar & Jharkhand) 73.3 58.9-87.6 4.0 54.6 41.1-68.2 5.0 57.6 46.2-69.0 6.5

Zone 4 (West Bengal & Andaman & Nicobar Islands) 22.6 12.3-32.9 2.4 42.1 29.6-54.7 2.2 36.6 26.7-46.5 3.0

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 41.9 25.4-58.4 1.4 58.5 42.8-74.1 1.2 54.0 41.1-66.9 1.6 Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 51.7 35.9-67.5 0.3 71.2 57.5-84.9 0.3 66.7 55.1-78.3 0.4

Zone 7 (Rajasthan) 81.7 73.2-90.2 2.3 35.4 24.9-45.8 2.6 45.9 36.9-55.0 3.5

Zone 8 (Gujarat, Daman & Diu) 11.4 4.3-18.6 1.1 10.2 2.6-17.8 2.2 10.4 3.9-16.8 2.8

Zone 9 (Madhya Pradesh & Chattisgarh) 20.5 11.7-29.2 2.9 16.2 9.3-23.2 2.6 17.2 10.9-23.4 3.8

Zone 10 (Orrisa) 70.8 60.0-81.6 1.3 51.5 39.3-63.7 1.5 55.9 45.9-65.9 1.9

Zone 11 (Maharashtra & Goa) 14.7 6.8-22.6 2.7 22.0 12.7-31.4 3.7 20.6 12.2-28.9 5.7

Zone 12 (Andhra Pradesh) 19.9 12.1-27.9 3.1 45.1 34.2-55.9 3.8 38.8 30.2-47.3 4.9

Zone 13 (Karnataka) 15.4 8.3-22.5 1.9 23.5 14.9-32.1 2.2 21.6 14.6-28.7 3.1

Zone 14 (Tamil Nadu & Pondicherry) 16.3 10.9-21.6 1.4 32.7 23.2-42.3 2.8 28.6 21.2-35.9 3.6

Zone 15 (Kerala & Lakshadweep Island) 21.1 7.7-34.4 1.1 26.9 15.4-38.4 1.3 25.9 15.8-36.2 1.8

Rural 35.2 30.9-39.5 3.6 33.1 28.9-37.4 4.7 33.6 29.9-37.2 6.6

ALL INDIA Urban 33.8 29.8-37.8 1.2 38.7 34.5-42.8 1.4 37.6 34.4-40.8 1.6

Total 34.8 31.6-38.0 2.9 34.5 31.1-37.9 4.0 34.6 31.7-37.5 5.5

Table 4.4.1 Unsafe Injections** (as % of Injections Observed)

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff)

Zone 1 (Chandigarh, Delhi, Punjab, 50.3-66.8 40.3-58.1 66.2-80.8 48.3-66.0 38.6-54.9 46.8-59.3 Himachal Pradesh, Jammu & Kashmir 58.6 49.2 73.5 57.1 46.8 53.0 & Haryana) (2.8) (3.2) (2.6) (5.8) (3.2) (4.7) Zone 2 (Uttaranchal & Uttar Pradesh) 59.0-75.2 50.9-70.7 78.4-91.6 57.5-74.7 44.7-65.5 56.7-71.1 67.1 60.8 84.9 66.1 55.1 63.9 (7.7) (10.9) (8.9) (20.6) (6.9) (17.5) Zone 3 (Bihar & Jharkhand) 50.7-74.9 47.3-71.2 52.1-75.1 49.3-70.1 58.1-77.4 50.7-69.9 62.9 59.2 63.6 59.7 67.8 60.3 (9.4) (8.7) (8.5) (18.3) (1.5) (17.2) Zone 4 (West Bengal & Andaman & 87.4-96.5 47.1-66.6 85.3-95.9 59.9-77.2 53.5-74.5 60.4-74.3 91.9 56.8 90.6 68.6 63.9 67.3 Nicobar Islands) (3.4) (4.7) (3.9) (9.1) (4.7) (7.9) Zone 5 (Assam, Arunchal Pradesh, 53.3-76.2 41.2-66.4 72.6-91.4 48.9-73.2 30.4-47.1 47.6-69.1 64.8 53.8 82.0 61.0 38.7 58.4 Meghalaya & Sikkim) (2.5) (2.8) (2.7) (7.2) (0.5) (6.3) Zone 6 (Manipur, Nagaland, Mizoram & 45.3-65.9 37.8-59.1 58.4-77.0 42.3-63.7 34.5-57.4 42.8-60.2 55.6 48.5 67.7 53.0 45.9 51.5 Tripura) (0.5) (0.6) (0.5) (1.4) (0.4) (1.2) Zone 7 (Rajasthan) 28.0-47.9 46.2-65.7 37.1-57.7 45.5-66.0 26.4-44.9 42.9-59.3 37.9 55.9 47.4 55.7 35.7 51.1 (3.5) (3.3) (3.6) (8.4) (2.2) (6.9) Zone 8 (Gujarat & Daman & Diu) 44.2-63.6 43.5-63.4 73.6-88.1 47.9-68.0 39.9-61.1 47.9-62.9 53.9 53.5 80.9 57.9 50.6 55.4 (2.8) (3.0) (2.6) (6.1) (3.5) (5.1) Zone 9 (Madhya Pradesh & Chattisgarh) 73.5-90.2 77.5-91.5 59.3-80.6 80.6-92.6 60.9-80.9 77.7-88.0 81.9 84.5 69.9 86.6 70.9 82.9 (5.8) (4.5) (6.6) (8.6) (4.2) (6.8) Zone 10 (Orrisa) 28.0-51.9 45.4-68.6 46.1-68.8 43.5-66.9 27.2-50.4 42.7-63.2 39.9 57.0 57.4 55.2 38.8 52.9 (3.2) (2.9) (2.9) (7.7) (1.2) (6.7) Zone 11 (Maharashtra & Goa) 66.0-82.7 42.7-62.1 63.8-81.6 66.2-85.1 37.3-57.7 51.9-66.2 74.4 52.4 72.7 75.7 47.5 59.1 (5.4) (5.4) (5.9) (8.6) (10.6) (9.2) Zone 12 (Andhra Pradesh) 72.9-89.4 58.3-78.2 53.1-75.4 63.1-83.2 56.8-75.1 63.4-78.7 81.1 68.3 64.3 73.2 65.9 71.0 (4.9) (5.1) (5.7) (12.2) (3.6) (9.4) Zone 13 (Karnataka) 67.1-82.1 60.7-77.4 62.9-78.5 67.4-82.8 50.3-70.4 64.3-76.6 74.6 69.0 70.7 75.1 60.3 70.5 (2.4) (2.5) (2.3) (5.1) (3.1) (4.3) Zone 14 (Tamil Nadu & Pondicherry) 71.9-88.3 52.1-70.2 72.0-86.8 58.8-77.3 54.8-74.2 59.9-73.7 80.1 61.2 79.4 68.0 64.5 66.8 (3.9) (3.3) (3.2) (7.3) (4.0) (6.1) Zone 15 (Kerala & Lakshadweep Island) 50.7-71.2 30.9-47.9 78.8-91.8 37.4-54.7 43.8-59.8 40.9-54.2 60.9 39.4 85.3 46.0 51.8 47.5 (2.1) (1.5) (1.6) (3.2) (0.1) (2.6) Cont…

Table 4.4.1 Unsafe Injections ** (as % of Injections Observed)

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI

(%) (Deff) (Deff) (Deff) (Deff)

67.9-73.2 59.2-67.5 73.5-80.0 62.9-68.9 Rural 70.6 63.3 76.8 65.9 (3.5) (8.1) (6.5) (12.6)

59.5-67.7 45.9-55.8 63.1-70.5 51.3-58.6 ALL INDIA Urban 63.6 50.9 66.8 54.9 (3.1) (4.0) (2.5) (6.6)

66.1-71.3 56.9-62.8 71.4-76.6 60.7-65.1 Total 68.7 59.9 74.0 62.9 (4.8) (5.5) (5.4) (9.8)

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Table 4.4.2 Unsafe Injections (as % of All Injections) Given with Glass Syringes – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, 79.9-100.2 85.2-101.4 88.5-99.0 85.4-98.1 91.1-101.4 87.2-97.8 Punjab, Himachal Pradesh, 90.1 93.3 93.8 91.7 96.2 92.5 (1.9) (1.4) (1.8) (2.8) (0.8) (2.6) Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar 97.6- 92.3- 79.3-102.2 96.8-100.6 92.3-101.1 86.5-99.1 Pradesh) 90.7 98.7 99.1 100.6 96.7 92.8 96.2 100.1 (11.5) (1.1) (11.5) (1.9) (3.4) (8.9) Zone 3 (Bihar & Jharkhand) 78.3- 92.9- 76.1-105.9 100-100 92.6-101.9 92.3-100.4 99.1 100 89.2 100.2 97.3 96.3 97.2 101.4 (5.1) (-) (5.7) (0.4) (2.5) (5.0) Zone 4 (West Bengal & Andaman 97.8-100.3 96.9-101.0 93.9-99.7 98.3-100.2 93.8-99.9 97.6-99.7 99.0 99.0 96.8 99.3 96.8 98.6 & Nicobar Islands) (1.2) (0.7) (2.5) (1.3) (1.1) (1.2) Zone 5 (Assam, Arunchal 86.4- 75.5-99.7 87.0-103.4 86.3-99.6 81.2-96.7 86.4-98.9 Pradesh, Meghalaya & Sikkim) 87.6 95.2 93.8 101.1 92.9 88.9 92.7 (2.9) (2.0) (4.3) (0.3) (3.9) (2.6) Zone 6 (Manipur, Nagaland, 77.0-98.7 72.8-100.9 90.9-99.3 78.1-96.8 90.3-102.2 80.7-96.7 87.9 86.8 95.1 87.4 96.3 88.7 Mizoram & Tripura) (0.5) (0.2) (0.2) (0.6) (0.1) (0.6) Zone 7 (Rajasthan) 90.3-102.9 85.9-100.1 63.6-97.7 86.8-99.1 75.6-102.3 86.8-98.1 96.6 92.9 80.7 92.9 88.9 92.4 (1.1) (1.3) (3.6) (3.1) (1.4) (2.8) Zone 8 (Gujarat & Daman & Diu) 73.7-101.2 55.3-96.6 91.8-99.4 58.7-98.6 70.1-100.6 67.1-95.1 87.5 75.9 95.6 78.6 85.3 81.1 (2.3) (3.7) (1.3) (10.2) (4.6) (8.7) Zone 9 (Madhya Pradesh & 95.1-100.8 98.3-100.6 69.3-98.2 97.5-99.9 91.4-101.8 96.9-99.7 97.9 99.4 83.7 98.7 96.6 98.3 Chattisgarh) (1.8) (1.1) (5.1) (1.8) (2.5) (2.1) Zone 10 (Orrisa) 56.2-102.8 67.8-101.7 60.3-93.6 69.7-97.8 46.1-105.5 69.8-95.6 79.5 84.7 76.9 83.8 75.8 82.7 (1.6) (1.3) (1.8) (3.1) (1.5) (2.9) Zone 11 (Maharashtra & Goa) 90.6-100.2 81.8-101.2 82.9-95.6 86.8-98.4 87.8-99.3 88.7-97.2 95.4 91.5 89.3 92.6 93.6 92.9 (3.4) (1.8) (3.6) (4.1) (2.6) (3.6) Zone 12 (Andhra Pradesh) 86.3-97.2 66.5-96.2 65.2-93.7 75.8-97.3 67.7-91.3 76.2-93.9 91.8 81.4 79.4 86.5 79.5 85.1 (2.6) (4.9) (4.9) (13.6) (3.0) (10.7) Zone 13 (Karnataka) 79.8-96.4 77.7-101.9 79.3-94.8 79.6-98.3 80.4-96.1 81.7-95.9 88.1 89.8 87.1 88.9 88.3 88.8 (2.1) (2.0) (1.7) (4.9) (1.3) (3.9) Zone 14 (Tamil Nadu & 75.1-92.9 50.8-85.4 79.9-93.6 62.1-85.9 87.2 78.8-95.5 67.6-86.5 84.0 68.1 86.7 73.9 77.0 Pondicherry) (4.5) (3.8) (2.9) (9.8) (2.5) (8.7) Zone 15 (Kerala & Lakshadweep 69.7-97.9 0.9-104.9 81.2-93.9 62.4-95.4 70.4-92.6 66.1-92.8 83.8 52.9 87.6 78.9 81.5 79.4 Island) (2.5) (2.2) (1.4) (4.2) (0.6) (3.6) Cont…

Table 4.4.2 Unsafe Injections (as % of All Injections) Given with Glass Syringes – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI

(Deff) (Deff) (Deff) (Deff)

88.9-94.9 85.8-94.2 89.9-95.1 88.4-93.5 Rural 91.9 89.9 92.6 90.9 (5.1) (4.5) (4.9) (9.6)

86.7-93.7 86.0-96.6 83.9-91.1 87.6-92.9 ALL INDIA Urban 90.2 91.3 87.5 90.3 (1.7) (1.9) (2.0) (2.6)

89.1-94.1 86.9-93.6 89.4-93.2 88.8-92.8 Total 91.6 90.2 91.3 90.8 (4.4) (3.6) (3.2) (7.5)

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Table 4.4.3 Unsafe Injections (as % of All Injections) Given with Plastic Syringes – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 42.1-60.8 33.6-51.2 49.3-69.6 37.3-56.9 34.5-51.4 38.6-51.9 51.5 42.4 59.5 47.1 42.9 45.3 Pradesh, Jammu & Kashmir & Haryana) (2.9) (2.8) (2.6) (4.8) (2.9) (3.9) Zone 2 (Uttaranchal & Uttar Pradesh) 47.5-67.3 43.2-64.7 55.2-81.4 46.7-67.6 37.3-59.3 46.7-63.8 57.4 53.9 68.3 57.1 48.3 55.2 (7.6) (10.5) (9.7) (19.3) (5.8) (16.3) Zone 3 (Bihar & Jharkhand) 45.9-71.5 39.5-64.9 46.6-72.1 42.5-64.6 50.5-72.6 43.8-64.4 58.7 52.2 59.4 53.5 61.5 54.1 (8.9) (8.8) (8.7) (16.2) (1.3) (15.2) Zone 4 (West Bengal & Andaman & Nicobar 66.9-90.9 39.7-60.6 47.5-84.9 43.6-67.1 36.9-62.8 44.6-63.2 78.9 50.2 66.2 55.4 49.8 53.9 Islands) (3.7) (4.6) (3.9) (9.2) (4.1) (7.8) Zone 5 (Assam, Arunchal Pradesh, Meghalaya 26.2-54.4 19.9-47.6 41.2-79.6 23.2-52.6 17.3-35.2 23.6-48.5 40.3 33.7 60.4 37.9 26.2 36.1 & Sikkim) (1.9) (2.6) (2.5) (5.6) (0.5) (4.8) Zone 6 (Manipur, Nagaland, Mizoram & 26.9-48.9 33.2-55.1 31.0-56.5 33.2-55.4 27.6-49.7 34.1-51.9 37.9 44.2 43.8 44.3 38.5 42.9 Tripura) (0.4) (0.6) (0.5) (1.1) (0.3) (0.9) Zone 7 (Rajasthan) 20.7-40.2 36.2-57.3 25.9-48.4 34.8-57.6 20.4-38.8 33.2-50.8 30.4 46.8 37.1 46.2 29.6 42.0 (3.4) (3.1) (3.6) (7.3) (1.9) (5.9) Zone 8 (Gujarat & Daman & Diu) 35.6-56.1 36.3-58.4 53.6-78.3 40.9-63.2 27.7-51.5 39.4-56.1 45.9 47.3 65.9 52.1 39.6 47.8 (2.5) (2.9) (2.6) (5.1) (3.2) (4.3) Zone 9 (Madhya Pradesh & Chattisgarh) 60.5-84.4 63.2-84.8 51.3-77.5 68.3-86.6 48.8-74.0 65.4-80.3 72.4 74.0 64.4 77.4 61.4 72.9 (5.6) (4.4) (6.6) (6.7) (3.8) (5.6) Zone 10 (Orrisa) 23.6-48.4 40.9-65.8 39.0-64.8 38.7-64.1 22.4-45.9 37.9-60.1 35.9 53.4 51.9 51.4 34.1 49.0 (3.3) (2.9) (2.9) (6.9) (1.1) (6.1) Zone 11 (Maharashtra & Goa) 43.3-69.6 37.4-57.9 32.1-64.4 52.9-80.2 28.6-51.2 40.4-57.8 56.5 47.6 48.3 66.5 39.9 49.1 (5.7) (5.5) (6.4) (8.6) (10.4) (9.1) Zone 12 (Andhra Pradesh) 47.1-80.5 50.2-74.1 39.9-69.4 48.4-76.7 49.3-72.1 51.9-71.9 63.8 62.1 54.7 62.6 60.7 61.9 (5.2) (4.7) (5.8) (9.9) (3.4) (7.7) Zone 13 (Karnataka) 54.1-74.9 55.6-73.6 47.3-70.4 61.3-79.1 40.4-63.7 57.1-71.5 64.5 64.6 58.8 70.2 52.1 64.3 (2.2) (2.3) (2.6) (4.0) (2.8) (3.5) Zone 14 (Tamil Nadu & Pondicherry) 40.5-77.9 47.9-68.3 34.6-68.5 47.1-74.9 41.5-67.0 48.4-67.6 59.2 58.1 51.6 61.0 54.2 58.0 (2.2) (2.9) (2.3) (6.2) (3.9) (5.2) Zone 15 (Kerala & Lakshadweep Island) 35.2-60.2 30.2-47.3 55.6-94.6 28.2-48.7 38.1-56.3 33.1-48.7 47.7 38.8 75.1 38.5 47.2 40.9 (1.9) (1.4) (1.8) (3.4) (0.9) (2.7)

Cont…

Table 4.4.3 Unsafe Injections (as % of All Injections) Given with Plastic Syringes – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI

(%) (Deff) (Deff) (Deff) (Deff)

52.3-59.9 51.6-60.1 55.5-66.9 52.8-59.5 Rural 56.1 55.8 61.2 56.1 (3.9) (6.4) (7.6) (9.5)

47.0-57.7 39.6-49.6 46.6-56.1 42.4-50.7 ALL INDIA Urban 52.3 44.6 51.4 46.5 (3.4) (3.6) (2.2) (6.2)

51.4-58.5 49.2-55.8 54.0-62.3 50.6-55.9 Total 54.9 52.5 58.2 53.3 (5.0) (5.5) (5.9) (8.9)

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Table 4.4.4 Unsafe Injections (as % of Injections Observed) According to Type of Health Provider

Rural Urban Total

Type of Health Provider

Est. (%) 95% CI Deff Est. (%) 95% CI Deff Est. (%) 95% CI Deff

Allopathic Practitioner 60.9 57.7-64.2 5.6 52.5 48.6-56.4 4.1 57.9 55.5-60.4 4.9

ISM Practitioner 68.0 61.3-74.8 9.3 53.8 44.0-63.6 5.0 64.8 59.2-70.4 8.3

Informal Practitioner 72.8 64.8-80.9 17.4 80.0 69.9-90.2 2.9 73.4 66.5-80.3 14.6

Table 4.4.5 Unsafe Injections (as % of Injections Observed) Carrying a Potential Risk of Transmission of BBV

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est 95% CI Est 95% CI Est 95% CI Est 95% CI Est 95% CI Est 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff)

Zone 1 (Chandigarh, Delhi, Punjab, 7.8-19.7 6.8-20.5 16.6-33.2 11.3-25.9 3.0-12.9 9.6-19.3 Himachal Pradesh, Jammu & Kashmir & 13.7 13.6 24.9 18.7 7.9 14.4 Haryana) (2.9) (3.9) (3.6) (6.3) (3.9) (5.6) Zone 2 (Uttaranchal & Uttar Pradesh) 7.8-22.3 12.2-29.8 15.8-37.1 12.9-27.9 9.4-27.5 13.7-26.2 15.1 21.0 26.5 20.4 18.4 19.9 (10.6) (12.3) (15.3) (21.7) (8.6) (19.3) Zone 3 (Bihar & Jharkhand) 9.7-28.6 9.6-29.7 13.6-34.0 10.7-27.9 17.6-35.6 11.9-27.8 19.2 19.7 23.8 19.3 26.7 19.8 (8.6) (9.8) (8.5) (19.9) (1.4) (18.2) Zone 4 (West Bengal & Andaman & Nicobar 58.8-77.9 8.4-23.1 46.2-66.9 23.7-38.9 20.5-38.8 24.8-36.9 68.3 15.8 56.5 31.3 29.6 30.8 Islands) (5.1) (4.9) (5.3) (7.1) (3.9) (6.2) Zone 5 (Assam, Arunchal Pradesh, 27.3-52.3 27.8-54.3 41.6-67.3 33.2-56.6 10.4-24.5 31.3-52.0 39.8 41.1 54.4 44.9 17.5 41.7 Meghalaya & Sikkim) (2.9) (3.2) (3.0) (6.4) (0.5) (5.8) Zone 6 (Manipur, Nagaland, Mizoram & 25.7-47.3 2.8-12.9 30.4-51.4 11.1-23.1 0.9-23.2 11.9-21.9 36.5 7.9 40.9 17.1 16.3 16.9 Tripura) (0.6) (0.5) (0.6) (0.8) (0.3) (0.7) Zone 7 (Rajasthan) 1.8-15.8 20.9-42.0 11.9-26.8 19.9-40.3 3.5-15.4 17.4-33.3 8.8 31.5 19.4 30.1 9.4 25.4 (5.2) (4.4) (3.0) (9.7) (2.4) (8.6) Zone 8 (Gujarat & Daman & Diu) 28.9-49.0 25.3-45.9 37.5-57.8 30.0-50.9 31.0 20.3-41.8 29.4-44.9 38.9 35.6 47.6 40.4 37.2 (3.1) (3.5) (3.1) (6.6) (4.3) (5.8) Zone 9 (Madhya Pradesh & Chattisgarh) 33.6-55.8 45.4-65.4 21.9-43.6 48.1-68.6 18.9-38.4 43.2-59.5 44.7 55.4 32.8 58.4 28.7 51.3 (6.1) (4.9) (6.5) (11.9) (3.9) (9.7) Zone 10 (Orrisa) 3.8-19.1 14.3-31.6 13.4-31.3 12.9-28.5 8.2-24.7 13.3-26.9 11.4 22.9 22.3 20.7 16.4 20.1 (3.1) (2.2) (2.5) (5.1) (1.0) (4.6) Zone 11 (Maharashtra & Goa) 42.0-62.2 29.3-48.7 33.6-53.2 45.8-66.8 22.9-42.6 35.1-49.7 52.1 38.9 43.4 56.3 32.8 42.4 (5.9) (5.7) (5.8) (8.0) (11.3) (9.4) Zone 12 (Andhra Pradesh) 54.5-74.4 34.4-54.9 24.1-46.3 41.7-63.4 29.1-49.9 40.5-57.0 64.5 44.7 35.2 52.5 39.5 48.7 (4.8) (4.8) (5.7) (11.1) (4.4) (9.1) Zone 13 (Karnataka) 43.9-62.7 37.9-59.0 21.8-40.1 44.4-65.2 24.6-44.5 40.6-56.2 53.3 48.5 30.9 54.8 34.6 48.4 (2.8) (3.5) (3.1) (7.1) (3.2) (5.7) Zone 14 (Tamil Nadu & Pondicherry) 32.8-54.2 27.5-48.4 23.4-42.1 27.8-50.1 27.9-49.5 30.7-47.1 43.5 37.9 32.7 38.9 38.7 38.9 (4.4) (4.4) (3.8) (9.8) (4.8) (8.1) Zone 15 (Kerala & Lakshadweep Island) 23.8-44.9 2.0-9.7 20.5-38.9 0.8-19.4 9.1-19.5 10.0-18.3 34.4 5.9 29.7 14.1 14.3 14.2 (2.4) (1.3) (1.9) (2.5) (0.9) (2.0)

Table 4.4.5 Unsafe Injections (as % of Injections Observed) Carrying a Potential Risk of Transmission of BBV

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI

(%) (Deff) (Deff) (Deff) (Deff)

32.2-39.5 28.6-36.3 31.6-38.3 30.4-36.5 Rural 35.8 32.5 34.9 33.4 (6.2) (7.4) (5.2) (13.6)

29.8-38.5 19.1-28.4 25.4-34.4 23.2-30.1 ALL INDIA Urban 34.2 23.8 29.9 26.6 (3.4) (4.9) (4.1) (7.5)

32.7-38.1 27.3-32.9 30.5-36.5 29.4-33.7 Total 35.4 30.1 33.5 31.6 (4.9) (5.9) (6.3) (10.0)

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Table 4.4.6 Unsafe Injections (as % of Injections Given with Glass Syringe) Carrying a Potential Risk of Transmission of BBV

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est 95% CI Est 95% CI Est 95% CI Est 95% CI Est 95% CI Est 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 30.8-70.2 51.5-96.2 27.4-58.0 44.0-79.8 41.9-90.4 47.2-78.1 Himachal Pradesh, Jammu & Kashmir & 50.5 73.9 42.7 61.9 66.1 62.6 (2.7) (3.3) (3.7) (7.2) (2.9) (6.5) Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 14.8-48.4 58.2-106.5 25.9-59.4 40.1-74.5 52.8-87.3 44.2-74.0 31.6 82.4 42.6 57.3 70.1 59.1 (9.6) (15.5) (15.7) (22.7) (4.4) (20.2) Zone 3 (Bihar & Jharkhand) 62.6-104.0 98.5-100.3 40.1-96.5 87.4-100.5 80.6-97.7 87.4-99.5 83.3 99.4 68.3 93.9 89.2 93.5 (5.7) (0.3) (7.4) (5.3) (0.6) (4.7) Zone 4 (West Bengal & Andaman & 88.4-97.5 89.1-101.6 53.9-76.7 86.5-95.4 74.6-91.5 84.7-92.9 92.9 95.3 65.3 90.9 83.0 88.8 Nicobar Islands) (2.4) (1.4) (5.3) (2.5) (1.9) (2.4) Zone 5 (Assam, Arunchal Pradesh, 46.5-82.2 77.2-98.8 48.1-78.6 69.2-87.1 59.3-87.9 69.4-86.4 64.4 87.9 63.4 78.2 73.6 77.9 Meghalaya & Sikkim) (3.1) (1.5) (2.8) (3.0) (0.4) (2.9) Zone 6 (Manipur, Nagaland, Mizoram & 44.9-82.8 8.7-67.7 48.9-79.2 33.3-68.1 60.3-91.2 38.8-69.9 63.9 38.2 64.1 50.7 75.7 54.4 Tripura) (0.7) (0.4) (0.6) (95.1) (0.2) (0.9) Zone 7 (Rajasthan) 46.0-102.9 69.1-96.6 27.5-69.4 66.4-94.2 43.8-91.4 65.9-91.4 74.5 82.9 48.4 80.3 67.6 78.6 (3.9) (2.2) (3.4) (6.5) (2.0) (5.9) Zone 8 (Gujarat & Daman & Diu) 57.6-92.9 48.7-90.8 44.1-71.6 43.9-87.7 57.4-91.6 53.6-84.5 75.3 69.7 57.9 65.8 74.5 69.0 (2.3) (3.3) (2.8) (9.2) (3.8) (7.6) Zone 9 (Madhya Pradesh & Chattisgarh) 58.5-87.3 87.8-99.1 50.2-83.5 84.6-96.7 53.9-89.9 81.6-93.6 72.9 93.4 66.8 90.6 71.9 87.6 (4.6) (2.5) (4.2) (6.8) (4.9) (6.3) Zone 10 (Orrisa) 45.6-102.4 38.7-90.6 21.9-67.0 41.7-84.9 37.3-96.2 44.6-82.9 73.9 64.7 44.5 63.4 66.8 63.8 (2.0) (1.7) (2.4) (4.3) (1.3) (3.9) Zone 11 (Maharashtra & Goa) 56.6-80.6 77.1-98.3 43.3-68.8 55.8-74.6 76.5-94.5 65.4-80.0 68.6 87.7 56.0 65.2 85.6 72.7 (4.4) (1.6) (5.6) (3.2) (3.2) (3.5) Zone 12 (Andhra Pradesh) 62.2-84.9 48.8-87.2 34.7-70.6 55.7-85.1 48.1-79.7 56.9-81.2 73.5 67.9 52.7 70.4 63.9 69.1 (4.4) (5.8) (5.1) (14.3) (3.8) (11.9) Zone 13 (Karnataka) 47.7-75.2 43.1-90.9 23.5-51.8 46.7-80.6 36.7-73.6 48.0-74.7 61.4 67.0 37.7 63.7 55.2 61.4 (2.6) (3.3) (2.8) (6.8) (2.9) (5.8) Zone 14 (Tamil Nadu & Pondicherry) 33.9-58.0 41.1-78.9 27.1-49.1 32.3-59.5 57.5-82.8 40.6-62.5 45.9 60.0 38.1 45.9 70.1 51.5 (4.5) (4.2) (3.7) (9.9) (3.1) (8.3) Zone 15 (Kerala & Lakshadweep Island) 31.6-69.4 -4.2-93.6 20.6-41.2 25.9-55.8 35.5-68.4 30.8-55.6 50.5 44.7 30.9 40.9 51.9 43.2 (2.4) (2.0) (1.9) (2.4) (0.7) (2.0)

Cont…

Table 4.4.6 Unsafe Injections (as % of Injections Given with Glass Syringe) Carrying a Potential Risk of Transmission of BBV

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI

(Deff) (Deff) (Deff) (Deff)

Rural 56.9-67.0 73.9-85.6 45.4-55.2 66.3-74.1 61.9 79.7 50.3 70.2 (4.6) (4.8) (5.0) (8.9)

Urban 63.5-76.6 73.8-89.6 43.7-58.3 67.5-78.1 ALL INDIA 70.0 81.7 51.0 72.8 (2.4) (2.2) (3.7) (4.4)

Total 59.1-68.3 74.7-85.5 45.8-55.2 67.2-74.3 63.7 80.1 50.5 70.7 (5.1) (5.2) (6.3) (9.5)

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Table 4.4.7 Unsafe Injections (as % of Injections Given with Plastic Syringe) Carrying a Potential Risk of Transmission of BBV

Government Private Health Immunization Rural Urban Total Health Facility Facility Clinic Zone Est. 95% CI Est. 95% CI Est 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) .(%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 1.6-9.3 0.7-7.9 5.2-19.9 2.0-10.2 0.2-6.7 2.3-7.6 Himachal Pradesh, Jammu & Kashmir & 5.4 4.3 12.6 6.1 3.5 4.9 (2.4) (2.8) (2.9) (3.6) (3.1) (3.4) Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 1.7-14.8 3.7-16.2 -0.04-14.9 3.5-15.6 2.0-16.4 4.5-14.4 8.2 9.9 7.4 9.5 9.2 9.5 (10.6) (9.9) (9.9) (18.2) (7.3) (15.9) Zone 3 (Bihar & Jharkhand) 1.8-17.4 1.6-14.3 6.9-26.0 2.6-14..5 6.6-19.5 3.4-14.4 9.6 7.9 16.5 8.6 13.0 8.9 (9.3) (7.6) (8.5) (14.7) (0.9) (13.3) Zone 4 (West Bengal & Andaman & Nicobar 8.2-37.9 0.3-6.1 2.6-41.5 1.6-9.7 2.8-10.5 2.8-9.0 23.1 3.2 22.0 5.7 6.6 5.9 Islands) (5.4) (2.9) (5.5) (5.0) (1.4) (3.9) Zone 5 (Assam, Arunchal Pradesh, 5.2-23.7 5.4-31.1 18.3-57.7 8.5-33.6 0.4-6.6 7.7-28.9 14.5 18.2 37.9 21.0 3.5 18.3 Meghalaya & Sikkim) (1.6) (3.3) (2.7) (5.8) (0.3) (5.4) Zone 6 (Manipur, Nagaland, Mizoram & 10.8-32.3 1.5-7.6 9.4-31.9 4.5-12.7 3.2-12.6 5.1-11.8 21.5 4.6 20.6 8.6 7.9 8.5 Tripura) (0.6) (0.2) (0.5) (0.5) (0.2) (0.4) Zone 7 (Rajasthan) -0.05-0.8 10.3-27.3 4.6-16.1 9.6-24.9 -0.5-6.0 7.8-19.4 0.4 18.8 10.4 17.3 2.8 13.6 (0.4) (3.3) (2.4) (5.8) (1.8) (5.3) Zone 8 (Gujarat & Daman & Diu) 19.9-40.7 15.4-37.2 24.2-50.5 21.8-44.6 8.0-26.7 19.5-35.9 30.3 26.3 37.3 33.2 17.3 27.7 (3.1) (3.7) (2.8) (5.9) (3.2) (5.2) Zone 9 (Madhya Pradesh & Chattisgarh) 15.7-40.6 17.4-40.2 8.4-29.8 22.7-45.2 6.1-19.0 19.6-36.1 28.2 28.8 19.1 33.9 12.5 27.9 (6.1) (4.6) (6.6) (7.9) (2.1) (6.7) Zone 10 (Orrisa) 0.2-10.0 9.6-25.3 7.5-24.7 8.4-21.6 3.3-16.9 8.5-20.1 5.1 17.5 16.1 15.0 10.1 14.3 (2.5) (2.0) (2.4) (3.7) (0.9) (3.4) Zone 11 (Maharashtra & Goa) 25.0-51.2 23.2-42.8 11.8-37.7 36.6-66.5 14.0-34.1 25.2-41.9 38.1 32.9 24.7 51.5 24.0 33.5 (5.8) (5.7) (5.5) (9.2) (10.8) (9.4) Zone 12 (Andhra Pradesh) 31.9-67.6 23.3-44.2 11.4-36.9 26.5-50.3 19.0-41.2 26.9-44.2 49.8 33.8 24.2 38.4 30.1 35.5 (5.5) (3.8) (5.9) (7.0) (3.6) (5.8) Zone 13 (Karnataka) 35.2-59.1 33.5-55.9 14.8-37.3 39.8-63.5 18.1-39.4 35.4-52.9 47.1 44.7 26.0 51.7 28.8 44.2 (2.7) (3.4) (3.1) (5.9) (2.9) (4.9) Zone 14 (Tamil Nadu & Pondicherry) 13.2-47.2 17.7-38.9 3.4-21.1 15.4-46.1 13.0-36.1 18.1-37.9 30.2 28.3 12.2 30.7 24.6 28.0 (2.1) (3.7) (1.5) (8.4) (4.4) (6.7) Zone 15 (Kerala & Lakshadweep Island) 13.3-36.9 0.7-7.3 6.8-41.8 2.9-13.1 4.1-12.9 4.2-11.9 25.1 4.0 24.3 7.9 8.5 8.1 (2.3) (1.3) (1.5) (2.7) (0.7) (2.1) Cont…

Table 4.4.7 Unsafe Injections (as % of Injections Given with Plastic Syringe) Carrying a Potential Risk of Transmission of BBV

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI (%) (Deff) (Deff) (Deff) (Deff)

14.2-22.4 16.7-22.4 15.6-23.8 16.9-21.7 Rural 18.3 19.5 19.7 19.3 (7.3) (4.5) (5.9) (7.6)

14.1-23.8 10.8-18.9 9.9-18.2 12.5-18.8 ALL INDIA Urban 18.9 14.9 14.1 15.7 (4.5) (4.8) (3.4) (6.8)

15.7-21.3 15.8-20.5 14.9-21.1 16.3-20.1 Total 18.5 18.1 18.0 18.2 (5.1) (4.7) (5.2) (7.6)

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Cont…

Table 4.4.8 Unsafe Injections (as % of Injections Observed) Carrying a Potential Risk of Transmission of BBV – According to Type of Health Provider

Rural Urban Total Type of Health Provider

Est. (%) 95% CI Deff Est. (%) 95% CI Deff Est. (%) 95% CI Deff

Allopathic Practitioner 28.3 24.9-31.7 7.4 24.2 20.7-27.8 4.7 26.9 24.7-29.0 5.0

ISM Practitioner 33.5 25.2-41.8 13.8 29.7 20.2-39.2 5.7 32.6 26.5-38.7 9.9

Informal Practitioner 44.9 38.2-51.5 9.5 50.9 34.6-67.3 4.8 45.3 38.0-52.7 12.9

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Table 4.4.9 Reuse of Syringes/Needles (as % of Injections Observed)

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 5.7-16.9 5.9-19.5 11.8-27.0 9.1-23.7 2.5-12.3 8.0-17.7 Himachal Pradesh, Jammu & Kashmir & 11.3 12.7 19.4 16.4 7.4 12.8 (3.1) (4.1) (3.7) (6.9) (4.1) 6.2 Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 3.6-14.0 10.1-26.7 4.3-18.7 8.7-22.8 6.9-24.3 9.8-21.6 8.8 18.4 11.5 15.7 15.6 15.7 (8.7) (12.3) (13.3) (23.5) (8.9) 20.6 Zone 3 (Bihar & Jharkhand) 4.4-21.8 5.4-22.8 7.6-23.7 6.0-21.0 11.7-27.9 7.0-20.9 13.1 14.1 15.7 13.5 19.8 13.9 (9.9) (9.5) (7.3) (20.2) (1.5) 18.3 Zone 4 (West Bengal & Andaman & 16.9-36.2 3.8-16.1 14.6-31.6 6.8-20.9 9.5-24.9 9.2-20.3 26.6 9.9 23.1 13.9 17.2 14.8 Nicobar Islands) (5.7) (5.1) (4.9) (10.9) (4.1) 8.8 Zone 5 (Assam, Arunchal Pradesh, 10.6-31.6 13.8-38.5 25.7-49.9 16.9-38.1 6.4-18.9 16.4-35.1 21.1 26.1 37.8 27.5 12.7 25.7 Meghalaya & Sikkim) (2.9) (3.5) (2.8) (6.6) (0.6) 6.1 Zone 6 (Manipur, Nagaland, Mizoram & 12.2-29.7 0.2-6.2 15.6-32.8 5.3-13.0 3.8-11.6 5.7-11.9 20.9 3.2 24.2 9.2 7.7 8.8 Tripura) (0.6) (0.4) (0.5) (0.5) (0.2) 0.5 Zone 7 (Rajasthan) 0.9-14.8 14.1-33.2 10.1-24.6 13.5-32.5 2.2-13.9 12.1-26.9 7.9 23.7 17.3 22.9 8.1 19.5 (5.6) (4.3) (3.1) (9.9) (2.8) 8.9 Zone 8 (Gujarat & Daman & Diu) 20.9-40.5 18.8-38.7 27.5-46.9 22.6-42.4 14.9-34.3 22.5-37.1 30.7 28.8 37.2 32.5 24.7 29.8 (3.3) (3.7) (3.0) (6.6) (3.9) 5.7 Zone 9 (Madhya Pradesh & Chattisgarh) 29.6-51.2 31.8-52.8 15.6-36.4 36.3-57.9 12.6-28.4 32.3-49.2 40.4 42.3 26.0 47.1 20.5 40.8 (5.9) (5.5) (6.8) (13.0) (3.3) (10.8) Zone 10 (Orrisa) 0.6-11.1 6.2-15.6 5.1-18.1 5.5-13.3- 4.6-19.0 6.2-13.3 5.8 10.9 11.6 9.4 11.8 9.7 (2.7) (2.7) (2.2) (2.5) (1.1) (2.3) Zone 11 (Maharashtra & Goa) 20.9-39.4 19.9-36.5 18.9-36.2 31.3-51.7 12.5-26.9 22.7-34.6 30.2 28.2 27.6 41.5 19.7 28.6 (5.9) (4.8) (5.5) (7.6) (8.4) (7.6) Zone 12 (Andhra Pradesh) 49.3-69.8 27.2-48.0 13.6-31.1 35.1-57.1 21.2-41.5 33.4-50.1 59.6 37.6 22.3 46.1 31.4 41.8 (4.8) (5.1) (4.7) (11.5) (4.6) (9.5) Zone 13 (Karnataka) 37.4-57.1 32.2-53.1 16.4-34.2 39.3-61.5 16.2-34.8 34.4-50.7 47.2 42.7 25.3 50.4 25.5 42.6 (3.1) (3.5) (3.3) (7.9) (3.4) (6.4) Zone 14 (Tamil Nadu & Pondicherry) 19.9-38.3 21.3-40.3 17.9-35.8 19.7-40.2 20.9-40.1 22.7-37.6 29.1 30.8 26.9 29.9 30.5 30.2 (3.9) (4.0) (3.9) (9.3) (4.2) (7.5) Zone 15 (Kerala & Lakshadweep Island) 10.0-27.4 0.1-6.5 12.5-28.2 3.9-12.8 4.3-10.2 4.8-11.4 18.7 3.3 20.3 8.4 7.3 8.1 (2.4) (1.5) (1.8) (2.7) (0.5) (2.2)

Cont…

Table 4.4.9 Reuse of Syringes/Needles (as % of Injections Observed)

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. 95% CI Est. 95% CI Est. (%) 95% CI

(%) (Deff) (%) (Deff) (%) (Deff) (Deff)

21.6-28.5 22.0-28.9 18.9-24.6 22.4-27.9 Rural 25.0 25.5 21.8 25.2 (6.7) (6.9) (5.1) (12.8)

18.1-26.1 14.5-21.3 17.2-23.7 16.7-21.4 ALL INDIA Urban 22.1 17.9 20.5 19.1 (3.8) (3.2) (2.8) (4.5)

21.8-26.7 20.8-26.0 18.9-23.8 21.5-25.5 Total 24.2 23.4 21.4 23.5 (4.9) (5.9) (5.4) (10.4)

** For the purpose of this study, an injection was considered/ defined as unsafe if:

• It had the potential to transmit Blood Borne Viruses (BBV) and/or;

• It was administered using faulty techniques (and could cause local infection and/or reaction).

Table 4.4.10 Reuse of Syringes/Needles (as % of Injections Given with Glass Syringes) – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 24.9-65.1 51.5-96.2 20.1-47.7 41.0-78.0 34.9-86.9 43.8-75.7 Himachal Pradesh, Jammu & Kashmir & 45.0 73.9 33.9 59.5 60.9 59.8 (2.8) (3.3) (3.2) (7.5) (3.1) (6.8) Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 8.2-37.8 53.5-100.8 4.0-27.4 29.2-63.3 47.0-85.4 34.3-63.9 23.0 77.1 15.7 46.2 66.2 49.1 (9.1) (12.3) (14.1) (22.0) (5.2) (19.2) Zone 3 (Bihar & Jharkhand) 41.7-95.4 61.8-105.5 7.9-66.3 58.3-96.8 54.4-87.3 59.4-94.2 68.5 83.6 37.1 77.5 70.8 76.8 (6.2) (6.6) (7.4) (14.7) (1.1) (13.2) Zone 4 (West Bengal & Andaman & Nicobar 18.1-42.0 30.7-82.6 14.4-33.2 18.2-51.7 27.9-59.6 24.5-50.1 30.0 56.6 23.8 34.9 43.8 37.3 Islands) (5.1) (4.3) (4.5) (12.9) (3.9) (10.0) Zone 5 (Assam, Arunchal Pradesh, 20.7-55.1 32.8-77.4 31.8-62.3 32.7-64.5 38.4-68.1 33.9-63.9 37.9 55.1 47.0 48.6 53.2 48.9 Meghalaya & Sikkim) (2.8) (2.8) (2.7) (6.5) (0.4) (6.2) Zone 6 (Manipur, Nagaland, Mizoram & 20.0-55.3 -6.0-26.6 20.4-46.6 12.9-40.9 12.8-38.2 14.7-38.8 37.7 10.3 33.5 26.9 25.5 26.7 Tripura) (0.6) (0.3) (0.4) (0.8) (0.1) (0.7) Zone 7 (Rajasthan) 38.3-98.4 39.5-82.3 25.9-67.7 40.8-81.8 28.8-85.8 42.5-79.0 68.4 60.9 46.8 61.3 57.3 60.8 (3.9) (3.1) (3.4) (9.3) (2.6) (8.5) Zone 8 (Gujarat & Daman & Diu) 31.9-74.4 38.2-80.2 29.7-55.9 36.5-79.9 30.7-71.4 40.0-71.2 53.1 59.2 42.8 58.3 51.1 55.6 (2.4) (2.9) (2.6) (8.4) (4.1) (6.7) Zone 9 (Madhya Pradesh & Chattisgarh) 52.1-81.7 62.9-90.9 30.2-67.0 65.1-90.3 32.0-69.4 62.1-84.5 66.9 76.9 48.6 77.7 50.7 73.3 (4.3) (5.3) (4.6) (14.4) (4.3) (12.1) Zone 10 (Orrisa) 0.1-76.8 4.7-44.9 4.7-47.5 8.5-43.5 6.7-69.3 11.7-43.5 38.5 24.9 26.1 26.0 37.9 27.6 (2.9) (1.3) (2.8) (3.4) (1.3) (3.1) Zone 11 (Maharashtra & Goa) 17.5-43.5 49.1-79.2 22.9-46.1 30.8-50.5 26.2-65.3 32.9-52.2 30.5 64.2 34.6 40.7 45.8 42.5 (5.2) (1.5) (5.0) (3.3) (7.3) (4.9) Zone 12 (Andhra Pradesh) 54.6-77.8 32.7-72.7 23.6-56.1 45.2-75.0 28.9-60.2 44.5-69.3 66.2 52.7 39.8 60.1 44.5 56.9 (3.9) (5.5) (4.3) (12.7) (3.5) (10.8) Zone 13 (Karnataka) 41.7-70.1 28.5-81.3 15.5-42.7 33.5-73.8 29.7-68.0 36.8-67.9 55.9 54.9 29.1 53.7 48.9 52.3 (2.7) (3.6) (2.9) (9.1) (3.1) (7.4) Zone 14 (Tamil Nadu & Pondicherry) 20.7-41.3 31.9-66.6 20.2-41.3 22.1-46.7 41.6-69.3 29.2-49.4 30.9 49.2 30.8 34.4 55.5 39.4 (3.8) (3.4) (3.8) (8.9) (3.1) (7.4) Zone 15 (Kerala & Lakhadweep Island) 8.2-38.6 -18.7-68.1 12.4-29.7 11.8-33.7 11.9-34.9 13.9-31.9 23.4 24.7 21.0 22.7 23.4 22.9 (2.2) (2.1) (1.7) (1.8) (0.5) (1.5)

Cont…

Table 4.4.10 Reuse of Syringes/Needles (as % of Injections Given with Glass Syringes) – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. 95% CI Est. 95% CI Est. (%) 95% CI

(%) (Deff) (%) (Deff) (%) (Deff) (Deff)

36.7-47.1 56.8-70.8 24.5-34.1 47.3-57.2 Rural 41.9 63.8 29.3 52.3 (4.7) (4.8) (5.7) (11.7)

32.8-47.6 54.1-74.6 26.4-38.9 45.1-56.4 ALL INDIA Urban 40.2 64.3 32.7 50.7 (2.7) (2.4) (3.0) (4.0)

36.9-46.1 57.6-70.2 26.2-34.1 47.8-56.1 Total 41.5 63.9 30.1 51.9 (4.8) (4.9) (5.2) (10.5)

Table 4.4.11 Reuse of Syringes/Needles (as % of Injections Given with Plastic Syringes) – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 0.5-6.9 0.2-6.2 2.2-16.2 0.7-7.0 0.1-6.5 1.4-5.9 Himachal Pradesh, Jammu & Kashmir & 3.7 3.2 9.2 3.9 3.3 3.6 (2.4) 2.5 (3.6) (3.3) (3.2) (3.2) Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 0.1-5.9 2.3-13.2 -0.8-13.9 1.7-11.8 0.9-12.2 2.6-10.9 2.9 7.8 6.5 6.8 6.6 6.7 (5.4) 9.4 (10.8) (17.6) (6.2) (15.2) Zone 3 (Bihar & Jharkhand) -0.9-10.8 0.9-6.8 5.0-19.2 1.7-6.9 3.7-13.6 2.2-7.1 4.9 3.9 12.1 4.4 8.7 4.7 (9.8) 3.1 (6.2) (5.4) (0.8) (4.8) Zone 4 (West Bengal & Andaman & 6.4-34.1 -0.2-5.4 0.6-39.9 0.9-8.6 2.2-9.4 2.1-7.1 20.3 2.6 20.2 4.8 5.8 5.1 Nicobar Islands) (5.2) 3.3 (5.9) (5.4) (1.4) (4.1) Zone 5 (Assam, Arunchal Pradesh, -1.9-9.5 0.7-23.5 3.6-38.2 1.4-23.3 -0.01-5.1 1.6-20.1 3.8 12.1 20.9 12.4 2.6 10.8 Meghalaya & Sikkim) (2.0) 3.7 (2.9) (6.7) (0.3) (6.4) Zone 6 (Manipur, Nagaland, Mizoram & 4.3-19.3 0.2-4.6 5.8-26.2 1.5-7.9 1.5-8.8 2.2-7.4 11.8 2.4 16.0 4.7 5.2 4.8 Tripura) (0.5) (0.2) (0.5) (0.5) (0.2) (0.4) Zone 7 (Rajasthan) -0.1-0.4 6.9-22.1 3.4-13.0 6.2-20.1 -0.8-5.7 5.2-15.7 0.1 14.5 8.2 13.2 2.5 10.5 (0.4) (3.3) (2.0) (5.9) (2.0) (5.4) Zone 8 (Gujarat & Daman & Diu) 15.0-35.8 10.2-30.7 19.3-43.9 14.5-35.7 6.9-25.7 14.4-29.8 25.4 20.4 31.6 25.1 16.3 22.1 (3.4) (3.9) (2.7) (6.1) (3.4) (5.3) Zone 9 (Madhya Pradesh & Chattisgarh) 12.9-36.8 9.1-27.2 6.3-27.6 14.3-33.5 4.2-14.2 12.7-26.7 24.8 18.2 16.9 23.9 9.2 19.7 (5.9) (4.0) (7.2) (7.1) (1.7) (6.1) Zone 10 (Orrisa) -0.6-5.6 4.6-13.6 3.3-11.8 3.6-10.7 2.0-15.0 4.2-10.5 2.5 9.1 7.5 7.2 8.5 7.4 (1.9) (1.2) (1.1) (2.0) (0.9) (1.9) Zone 11 (Maharashtra & Goa) 17.5-42.1 15.6-32.1 6.5-28.1 27.8-55.9 8.0-22.8 17.7-31.4 29.8 23.8 17.3 41.9 15.4 24.6 (5.8) (4.9) (4.9) (8.4) (8.2) (7.6) Zone 12 (Andhra Pradesh) 30.9-66.6 19.8-41.2 3.5-19.0 23.1-46.9 15.2-37.3 23.4-40.6 48.8 30.5 11.3 34.9 26.3 31.9 (5.5) (4.2) (3.9) (7.2) (3.9) (6.1) Zone 13 (Karnataka) 28.1-53.3 29.2-51.2 11.6-33.5 36.9-61.5 9.8-28.1 30.5-48.2 40.7 40.2 22.6 49.3 18.9 39.4 (3.1) (3.4) (3.2) (6.4) (2.8) (5.2) Zone 14 (Tamil Nadu & Pondicherry) 6.1-32.2 13.1-32.6 3.4-21.1 10.9-38.4 8.8-29.8 13.3-31.2 19.1 22.8 12.2 24.6 19.3 22.3 (1.7) (3.6) (1.5) (7.7) (4.3) (6.3) Zone 15 (Kerala & Lakshadweep Island) 5.9-26.0 -0.2-4.9 2.1-32.2 0.6-9.6 2.4-7.2 1.7-8.3 15.9 2.3 17.2 5.1 4.8 5.0 (2.3) (1.3) (1.4) (3.2) (0.4) (2.4)

Cont…

Table 4.4.11 Reuse of Syringes/Needles (as % of Injections Given with Plastic Syringes) – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (%) (Deff) (%) (Deff) (%) (Deff) (Deff)

10.5-16.9 12.6-17.4 10.6-18.0 12.9-16.5 Rural 13.7 15.0 14.3 14.7 (5.6) (4.0) (6.4) (5.5)

9.9-19.1 7.9-13.6 8.3-14.4 9.4-13.7 ALL INDIA Urban 14.5 10.8 11.4 11.6 (4.9) (3.0) (2.2) (4.2)

11.6-16.3 11.7-15.8 10.8-16.0 12.2-15.4 Total 13.9 13.8 13.4 13.8 (4.6) (4.4) (4.9) (6.8)

Table 4.4.12 Reuse of Syringes/Needles (as % of Injections Observed) – According to Type of Health Provider

Rural Urban Total Type of Health Provider Est. (%) 95% CI Deff Est. (%) 95% CI Deff Est. (%) 95% CI Deff

Allopathic Practitioner 20.9 18.0-23.8 6.3 17.6 14.7-20.4 3.7 19.7 17.8-21.7 4.9

ISM Practitioner 26.6 19.5-33.7 11.6 21.0 13.8-28.4 4.2 25.4 19.9-30.7 9.0

Informal Practitioner 35.0 27.8-42.2 12.1 35.4 21.8-49.0 3.6 35.0 27.9-42.1 13.2

Table 4.4.13 Presence of Syringes/Needles in Sterilization Equipment at Health Facilities: Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 9.1-27.0 7.5-24.6 5.5-21.6 11.6-30.4 1.8-16.7 9.9-22.8 Himachal Pradesh, Jammu & Kashmir & 18.1 16.0 13.5 21.0 9.2 16.3 (1.1) (1.1) (1.1) (1.9) (1.6) (1.8) Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 17.5-41.5 23.3-48.7 6.6-25.5 21.6-46.9 17.4-40.1 22.8-43.5 29.5 35.9 16.0 34.2 28.7 33.1 (3.6) (3.6) (3.5) (8.9) (1.9) (7.6) Zone 3 (Bihar & Jharkhand) 7.5-28.8 4.9-25.0 2.9-20.2 6.2-24.4 17.1 8.3-25.9 7.5-23.5 18.2 15.0 11.6 15.3 15.5 (2.5) (2.6) (2.3) (5.4) (0.7) (4.7) Zone 4 (West Bengal & Andaman & Nicobar) 24.2-48.1 2.7-16.4 15.2-37.2 8.1-23.6 11.2-28.0 10.8-22.9 36.2 9.5 26.2 15.9 19.6 16.9 (1.5) (1.3) (1.5) (2.3) (0.9) (1.9) Zone 5 (Assam, Arunchal Pradesh, 43.2-70.9 16.1-42.1 23.2-50.6 25.6-49.5 15.9-36.2 25.6-46.8 57.1 29.1 36.9 37.6 26.1 36.2 Meghalaya & Sikkim) (0.7) (0.7) (0.7) (1.5) (0.2) (1.3) Zone 6 (Manipur, Nagaland, Mizoram & 35.8-61.5 5.9-23.4 28.1-53.6 15.9-31.9 15.4-37.1 17.8-31.1 48.6 14.7 40.8 23.9 26.3 24.4 Tripura) (0.2) (0.2) (0.2) (0.2) (0.1) (0.2) Zone 7 (Rajasthan) 3.5-20.3 12.3-34.6 3.0-19.7 12.4-33.6 2.3-17.4 11.6-28.3 11.9 23.5 11.3 22.9 9.8 19.9 (1.1) (1.2) (1.2) (2.5) (0.7) (2.2) Zone 8 (Gujarat & Daman & Diu) 46.0-67.7 27.5-50.5 41.2-63.9 40.4-65.2 17.1-37.9 35.2-52.9 56.9 38.9 52.5 52.8 27.6 44.0 (0.7) (0.9) (0.8) (1.9) (0.9) (1.5) Zone 9 (Madhya Pradesh & Chattisgarh) 48.4-73.1 36.3-61.7 24.7-49.5 41.5-66.5 29.0-52.8 40.9-60.9 60.7 48.9 37.1 54.0 40.9 50.9 (1.6) (1.6) (1.6) (3.5) (0.1) (2.9) Zone 10 (Orrisa) 14.7-39.6 22.7-49.7 11.8-35.2 20.8-47.5 15.2-38.9 21.5-44.9 27.2 36.2 23.5 34.1 27.1 33.2 (0.9) (0.9) (0.8) (2.2) (0.3) (1.9) Zone 11 (Maharashtra & Goa) 35.3-57.7 25.1-44.9 32.7-55.3 45.6-69.5 14.6-36.3 30.2-46.4 46.5 34.9 43.9 57.6 25.5 38.3 (1.5) (1.3) (1.5) (2.1) (3.3) (2.4) Zone 12 (Andhra Pradesh) 33.4-58.0 31.3-55.9 15.4-36.7 31.3-55.6 30.0-53.5 33.6-52.4 45.7 43.6 26.1 43.5 41.7 42.9 (1.4) (1.4) (1.3) (2.9) (1.0) (2.4) Zone 13 (Karnataka) 57.9-79.3 29.4-52.9 42.4-66.2 43.0-66.2 24.4-46.2 39.8-57.1 68.6 41.1 54.3 54.6 35.3 48.5 (0.8) (0.9) (0.9) (1.7) (0.8) (1.4) Zone 14 (Tamil Nadu & Pondicherry) 22.8-44.4 36.6-60.1 16.7-37.0 29.4-52.8 36.3-59.3 34.8-52.1 33.6 48.4 26.8 41.1 47.8 43.4 (0.9) (1.0) (0.9) (2.1) (1.0) (1.7) Zone 15 (Kerala & Lakshadweep Island) 24.4-45.6 37.3-62.1 19.7-42.5 21.7-45.2 25.1-49.5 27.2-44.1 49.7 31.1 33.5 35.0 (1.0) 37.3 35.6 (0.6) (0.6) (0.6) (0.5) (0.9)

Cont…

Table 4.4.13 Presence of Syringes/Needles in Sterilization Equipment at Health Facilities: Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. 95% CI (%) (%) (Deff) (Deff) (Deff) (Deff)

33.8-43.9 30.2-38.3 23.3-29.8 31.3-38.4 Rural 38.9 34.3 26.5 34.8 (2.3) (1.6) (1.2) (3.6)

30.8-37.9 21.5-29.6 25.1-32.9 24.5-31.2 ALL INDIA Urban 34.4 25.5 29.0 27.8 (0.5) (0.7) (0.6) (1.4)

34.2-41.0 28.4-35.2 24.2-30.3 30.2-35.6 Total 37.6 31.8 27.2 32.9 (1.5) (1.6) (1.4) (3.1)

Table 4.4.14 Prescribers (%) Who thought that Plastic Syringes could be Reused

Government Health Private Health Facilities Total Facilities Zone Est 95% CI (Deff) Est. 95% CI (Deff) Est. 95% CI (Deff) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 0.9 -0.9-2.9 (0.8) 4.1 -0.6-8.8 (1.1) 3.3 -0.2-6.8 (1.5) Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 1.9 -1.9-5.9 (4.2) 14.5 5.2-23.8 (3.7) 11.4 3.9-18.8 (5.7)

Zone 3 (Bihar & Jharkhand) 9.3 0.9-17.7 (2.7) 4.7 -1.4-10.7 (2.7) 5.9 -0.3-12.0 (4.5)

Zone 4 (West Bengal & Andaman & Nicobar Islands) 7.5 0.9-14.0 (1.5) 5.5 -0.7-11.6 (1.7) 5.9 0.7-11.3 (2.4)

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 7.1 -0.5-14.7 (0.8) 7.3 0.0-14.7 (0.7) 7.3 0.9-13.6 (1.1)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 14.3 4.7-23.8 (0.2) 3.6 -0.7-7.9 (0.1) 6.3 2.4-10.1 (0.1)

Zone 7 (Rajasthan) 1.9 -1.9-5.6 (1.3) 2.5 -1.5-6.6 (1.1) 2.4 -0.8-5.5 (1.4)

Zone 8 (Gujarat & Daman & Diu) 9.1 2.3-15.9 (0.9) 10.7 3.3-18.2 (0.9) 10.3 4.7-15.9 (1.0)

Zone 9 (Madhya Pradesh & Chattisgarh) 11.2 3.4-18.9 (1.5) 12.6 3.8-21.5 (1.7) 12.3 5.2-19.3 (2.2)

Zone 10 (Orrisa) 4.9 -1.1-10.8 (0.8) 16.6 5.8-27.4 (0.9) 13.5 4.7-22.4 (1.4)

Zone 11 (Maharashtra & Goa) 7.9 2.9-13.1 (1.0) 19.9 11.1-28.9 (1.5) 16.9 9.9-23.9 (2.0)

Zone 12 (Andhra Pradesh) 17.9 8.2-27.7 (1.4) 26.6 15.5-37.7 (1.4) 24.4 16.1-32.7 (1.7)

Zone 13 (Karnataka) 19.2 9.7-28.7 (0.9) 29.5 18.4-40.6 (0.9 26.9 18.6-35.3 (1.1)

Zone 14 (Tamil Nadu & Pondicherry) 5.0 -0.1-10.1 (1.0) 21.6 11.9-31.4 (1.1 17.4 9.9-24.9 (1.5)

Zone 15 (Kerala & Lakshadweep Island) 4.3 -0.9-9.6 (0.6) 3.3 0.5-6.0 (0.2) 3.5 1.1-5.9 (0.3)

Rural 8.5 6.0-10.9 (1.7) 14.3 10.9-17.7 (2.0) 12.8 9.9-15.7 (3.3)

ALL INDIA Urban 5.1 3.4-6.7 (0.5) 10.1 6.7-13.6 (1.1) 8.9 6.2-11.5 (1.5)

Total 7.5 5.7-9.3 (1.5) 13.1 10.6-15.6 (1.7) 11.7 9.7-13.7 (2.4)

Table 4.4.15 Unsafe Injections (as % of Injections Observed) due to Faulty Technique

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff)

Zone 1 (Chandigarh, Delhi, Punjab, 46.5-63.3 38.7-55.9 63.1-77.6 45.2-63.3 37.2-53.2 44.3-56.9 Himachal Pradesh, Jammu & Kashmir & 54.9 47.3 70.4 54.2 45.2 50.6 Haryana) (2.8) (2.9) (2.5) (5.9) (3.0) (4.7) Zone 2 (Uttaranchal & Uttar Pradesh) 55.2-72.4 45.1-65.8 72.6-87.9 52.7-70.9 38.1-58.4 51.5-66.7 63.8 55.5 80.3 61.8 48.3 59.1 (8.3) (11.4) (9.7) (22.2) (6.5) (18.7) Zone 3 (Bihar & Jharkhand) 48.7-72.4 42.7-66.8 47.1-70.7 45.0-66.5 53.7-74.7 46.4-66.3 60.5 54.8 58.9 55.7 64.2 56.4 (8.8) (8.6) (8.6) (19.0) (1.7) (17.8) Zone 4 (West Bengal & Andaman & Nicobar 59.7-77.2 43.6-64.0 63.5-83.0 49.2-68.5 47.1-68.6 50.9-66.2 68.4 53.8 73.2 58.8 57.8 58.6 Islands) (4.3) (5.0) (5.9) (10.1) (4.6) (8.6) Zone 5 (Assam, Arunchal Pradesh, 33.4-56.8 27.1-51.9 47.6-72.8 31.9-55.2 24.5-40.1 31.9-52.5 45.1 39.5 60.2 43.6 32.3 42.2 Meghalaya & Sikkim) (2.5) (2.8) (3.0) (6.4) (0.4) (5.7) Zone 6 (Manipur, Nagaland, Mizoram & 33.5-54.1 34.9-56.1 44.5-64.8 36.9-58.1 28.4-50.2 37.1-54.3 43.8 45.5 54.6 47.5 39.3 45.7 Tripura) (0.6) (0.6) (0.5) (1.3) (0.4) (1.1) Zone 7 (Rajasthan) 26.7-46.4 38.1-58.3 32.9-53.9 37.6-59.1 24.9-43.8 36.6-53.7 36.5 48.2 43.4 48.4 34.4 45.1 (3.5) 3.5 (3.8) (9.1) (2.3) (7.5) Zone 8 (Gujarat & Daman & Diu) 26.1-43.4 34.1-54.1 53.2-71.3 34.3-54.1 30.9-51.7 35.8-50.6 34.8 44.1 62.3 44.2 41.3 43.2 (2.4) (3.1) (2.6) (5.8) (3.5) (5.0) Zone 9 (Madhya Pradesh & Chattisgarh) 62.7-82.9 68.2-86.1 55.9-78.5 70.8-87.0 53.8-74.8 68.8-82.1 72.8 77.1 67.2 78.9 64.3 75.5 (6.4) (5.5) (6.9) (10.9) (4.1) (8.8) Zone 10 (Orrisa) 24.5-47.9 35.9-60.1 35.9-60.4 34.7-59.7 21.2-43.7 34.3-56.1 36.2 47.9 48.2 47.2 32.4 45.2 (3.2) (3.1) (3.3) (8.6) (1.3) (7.7) Zone 11 (Maharashtra & Goa) 35.6-54.0 22.9-40.5 51.5-71.3 37.6-57.9 20.8-37.8 30.4-43.4 44.8 31.7 61.4 47.8 29.3 36.9 (5.0) (5.1) (6.1) (7.3) (8.9) (7.9) Zone 12 (Andhra Pradesh) 59.6-79.1 43.2-64.6 42.7-65.1 48.5-69.9 43.7-63.1 49.4-65.6 69.4 53.9 53.9 59.2 53.4 57.5 (4.9) (5.1) (5.3) (11.1) (3.7) (8.9) Zone 13 (Karnataka) 47.9-67.0 34.6-53.4 50.9-68.9 42.1-60.4 32.4-51.3 41.4-55.2 57.5 44.0 59.9 51.2 41.9 48.3 (2.9) (2.8) (2.7) (5.4) (2.7) (4.5) Zone 14 (Tamil Nadu & Pondicherry) 56.7-75.2 39.9-57.7 58.9-76.4 47.7-65.3 38.9-59.9 47.3-60.9 65.9 48.8 67.7 56.5 49.5 54.1 (3.6) (2.9) (3.3) (5.9) (4.4) (5.3) Zone 15 (Kerala & Lakshadweep Island) 31.2-50.4 27.9-43.8 67.6-83.9 30.8-45.9 34.9-51.7 33.7-45.7 40.8 35.9 75.8 38.4 43.4 39.7 (1.8) (1.3) (1.8) (2.6) (1.1) (2.2) Cont…

Table 4.4.15 Unsafe Injections (as % of Injections Observed) due To Faulty Technique

Government Health Facilities Private Health Facilities Immunization Clinic Total

Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (%) (Deff) (%) (Deff) (%) (Deff) (Deff)

56.9-62.8 50.2-57.8 64.4-71.4 53.5-59.1 Rural 59.9 53.9 67.9 56.3 (4.0) (6.3) (6.0) (10.2)

46.0-52.6 37.5-46.2 54.5-61.8 41.5-47.9 ALL INDIA Urban 49.3 41.8 58.2 44.7 (1.8) (3.3) (2.3) (5.1)

54.1-59.8 47.6-53.7 62.3-68.0 50.8-55.4 Total 56.9 50.7 65.2 53.1 (4.9) (5.6) (5.6) (9.9)

Table 4.4.16 Unsafe Injections (as % of Injections Given with Glass Syringes) due to Faulty Technique – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff)

Zone 1 (Chandigarh, Delhi, Punjab, 55.4-87.4 79.5-99.6 81.5-94.9 75.2-95.0 67.4-96.9 75.9-93.2 Himachal Pradesh, Jammu & Kashmir & 71.4 89.6 88.2 85.1 82.1 84.6 Haryana) (2.2) (1.4) (1.6) (4.1) (1.6) (3.7) Zone 2 (Uttaranchal & Uttar Pradesh) 68.8-98.2 69.9-98.7 84.2-98.4 78.5-94.8 58.3-95.4 77.7-92.8 83.5 84.3 91.3 86.7 76.8 85.3 (11.5) (6.1) (8.7) (10.9) (6.1) (9.9) Zone 3 (Bihar & Jharkhand) 69.5-102.8 39.9-98.8 64.0-97.9 49.2-96.8 68.9-97.1 52.7-95.4 86.1 69.4 81.0 72.9 83.0 74.1 (4.3) (7.7) (3.8) (19.9) (1.2) (18.4) Zone 4 (West Bengal & Andaman & 54.4-76.6 63.5-99.8 68.9-88.8 58.0-81.4 73.6-90.3 64.4-81.6 65.5 81.6 78.9 69.7 81.9 72.9 Nicobar Islands) (4.1) (3.5) (5.5) (6.7) (1.8) (5.4) Zone 5 (Assam, Arunchal Pradesh, 37.0-73.8 48.2-89.4 59.6-87.0 51.3-79.2 50.7-77.8 52.0-78.3 55.4 68.8 73.3 65.2 64.2 65.2 Meghalaya & Sikkim) (3.0) (2.7) (2.7) (5.5) (0.3) (5.2) Zone 6 (Manipur, Nagaland, Mizoram & 59.9-88.4 44.2-96.4 67.3-89.8 59.8-88.9 50.1-86.2 60.6-86.3 74.2 70.3 78.5 74.4 68.2 73.5 Tripura) (0.5) (0.4) (0.4) (0.9) (0.2) (0.8) Zone 7 (Rajasthan) 71.6-98.5 64.5-98.1 55.9-91.3 66.2-96.8 60.8-98.1 67.7-94.7 85.1 81.3 73.7 81.5 79.4 81.2 (1.3) (3.0) (3.1) (8.2) (1.7) (7.3) Zone 8 (Gujarat & Daman & Diu) 26.8-70.2 37.6-80.5 59.9-81.9 40.2-80.7 35.7-76.3 44.0-73.6 48.5 59.1 70.9 60.5 55.9 58.8 (2.5) (2.9) (2.2) (7.4) (4.2) (6.1) Zone 9 (Madhya Pradesh & Chattisgarh) 85.1- 74.9-97.9 62.6-93.7 85.9-99.6 66.6-95.6 84.6-97.1 86.4 93.1 101.1 78.2 92.8 81.1 90.9 (4.9) (4.8) (11.1) (4.2) (8.9) (4.8) Zone 10 (Orrisa) 12.2-87.4 22.6-76.2 37.2-85.4 28.9-75.3 22.5-64.8 30.8-71.3 49.8 49.4 61.3 52.1 43.6 51.0 (2.7) (1.7) (2.8) (4.6) (0.6) (4.0) Zone 11 (Maharashtra & Goa) 39.8-66.1 46.6-91.2 66.9-85.1 49.5-75.1 44.1-81.4 51.8-73.1 52.9 68.9 76.0 62.3 62.7 62.5 (4.5) (3.5) (3.8) (5.7) (7.1) (6.2) Zone 12 (Andhra Pradesh) 69.8-90.3 39.8-73.8 55.6-87.0 55.8-79.7 48.8-72.3 56.5-76.0 80.0 56.8 71.3 67.7 60.6 66.3 (4.3) (4.0) (4.7) (8.9) (2.1) (7.4) Zone 13 (Karnataka) 64.2-88.6 37.9-83.7 62.2-86.7 54.6-86.6 46.9-81.0 56.3-81.3 76.4 60.8 74.4 70.6 63.9 68.8 (2.7) (2.8) (2.6) (6.9) (2.7) (5.6) Zone 14 (Tamil Nadu & Pondicherry) 60.7-81.1 33.7-65.2 64.2-82.9 51.2-73.4 46.1-70.3 52.4-70.3 70.9 49.5 73.6 62.3 58.2 61.4 (3.9) (2.8) (3.3) (6.9) (2.4) (5.9) Zone 15 (Kerala & Lakshadweep Island) 45.1-78.2 -7.7-57.1 68.0-86.1 44.3-81.4 33.7-63.5 45.1-74.7 61.7 24.7 77.0 62.8 48.6 59.9 (1.9) (1.2) (1.7) (3.8) (0.6) (2.9)

Cont…

Table 4.4.16 Unsafe Injections (as % of Injections Given With Glass Syringes) due to Faulty Technique – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. 95% CI Est. 95% CI Est. (%) 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (Deff)

68.8-78.3 67.7-78.9 77.4-83.9 70.7-77.9 Rural 73.5 73.3 80.7 74.3 (4.9) (3.6) (3.6) (8.2)

58.4-70.5 60.3-77.9 69.3-79.6 63.6-72.9 ALL INDIA Urban 64.5 69.1 74.4 68.2 (1.9) (1.9) (2.4) (3.1)

67.5-75.6 67.2-77.9 76.1-82.2 69.9-76.1 Total 71.5 72.5 79.1 73.0 (4.5) (4.2) (4.1) (7.6)

Table 4.4.17 Unsafe Injections (as % of Injections Given With Plastic Syringes) due to Faulty Technique – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 41.9-60.5 32.3-49.2 48.1-67.9 35.4-55.0 33.9-50.7 37.4-50.6 Himachal Pradesh, Jammu & Kashmir & 51.2 40.8 57.9 45.2 42.3 43.9 (2.8) (2.6) (2.5) (4.8) (2.8) (3.9) Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 45.7-65.6 39.6-61.0 53.4-81.0 43.9-65.2 32.4-53.9 43.4-60.8 55.7 50.3 67.2 54.5 43.1 52.1 (7.5) (10.4) (10.6) (19.9) (5.6) (16.8) Zone 3 (Bihar & Jharkhand) 44.2-69.3 38.9-64.3 42.5-67.9 41.4-63.5 48.7-71.6 42.7-63.3 56.7 51.6 55.2 52.5 60.1 53.0 (8.5) (8.8) (8.6) (16.2) (1.4) (15.1) Zone 4 (West Bengal & Andaman & Nicobar 61.5-86.1 38.9-60.0 31.7-70.5 42.4-65.9 34.3-60.6 43.1-61.6 73.8 49.4 51.1 54.2 47.5 52.4 Islands) (3.4) (4.8) (3.7) (9.1) (4.2) (7.8) Zone 5(Assam, Arunchal Pradesh, 19.7-47.3 12.9-37.6 17.8-54.3 14.5-41.1 15.6-33.1 15.9-38.6 33.5 25.3 36.1 27.8 24.4 27.3 Meghalaya & Sikkim) (1.9) (2.4) (2.3) (5.4) (0.5) (4.6) Zone 6 (Manipur, Nagaland, Mizoram & 17.5-36.9 31.7-53.6 22.4-45.1 29.5-52.0 23.8-45.9 30.3-48.4 27.2 42.7 33.8 40.7 34.8 39.4 Tripura) (0.4) (0.6) (0.4) (1.1) (0.3) (0.9) Zone 7 (Rajasthan) 20.6-40.0 29.7-50.4 22.7-45.4 28.5-51.3 19.9-38.5 28.4-46.0 30.3 40.0 34.0 39.9 29.2 37.2 (3.4) (3.1) (3.8) (7.5) (1.9) (6.2) Zone 8 (Gujarat & Daman & Diu) 22.6-40.4 28.9-51.1 40.3-66.6 28.6-50.5 24.8-48.6 30.3-46.8 31.5 39.9 53.5 39.5 36.7 38.6 (2.2) (3.1) (2.7) (5.1) (3.2) (4.5) Zone 9 (Madhya Pradesh & Chattisgarh) 51.9-77.9 53.1-78.9 49.4-76.2 56.4-80.4 44.9-71.2 56.1-74.8 64.9 66.0 62.8 68.4 58.1 65.5 (5.8) (5.4) (6.8) (9.4) (3.9) (7.6) Zone 10 (Orrisa) 22.5-47.1 35.1-60.6 31.0-57.9 33.4-59.7 19.2-42.8 32.9-55.9 34.8 47.8 44.5 46.6 31.0 44.4 (3.3) (3.1) (3.2) (7.5) (1.1) (6.7) Zone 11 (Maharashtra & Goa) 25.4-50.4 18.6-35.7 23.8-55.9 27.9-52.1 14.9-32.8 22.2-36.6 37.9 27.2 39.8 39.9 23.8 29.4 (5.4) (4.8) (6.6) (6.3) (8.6) (7.4) Zone 12 (Andhra Pradesh) 35.3-68.8 39.7-65.3 29.1-56.8 37.1-67.8 38.4-62.8 40.9-62.7 52.1 52.5 42.9 52.5 50.6 51.8 (4.8) (5.0) (5.2) (11.1) (3.7) (8.5) Zone 13 (Karnataka) 30.9-55.6 30.7-50.1 37.4-61.4 34.3-54.4 25.1-45.3 33.8-48.9 43.3 40.4 49.4 44.4 35.2 41.4 (2.9) (2.6) (2.7) (4.4) (2.3) (3.7) Zone 14 (Tamil Nadu & Pondicherry) 18.9-60.3 38.3-58.8 29.5-60.7 36.1-63.3 32.9-58.2 38.4-57.3 39.6 48.5 45.1 49.7 45.5 47.8 (2.7) (2.8) (1.9) (5.6) (3.9) (4.9) Zone 15 (Kerala & Lakshadweep Island) 19.1-38.3 28.4-44.4 51.5-88.9 23.9-41.7 33.8-51.3 28.6-42.4 28.7 36.4 70.2 32.8 42.5 35.5 (1.4) (1.3) (1.5) (2.8) (0.9) (2.2)

Cont…

Table 4.4.17 Unsafe Injections (as % of Injections Given With Plastic Syringes) due To Faulty Technique – Direct Observation

Government Health Facilities Private Health Facilities Immunization Clinic Total

Est. 95% CI Est. 95% CI Est. 95% CI Est. (%) 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (Deff)

46.3-54.9 44.5-52.6 49.4-61.0 46.0-52.4 Rural 50.6 48.5 55.2 49.2 (4.9) (5.7) (7.6) (8.7)

38.4-47.4 33.3-41.9 40.9-51.1 35.6-42.6 ALL INDIA Urban 42.9 37.6 45.9 39.1 (2.5) (2.9) (2.6) (4.6)

44.7-51.8 42.1-48.6 48.1-56.7 43.5-48.9 Total 48.2 45.3 52.4 46.2 (5.0) (5.4) (6.0) (9.1)

Table 4.4.18 Injection Practices in India: Health Facilities with “All Safe Injections During Observations”

Government Health Facilities Private Health Facilities Immunization Clinics All India Total

Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Total

Estimate 12.7 17.5 14.0 15.9 27.5 19.1 12.0 16.6 13.3 14.9 24.4 17.5 (%)

95% C.I. 10.4 -15.0 13.3-21.8 11.8-16.2 12.9-18.9 22.3-32.7 16.4-21.8 9.4 -14.6 13.0-20.2 11.0-15.6 12.6-17.2 20.8-28.1 15.5-19.6

Deff. 1.0 1.0 1.3 1.5 1.1 1.5 1.4 0.8 1.4 2.7 1.8 2.7

Table 4.4.19 Injections where Needle was Recapped after Injection (as % of Injections Observed)

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 9.0-21.9 26.2-46.2 12.6-29.6 11.8-31.6 29.9-57.2 22.3-38.4 15.4 36.2 21.1 21.7 43.6 30.4 Pradesh, Jammu & Kashmir & Haryana) (3.1) (4.3) (4.3) (10.3) (8.9) (9.1) Zone 2 (Uttaranchal & Uttar Pradesh) 7.3-22.1 15.1-34.9 6.9-24.3 10.8-29.9 17.9-38.9 14.0-29.9 14.7 25.0 15.6 20.3 28.5 21.9 (11.5) (13.7) (15.1) (35.5) (8.5) (28.9) Zone 3 (Bihar & Jharkhand) 29.8-55.6 35.4-60.6 29.2-54.7 34.4-56.7 45.6-67.6 36.1-56.7 42.7 47.9 41.9 45.5 56.6 46.4 (10.1) (9.8) (9.9) (21.1) (1.7) (19.5) Zone 4 (West Bengal & Andaman & Nicobar 2.7-16.8 29.7-52.9 1.3-10.9 21.4-42.1 20.1-41.6 23.4-39.6 9.7 41.3 6.1 31.8 30.8 31.5 (6.8) (6.7) (4.8) (12.9) (5.3) (10.9) Zone 5 (Assam, Arunchal Pradesh, Meghalaya 10.9-32.8 19.9-45.2 13.7-35.4 18.0-40.8 18.8-41.7 19.4-39.6 21.9 32.6 24.5 29.4 30.2 29.5 & Sikkim) (3.1) (3.2) (2.9) (7.3) (0.9) (6.5) Zone 6 (Manipur, Nagaland, Mizoram & 30.8-52.5 57.5-80.5 25.9-46.9 47.5-70.9 53.1-75.7 50.8-69.8 41.7 68.9 36.4 59.2 64.4 60.3 Tripura) (0.6) (0.8) (0.6) (1.7) (0.5) (1.4) Zone 7 (Rajasthan) 8.3-25.7 19.9-41.3 8.3-25.9 19.3-39.5 16.9 8.1-25.7 18.5-34.5 17.0 30.6 17.1 29.4 26.5 (4.5) (4.6) (4.7) (9.6) (3.2) (8.4) Zone 8 (Gujarat & Daman & Diu) 4.2-15.9 14.7-31.9 12.4-30.1 8.6-24.2 16.9-37.5 13.9-26.4 10.1 23.3 21.2 16.4 27.2 20.2 (2.7) (3.2) (3.5) (6.5) (4.2) (5.4)

Zone 9 (Madhya Pradesh & Chattisgarh) 6.9-21.9 7.5-22.8 31.4-55.5 6.7-20.4 16.7-38.6 11.0-22.8 14.4 15.1 43.5 13.6 27.6 16.9 (5.6) (5.5) (7.2) (11.3) (5.2) (8.9) Zone 10 (Orrisa) 16.4-41.2 10.2-31.4 11.6-34.1 11.9-33.4 12.4-36.2 13.5-32.3 28.8 20.8 22.8 22.7 24.3 22.9 (4.1) (3.6) (3.9) (8.9) (1.7) (7.9) Zone 11 (Maharashtra & Goa) -0.4-7.1 7.6-22.6 0.6-9.6 9.0-27.4 0.9-13.1 6.4-16.8 3.3 15.1 5.1 18.2 7.0 11.6 (6.3) (6.4) (6.1) (10.0) (14.7) (11.5) Zone 12 (Andhra Pradesh) 12.9-31.6 31.2-54.8 26.7-50.4 28.9-51.7 20.5-43.3 29.2-46.6 22.3 43.0 38.5 40.3 31.9 37.9 (5.5) (6.3) (6.2) (12.5) (5.8) (10.7) Zone 13 (Karnataka) 8.9-24.7 31.9-53.3 14.2-32.1 24.3-45.2 25.3-46.9 27.2-43.1 16.8 42.6 23.1 34.7 36.1 35.2 (3.5) (3.7) (3.6) (7.8) (3.8) (6.5) Zone 14 (Tamil Nadu & Pondicherry) 1.7-10.9 21.1-41.6 4.7-18.3 13.0-33.4 15.4-36.4 16.6-31.8 6.3 31.3 11.5 23.2 25.9 24.2 (3.4) (4.6) (4.4) (10.9) (5.7) (8.9) Zone 15 (Kerala & Lakshadweep Island) 7.7-23.8 19.9-37.4 0.1-5.1 14.3-30.2 19.9-36.7 17.6-30.1 15.7 28.7 2.6 22.2 28.3 23.9 (2.4) (1.8) (1.2) (3.8) (1.3) (3.1)

Cont…

Table 4.4.19 Injections where Needle was Recapped after Injection (As % Of Injections Observed)

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. 95% CI Est. 95% CI Est. (%) 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (Deff)

15.3-20.3 26.8-35.3 19.6-27.0 24.3-30.5 Rural 17.8 31.0 23.3 27.4 (4.7) (9.1) (8.4) (15.5)

12.4-17.7 27.1-35.5 14.0-19.1 23.3-29.7 ALL INDIA Urban 15.1 31.3 16.6 26.5 (2.3) (3.4) (1.9) (6.6)

14.6-19.4 28.1-34.1 18.7-24.2 24.8-29.5 Total 17.0 31.1 21.4 27.2 (6.3) (6.7) (6.8) (13.2)

Table 4.4.20 Recapping (%) after Injections Given with Plastic Syringe – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, 10.4-25.9 25.2-45.5 20.9-45.7 9.4-30.1 31.9-60.3 22.7-39.9 Himachal Pradesh, Jammu & Kashmir & 18.2 35.4 33.3 19.7 46.1 31.4 Haryana) (3.3) (3.9) (4.2) (8.4) (7.9) (7.7) Zone 2 (Uttaranchal & Uttar Pradesh) 9.2-28.9 14.3-34.9 16.4-48.2 11.6-32.7 17.9-40.9 15.1-32.3 19.0 24.6 32.3 22.1 29.4 23.7 (11.9) (12.9) (14.2) (27.8) (7.6) (22.8) Zone 3 (Bihar & Jharkhand) 32.3-60.3 35.9-63.4 31.5-58.2 35.4-60.7 42.3-68.4 36.8-60.3 46.3 49.7 44.8 48.1 55.4 48.6 (10.4) (10.3) (9.4) (20.9) (1.8) (19.5) Zone 4 (West Bengal & Andaman & Nicobar 4.2-36.6 31.2-55.9 4.4-43.2 26.9-54.4 25.6-54.3 29.7-51.2 20.4 43.6 23.8 40.6 39.9 40.4 Islands) (7.0) (6.7) (5.2) (12.9) (5.2) (10.8) Zone 5 (Assam, Arunchal Pradesh, 19.4-54.7 23.2-55.1 18.6-63.4 23.7-55.2 22.1-48.5 25.3-52.3 37.1 39.1 41.0 39.5 35.3 38.8 Meghalaya & Sikkim) (3.0) (3.2) (3.4) (6.3) (0.9) (5.5) Zone 6 (Manipur, Nagaland, Mizoram & 47.5-73.6 63.7-85.5 45.9-73.5 59.5-83.4 59.5-81.9 61.8-80.8 60.5 74.6 59.7 71.5 70.7 71.3 Tripura) (0.6) (0.7) (0.6) (1.5) (0.4) (1.3) Zone 7 (Rajasthan) 5.1-21.5 15.2-37.2 4.7-23.6 13.8-34.2 7.2-26.3 14.2-30.2 13.3 26.2 14.2 23.9 16.7 22.2 (4.5) (4.4) (4.8) (7.9) (3.1) (6.9) Zone 8 (Gujarat & Daman & Diu) 5.4-19.5 13.6-32.9 18.4-44.5 7.8-25.2 17.8-41.5 13.9-28.1 12.4 23.2 31.5 16.5 29.6 21.0 (2.8) (3.2) (3.0) (5.6) (3.6) (4.7) Zone 9 (Madhya Pradesh & Chattisgarh) 8.0-30.1 8.9-30.1 38.7-67.1 7.6-26.0 21.6-48.9 14.2-29.9 19.1 19.5 52.9 16.8 35.3 22.0 (6.2) (5.2) (7.2) (8.6) (4.5) (7.1) Zone 10 (Orrisa) 15.8-41.7 10.7-33.5 9.8-35.1 11.9-35.3 12.5-37.4 13.6-34.0 28.8 22.1 22.5 23.6 24.9 23.8 (4.1) (3.6) (4.0) (8.2) (1.4) (7.2) Zone 11 (Maharashtra & Goa) -1.5-10.6 7.8-23.8 -0.4-14.2 12.9-39.8 0.1-13.6 7.2-20.0 4.5 15.8 6.9 26.3 6.9 13.6 (6.9) (6.2) (5.1) (9.6) (13.9) (10.5) Zone 12 (Andhra Pradesh) 12.6-44.1 34.2-60.5 38.9-69.4 36.2-64.9 20.8-48.3 34.5-55.5 28.4 47.4 54.1 50.6 34.6 45.0 (5.3) (5.3) (6.2) (9.6) (5.2) (8.0) Zone 13 (Karnataka) 16.5-41.2 36.8-59.7 23.4-49.7 31.9-56.6 31.0-56.7 34.8-53.4 28.8 48.2 36.5 44.2 43.9 44.1 (3.4) (3.5) (3.5) (6.6) (3.5) (5.6) Zone 14 (Tamil Nadu & Pondicherry) 7.6-40.8 20.8-44.5 12.9-48.2 15.3-48.2 19.2-45.6 21.2-42.9 24.2 32.7 30.6 31.7 32.4 32.0 (2.3) (4.3) (2.9) (9.4) (4.8) (7.4) Zone 15 (Kerala & Lakshadweep Island) 12.6-35.5 19.9-38.0 -1.4-4.3 16.4-35.8 22.3-41.2 20.2-35.1 24.1 28.9 1.4 26.1 31.7 27.7 (2.2) (1.9) (0.5) (3.7) (1.2) (2.9)

Cont…

Table 4.4.20 Recapping (%) after Injections Given with Plastic Syringe – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities

Est. 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI (%) (Deff) (Deff) (Deff) (Deff)

20.8-29.6 27.6-37.5 33.1-45.5 27.6-35.4 Rural 25.2 32.6 39.3 31.5 (6.7) (9.7) (8.9) (14.8)

15.3-21.8 28.4-36.6 19.2-27.7 25.9-32.6 ALL INDIA Urban 18.6 32.5 23.4 29.2 (2.1) (2.8) (2.4) (4.9)

19.6-26.6 29.2-35.9 30.1-38.9 27.9-33.6 Total 23.1 32.6 34.5 30.8 (6.7) (6.6) (7.0) (11.7)

Table 4.4.21 Recapping (%) after Injections Given with Glass Syringe – Direct Observation

Government Private Health Immunization Rural Urban Total Health Facilities Facilities Clinic Zone Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI Est. 95% CI (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) (%) (Deff) Zone 1 (Chandigarh, Delhi, Punjab, -1.5-8.1 12.7-70.9 -1.9-7.4 7.0-49.9 -2.4-23.1 7.1-43.5 Himachal Pradesh, Jammu & Kashmir & 3.3 41.8 2.8 28.5 10.3 25.3 (1.3) (4.5) (3.0) (12.0) (1.9) (11.2) Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) -0.6-8.9 5.1-49.8 -0.6-3.6 0.7-27.7 -2.8-49.0 3.2-27.7 4.1 27.5 1.5 14.2 23.1 15.5 (4.2) (9.7) (4.2) (28.2) (11.9) (25.0) Zone 3 (Bihar & Jharkhand) -8.2-45.8 5.9-67.2 4.8-44.3 3.8-52.2 43.7-81.1 9.9-53.3 18.8 36.6 24.6 27.9 62.4 31.6 ()8.9 (7.6) (4.3) (20.2) (1.23) (16.8) Zone 4 (West Bengal & Andaman & Nicobar -1.1-8.9 1.8-51.6 -0.2-3.4 0.2-22.0 0.1-19.3 2.3-19.1 3.9 26.7 1.6 11.1 9.7 10.7 Islands) (5.0) (5.0) (2.0) (12.7) (4.1) (10.6) Zone 5 (Assam, Arunchal Pradesh, -2.5-16.7 1.4-37.1 4.7-26.5 3.2-27.6 -8.0-27.7 3.6-26.6 7.1 19.2 15.6 15.4 9.9 15.1 Meghalaya & Sikkim) (3.1) (2.8) (2.6) (7.4) (1.5) (7.1) Zone 6 (Manipur, Nagaland, Mizoram & -1.9-16.4 -1.9-37.3 2.9-16.4 0.6-20.0 4.4-33.6 2.8-20.3 7.2 17.7 9.7 10.3 18.9 11.6 Tripura) (0.5) (0.3) (0.3) (0.8) (0.2) (0.7) Zone 7 (Rajasthan) 15.8-76.7 25.7-71.2 8.9-44.4 28.4-72.4 -0.4-37.2 26.5-65.9 46.3 48.5 26.7 50.4 18.4 46.2 (3.5) (3.4) (3.1) (10.2) (1.9) (9.4) Zone 8 (Gujarat & Daman & Diu) 0-0 6.2-41.2 2.7-19.6 0.7-31.5 2.9-36.1 5.8-28.8 0 23.7 11.1 16.1 19.5 17.3 (-) (2.7) 2.7 (7.6) (4.4) (6.3) Zone 9 (Madhya Pradesh & Chattisgarh) 1.9-11.1 -1.2-19.0 6.0-33.9 0.1-18.4 -5.0-19.5 1.4-16.8 6.5 8.9 19.9 9.3 7.2 8.9 (1.5) (6.0) (4.1) (15.7) (6.9) (14.5) Zone 10 (Orrisa) -2.1-60.7 -0.9-22.4 0.3-47.9 3.2-27.9 -0.6-38.8 4.9-27.1 29.3 10.8 24.1 15.5 19.1 15.9 (2.3) (0.8) (3.6) (2.5) (0.8) (2.2) Zone 11 (Maharashtra & Goa) -0.4-4.3 -0.9-19.7 -0.4-8.1 -0.1-6.3 0.2-15.3 1.4-8.2 1.9 9.4 3.9 3.1 7.8 4.8 (1.8) (1.9) (4.2) (2.7) (3.8) (3.3) Zone 12 (Andhra Pradesh) 8.1-28.9 14.6-52.9 3.8-23.9 12.9-41.9 9.4-40.7 14.9-38.9 18.5 33.8 13.8 27.4 25.0 26.9 (4.8) (5.6) (3.3) (14.5) (4.6) (12.5) Zone 13 (Karnataka) -0.8-2.4 -5.7-35.6 -0.6-10.2 -4.7-20.3 -6.5-23.5 -1.9-17.9 0.8 14.9 4.8 7.8 8.5 8.0 (1.1) (4.3) (2.1) (11.9) (6.2) (10.3) Zone 14 (Tamil Nadu & Pondicherry) -1.4-7.4 12.4-44.0 0.5-12.4 5.6-26.5 -0.03-22.9 6.5-23.5 2.9 28.2 6.5 16.0 11.5 14.9 (5.1) (3.4) (4.3) (10.9) (5.3) (9.8) Zone 15 (Kerala & Lakshadweep Island) -0.8-3.5 -6.9-51.7 -0.2-5.8 0.3-10.7 -0.8-13.3 1.2-10.0 1.4 22.4 2.8 5.5 6.3 5.6 (0.6) (1.0) (1.2) (1.4) (0.6) (1.2)

Cont…

Table 4.4.21 Recapping (%) after Injections Given with Glass Syringe – Direct Observation

Government Health Facilities Private Health Facilities Immunization Clinic Total

Est. 95% CI Est. (%) 95% CI Est. (%) 95% CI Est. (%) 95% CI (%) (Deff) (Deff) (Deff) (Deff)

4.0-9.6 18.7-32.1 5.2-8.9 12.9-20.9 Rural 6.8 25.4 7.0 16.9 (5.3) (5.4) (2.7) (13.6)

3.5-10.0 13.6-32.9 4.8-9.9 10.1-19.7 ALL INDIA Urban 6.8 23.3 7.4 14.9 (1.9) (2.8) (1.7) (5.7)

4.6-9.0 19.1-30.8 5.4-8.9 13.1-19.8 Total 6.8 24.9 7.1 16.5 (4.3) (5.3) (3.3) (12.7)

Table 4.4.22 Needle Stick Injury after Injection (as % of Injections Observed)

Government Health Facilities Private Health Facilities Immunization Clinic Total Type of syringe Est. (%) 95% CI Deff Est. (%) 95% CI Deff Est. (%) 95% CI Deff Est. (%) 95% CI Deff

Rural 1.6 0.8-2.3 3.8 2.7 1.9-3.5 2.6 4.0 2.9-5.0 3.1 2.5 1.9-3.1 5.1

Overall Urban 1.6 0.6-2.5 2.3 1.8 1.0-2.6 1.5 4.7 3.2-6.2 2.2 1.9 1.3-2.6 2.5

Total 1.6 0.9-2.2 4.2 2.4 1.8-3.1 2.9 4.2 3.4-5.0 2.6 2.4 1.8-2.9 5.6

Rural 0.7 0.01-1.4 4.6 1.5 0.9-2.1 1.9 3.1 1.8-4.3 2.9 1.4 0.9-1.9 2.9

Plastic Urban 0.8 0.2-1.4 1.3 0.9 0.5-1.3 0.7 3.8 2.0-5.6 2.1 1.0 0.7-1.3 1.0 Syringe

Total 0.7 0.2-1.3 3.7 1.3 0.9-1.8 2.2 3.3 2.3-4.3 2.5 1.3 0.9-1.7 3.4

Rural 2.8 1.3-4.4 3.6 6.9 4.1-9.7 2.7 4.9 3.5-6.4 2.4 5.3 3.6-6.9 6.9

Glass Urban 3.4 1.3-5.4 1.5 7.9 2.7-13.3 2.0 5.9 3.4-8.4 1.9 5.9 3.2-8.8 4.3 Syringe

Total 2.9 1.6-4.3 3.8 7.1 4.5-9.7 3.0 5.2 3.9-6.4 2.2 5.4 3.9-6.9 7.4

Table 4.4.23 Stakeholders’ Perception of ‘A Safe Injection’*

Prescriber Perception Community Perception Client Perception

(Community Survey) (Exit Interviews) Determinants of Safety

Est. 95% CI Deff Est. 95% CI Deff Est. 95% CI Deff (%) (%) (%)

Do not know 3.6 2.5-4.7 2.2 21.2 19.9-22.5 6.0 29.1 27.3-30.8 4.4

Injection equipment related 84.4 82.4-86.4 1.9 68.2 66.6-69.7 6.3 58.7 56.9-60.5 4.2 (New syringe/avoid reuse/flushing of syringe/needle)

Technique related 53.5 50.6-56.4 2.2 15.1 13.9-16.4 7.1 14.9 13.5-16.3 4.8 (Proper site/given slowly/clean injection site)

Rationality of injection 6.4 5.1-7.7 1.7 5.2 4.6-5.7 3.5 7.2 6.0-8.4 6.5 (Given when necessary/for immunization)

Misconceptions 4.8 3.3-6.3 3.1 5.5 4.5-6.5 11.5 1.7 0.7-2.7 18.9 (All injections are safe/its safe to reuse syringes/needles)

Effectiveness of injection 12.7 10.9-14.6 1.9 7.2 6.3-8.1 7.3 4.6 3.9-5.3 3.5 (Disease should be cured/maximum effect)

* Multiple responses

Table 4.4.24 Stakeholders’ Perception of Complications of Unsafe Injection*

Prescriber Perception Community Perception Client perception

(Prescriber Interview) (Community Survey) (Exit Interview) Complications

Est. (%) 95% CI Deff Est. (%) 95% CI Deff Est. (%) 95% CI Deff

Not sure 1.0 0.3-1.7 2.8 12.1 11.2-13.1 4.8 21.5 20.1-22.9 3.6

No complications 2.2 1.0-3.4 4.1 1.7 1.4-1.9 2.8 3.6 2.5-4.7 10.2

Local complications 59.5 56.6-62.4 2.2 28.6 27.0-30.1 6.8 24.9 23.3-26.7 5.0

Blood Borne Diseases 74.1 71.3-76.9 2.6 33.3 31.9-34.6 4.7 27.3 25.8-28.8 3.5

Spread of diseases 53.1 50.2-56.0 2.1 66.6 65.1-67.9 5.5 56.6 54.8-58.4 4.0

* Multiple responses

Table 4.4.25 Potential Risks to Injection Givers with Faulty Injection Techniques: According to Type of Prescriber

Allopathic Prescriber ISM Prescriber Informal Prescriber Risk to Injection Givers Estimate (%) 95% CI Deff Estimate (%) 95% CI Deff Estimate (%) 95% CI Deff

Local Reaction 52.5 49.2-55.8 1.7 40.4 32.7-48.0 2.9 41.7 33.2-50.1 3.4

Blood Borne Complications 57.3 53.9-60.7 1.8 29.8 23.2-36.5 2.5 18.1 12.1-24.1 2.8

Spread of Other Diseases 44.8 41.6-48.1 1.6 46.5 38.6-54.2 2.9 55.1 46.6-63.5 3.4

* Multiple responses

Table 4.5.1 Injections Prescribed by Allopathic Practitioners (as % of all Injections) - Community Survey

Rural Urban Total

Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 39.6 29.8-49.4 2.2 70.8 63.8-77.9 0.9 52.8 46.2-59.4 1.7 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 34.3 23.8-44.8 8.6 50.0 40.9-59.1 1.5 37.5 29.1-45.8 6.6

Zone 3 (Bihar & Jharkhand) 26.8 15.1-38.6 11.5 62.3 46.5-78.1 2.2 30.8 19.9-41.6 10.1

Zone 4 (West Bengal & Andaman & Nicobar Islands) 23.2 14.7-31.8 2.5 39.8 30.9-48.7 0.7 27.5 20.6-34.4 2.0

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 53.7 41.8-65.5 1.5 63.6 51.9-75.3 0.2 54.8 44.2-65.4 1.4

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 52.2 36.7-67.8 0.6 76.9 67.5-86.5 0.1 57.4 44.9-69.9 0.5

Zone 7 (Rajasthan) 56.6 49.6-63.7 1.4 76.9 69.6-84.3 0.5 60.7 54.8-66.5 1.2

Zone 8 (Gujarat & Daman & Diu) 48.5 39.3-57.7 1.7 66.5 57.1-75.8 0.8 53.8 46.7-60.9 1.4

Zone 9 (Madhya Pradesh & Chattisgarh) 34.2 25.0-43.4 3.3 64.4 52.9-75.9 1.3 40.4 32.7-48.1 2.7

Zone 10 (Orrisa) 69.1 61.4-76.8 1.5 74.7 64.7-84.7 0.4 69.9 63.1-76.6 1.4

Zone 11 (Maharashtra & Goa) 56.6 48.2-64.9 2.2 44.9 35.6-54.2 3.4 50.2 43.7-56.6 2.9

Zone 12 (Andhra Pradesh) 46.6 38.7-54.5 2.8 58.8 47.9-69.7 2.2 50.0 43.6-56.4 2.6

Zone 13 (Karnataka) 62.9 52.8-73.0 3.3 72.2 63.7-80.7 1.1 65.6 57.9-73.3 2.8

Zone 14 (Tamil Nadu & Pondicherry) 79.8 72.9-86.8 3.2 85.0 80.5-89.5 0.9 81.6 76.8-86.4 2.5

Zone 15 (Kerala & Lakshad Island) 78.1 69.9-86.2 1.1 71.4 60.4-82.5 0.5 76.5 69.7-83.3 0.9

< 1 year 33.6 28.4-38.7 0.9 48.9 45.4-52.2 4.9 35.8 31.9-39.6 0.7

ALL INDIA ≥ 1 year 40.3 34.9-45.7 0.4 65.6 61.8-69.4 2.4 53.3 50.5-56.0 4.4

Total 46.9 43.8-49.9 4.4 61.6 58.3-64.9 1.9 50.9 48.4-53.5 4.3

Table 4.5.2 Injections Prescribed by Informally Qualified Practitioners (as % of All Injection) - Community Survey

Rural Urban Total Zone Est Est 95% CI Deff Est (%) 95% CI Deff 95% CI Deff (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 25.7 15.0-36.3 3.3 2.9 -0.4-6.1 1.6 16.0 9.6-22.4 2.9 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 29.6 20.1-39.1 7.6 15.5 8.6-22.3 1.6 26.8 19.1-34.4 6.6

Zone 3 (Bihar & Jharkhand) 23.8 11.7-35.9 13.2 4.2 -0.1-9.5 1.4 21.6 11.0-32.2 12.2

Zone 4 (West Bengal & Andaman & Nicobar Islands) 11.3 6.2-16.4 1.6 8.3 1.5-15.0 1.3 10.5 6.4-14.6 1.5

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 2.9 -1.6-7.5 2.0 0.0 0.0-0.0 - 2.6 -1.5-6.7 2.0

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 2.9 0.1-5.9 0.2 1.6 -0.6-3.8 0.1 2.7 0.4-4.9 0.2

Zone 7 (Rajasthan) 6.1 -0.5-12.8 5.3 2.2 -0.4-4.9 0.5 5.4 0.0-10.7 4.9

Zone 8 (Gujarat & Daman & Diu) 1.5 -0.2-3.2 0.9 0.0 0.0-0.0 - 1.0 -0.1-2.2 0.9

Zone 9 (Madhya Pradesh & Chattisgarh) 35.8 26.5-45.1 3.3 10.6 4.4-16.8 0.9 30.6 22.9-38.2 3.0

Zone 10 (Orrisa) 3.0 -0.2-6.3 1.9 0.0 0.0-0.0 - 2.6 -0.2-5.5 1.9

Zone 11 (Maharashtra & Goa) 1.5 0.04-2.9 1.1 0.0 0.0-0.0 - 0.7 0.02-1.3 1.1

Zone 12 (Andhra Pradesh) 32.3 24.0-40.5 3.6 15.6 8.3-22.8 1.8 27.6 21.3-33.9 3.2

Zone 13 (Karnataka) 14.1 5.8-22.5 4.3 3.6 -0.1-7.4 1.2 11.1 4.9-17.2 4.0

Zone 14 (Tamil Nadu & Pondicherry) 2.9 0.7-5.1 1.9 0.0 0.0-0.0 - 1.9 0.5-3.3 1.8

Zone 15 (Kerala & Lakshad Island) 0.0 0.0-0.0 - 0.8 -0.8-2.3 0.3 0.2 -0.2-0.5 0.2

< 1 year 5.6 2.6-8.5 0.1 19.3 16.4-22.3 5.9 4.1 2.0-6.1 0.1

ALL INDIA ≥ 1 year 0.9 -0.1-1.9 0.4 5.7 4.2-7.2 1.6 15.7 13.5-17.9 5.2

Total 17.6 14.9-20.2 5.6 4.9 3.7-6.2 1.5 14.1 12.1-16.2 5.5

Table 4.5.3 Injections Prescribed by Practitioners of Indian Systems of Medicine (ISM) (as % of All Injections) – Community Survey

Rural Urban Total Zone Est 95% CI Deff Est (%) 95% CI Deff Est 95% CI Deff (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 9.6 2.7-16.6 3.1 12.9 8.0-17.8 0.9 11.0 65.5-15.5 2.0 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 13.0 6.8-19.3 6.1 8.9 3.1-14.8 1.8 12.2 7.1-17.3 5.3

Zone 3 (Bihar & Jharkhand) 6.1 1.8-10.3 5.3 3.7 0.1-7.2 0.7 5.8 1.9-9.6 4.9

Zone 4 (West Bengal & Andaman & Nicobar Islands) 4.9 0.6-0.9 2.5 3.8 0.1-0.7 0.8 4.6 1.3-7.9 2.1

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 0.0 0.0-0.0 - 3.0 0.1-5.9 0.1 0.3 0.1-0.7 0.1

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 0.7 -0.7-2.2 0.2 1.6 -0.5-3.7 0.1 0.9 -0.3-2.1 0.1

Zone 7 (Rajasthan) 3.8 0.9-6.7 1.6 6.2 2.4-9.9 0.4 4.3 1.8-6.7 1.3

Zone 8 (Gujarat & Daman & Diu) 20.3 12.2-28.4 2.0 14.6 8.0-21.1 0.7 18.6 12.5-24.7 1.7

Zone 9 (Madhya Pradesh & Chattisgarh) 5.8 1.9-9.6 2.3 11.9 2.1-21.6 2.1 7.0 3.4-10.7 2.3

Zone 10 (Orrisa) 4.8 1.8-7.8 1.1 0.4 -0.4-1.3 0.1 4.2 1.6-6.9 1.1

Zone 11 (Maharashtra & Goa) 19.5 11.6-27.4 3.1 18.5 10.0-27.0 4.5 18.9 13.1-24.8 3.9

Zone 12 (Andhra Pradesh) 5.7 0.8-10.7 5.2 1.4 0.1-2.7 .6 4.5 0.9-8.1 4.8

Zone 13 (Karnataka) 8.8 2.8-14.9 3.5 9.7 2.2-17.2 2.0 9.1 4.2-13.9 3.0

Zone 14 (Tamil Nadu & Pondicherry) 4.3 1.0-0.8 2.9 1.2 -0.2-2.6 0.9 3.2 1.0-5.5 2.6

Zone 15 (Kerala & Lakshad Island) 2.6 -0.6-5.7 1.1 2.3 -0.3-4.8 0.2 2.5 0.2-4.9 0.9

< 1 year 5.4 2.4-8.3 0.1 8.7 6.9-10.5 4.4 4.9 2.8-7.0 0.1

ALL INDIA ≥ 1 year 3.9 1.8-6.1 0.4 10.1 7.7-12.6 2.6 9.1 7.6-10.6 3.9

Total 8.3 6.7-9.9 3.9 9.1 6.9-11.4 2.7 8.5 7.2-9.7 3.5

Table 4.5.4 Injections Prescribed by Paramedics (as % of All Injections) - Community Survey

Rural Urban Total Zone Est (%) 95% CI Deff Est 95% CI Deff Est (%) 95% CI Deff (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 19.8 12.3-27.3 1.9 7.7 3.1-12.2 1.2 14.6 9.9-19.4 1.7 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 23.1 15.8-30.3 5.2 21.4 14.8-28.1 1.6 22.7 16.8-28.7 4.4

Zone 3 (Bihar & Jharkhand) 12.6 4.6-20.5 9.4 16.2 9.2-23.3 0.7 12.9 5.9-20.1 8.2

Zone 4 (West Bengal & Andaman & Nicobar Islands) 50.7 39.2-62.3 3.3 36.8 25.8-47.9 1.1 47.1 38.0-56.3 2.8

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 42.6 29.5-55.8 1.9 27.3 15.3-39.2 0.3 40.9 29.1-52.7 1.8

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 41.0 26.5-55.6 0.6 19.8 10.2-29.5 0.1 36.6 24.9-48.3 49.3

Zone 7 (Rajasthan) 28.3 21.8-34.8 1.4 12.4 7.2-17.5 0.4 25.1 19.7-30.5 1.3

Zone 8 (Gujarat & Daman & Diu) 29.2 22.1-36.3 1.2 20.3 12.1-28.4 0.9 26.6 21.0-32.1 1.1

Zone 9 (Madhya Pradesh & Chattisgarh) 14.7 7.9-21.6 3.3 10.0 5.0-14.9 0.6 13.8 8.2-19.3 2.8

Zone 10 (Orrisa) 20.0 13.0-26.9 1.7 14.7 8.3-20.9 0.3 19.3 13.2-25.4 1.5

Zone 11 (Maharashtra & Goa) 20.6 15.0-26.2 0.3 37.5 27.5-47.5 4.0 29.9 23.8-35.9 3.1

Zone 12 (Andhra Pradesh) 16.8 11.9-21.8 2.0 17.9 11.7-24.2 1.2 17.2 13.2-21.1 1.8

Zone 13 (Karnataka) 14.1 7.6-20.6 2.7 14.9 8.4-21.5 1.0 14.4 9.3-19.4 2.2

Zone 14 (Tamil Nadu & Pondicherry) 14.1 5.9-22.4 6.0 12.4 7.8-16.9 1.1 13.5 7.9-19.2 4.6

Zone 15 (Kerala & Lakshad Island) 18.1 10.7-25.4 0.9 25.6 14.0-37.1 0.6 19.8 13.5-26.1 0.9

< 1 year 53.9 48.9-58.9 0.1 16.2 13.9-18.5 4.3 54.0 50.1-58.0 0.1

ALL INDIA ≥ 1 year 54.2 47.9-60.5 0.1 14.9 12.1-17.7 2.3 15.9 14.0-17.7 3.8

Total 20.9 18.8-23.1 3.3 21.2 18.3-24.0 2.1 21.0 19.2-22.9 3.4

Table 4.5.5 Profile of Injection Prescribers for <1 and ≥1 Year Age Group (Proportion of All Injections) – Community Survey

Age Rural Urban Total group Type of prescriber Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff (%) (%) (%)

<1 yr 33.6 28.4 -38.7 0.1 40.3 34.9-45.7 4.3 35.8 31.9-39.6 0.1 Allopathic >1 yr 48.9 45.4 –52.2 4.9 65.6 61.8-69.4 2.4 53.3 50.5-56.3 4.4

<1 yr 5.6 2.6-8.5 0.1 0.9 -0.1-1.9 0.03 4.1 2.0-6.1 0.1 Informally Qualified >1 yr 19.3 16.4-22.3 5.9 5.7 4.2-7.8 1.6 15.7 13.5-17.9 5.2

<1 yr 5.4 2.4-8.3 0.1 3.9 1.8-6.1 0.04 4.9 2.8-7.0 0.1 ISM >1 yr 8.7 6.9-10.5 4.4 10.1 7.7-12.6 2.6 9.1 7.6-10.6 3.9

<1 yr 53.9 48.9-58.9 0.1 54.2 47.9-60.5 0.1 54.0 50.1-57.9 0.1 Paramedics * >1 yr 16.2 13.9-18.5 4.3 14.9 12.1-17.7 2.3 15.9 13.9-17.7 3.8

<1 yr 1.8 0.03-3.4 0.1 1.6 0.04-2.8 0.03 1.7 0.06-2.9 0.1 Self/ friends >1 yr 8.5 4.1-12.9 26.2 4.8 2.9-6.7 3.1 7.5 4.2-10.8 22.3

Table 4.5.6 Injections Given by Paramedics (as % of All Injections) - Community Survey

Rural Urban Total

Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 44.9 35.1-54.7 2.2 64.6 56.3-72.9 1.2 53.3 46.3-60.3 1.9 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 37.5 32.1-42.9 2.1 47.6 39.7-55.5 1.1 39.5 34.9-44.2 1.9

Zone 3 (Bihar & Jharkhand) 38.8 22.1-55.5 19.3 76.9 63.6-90.3 2.0 42.9 27.8-58.2 17.5

Zone 4 (West Bengal & Andaman & Nicobar Islands) 68.8 60.7-76.8 1.9 66.4 57.0-75.8 0.8 68.2 61.7-74.6 1.6

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 70.1 58.3-81.9 1.8 75.6 63.5-87.6 0.3 70.8 60.2-81.4 1.6

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 85.4 77.6-93.1 0.3 89.8 83.6-95.9 0.1 86.3 80.1-92.6 0.3

Zone 7 (Rajasthan) 68.4 58.7-78.1 2.9 73.2 65.0-81.3 0.6 69.4 61.5-77.3 2.5

Zone 8 (Gujarat & Daman & Diu) 50.7 43.3-58.2 1.1 43.8 32.9-54.7 1.0 48.7 42.5-54.9 1.1

Zone 9 (Madhya Pradesh & Chattisgarh) 34.4 25.9-42.9 2.8 58.0 49.0-67.0 0.8 39.3 32.2-46.4 2.3

Zone 10 (Orrisa) 79.2 70.4-88.0 2.6 69.9 55.9-83.8 0.8 77.9 70.1-85.9 2.3

Zone 11 (Maharashtra & Goa) 32.6 24.7-40.5 2.2 26.5 19.8-33.3 2.2 29.3 24.2-34.4 2.2

Zone 12 (Andhra Pradesh) 41.9 34.1-49.8 2.9 57.2 48.0-66.4 1.5 46.2 39.9-52.5 2.5

Zone 13 (Karnataka) 33.8 24.8-42.8 2.7 43.4 33.9-52.8 1.1 36.6 29.6-43.5 2.3

Zone 14 (Tamil Nadu & Pondicherry) 59.4 50.9-67.8 3.1 52.4 46.1-58.6 0.9 56.9 50.9-63.0 2.4

Zone 15 (Kerala & Lakshad Island) 92.9 88.7-97.1 0.7 88.6 81.8-95.5 0.4 91.9 88.3-95.5 0.6

< 1 year 74.9 70.4-79.4 0.8 44.1 40.7-47.5 4.9 70.5 66.8-74.2 0.7

ALL INDIA ≥ 1 year 61.1 54.7-67.5 0.6 49.3 46.7-51.9 1.1 45.5 42.9-48.1 3.9

Total 48.1 44.9-51.2 4.5 51.3 48.8-53.8 1.1 48.9 46.4-51.5 4.2

Table 4.5.7 Proportion of Injections Given by Allopathic Practitioners - Community Survey

Rural Urban Total Zone Est (%) 95% CI Deff Est 95% CI Deff Est (%) 95% CI Deff (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 18.7 10.4-27.0 2.5 21.7 14.6-28.8 1.2 19.9 14.4-25.6 1.9 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 17.9 8.9-26.8 9.5 30.9 23.9-37.9 1.0 20.5 13.4-27.5 6.6

Zone 3 (Bihar & Jharkhand) 7.3 4.1-10.6 2.6 8.9 3.9-13.9 0.6 75.0 4.5-10.5 2.3

Zone 4 (West Bengal & Andaman & Nicobar Islands) 6.4 1.7-11.0 2.2 23.7 17.5-29.8 0.4 10.8 6.9-14.7 1.3

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 11.9 6.2-17.7 0.8 17.0 9.2-24.9 0.2 12.5 7.4-17.7 0.7

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 3.8 0.8-6.9 0.2 3.9 0.5-7.3 0.1 3.9 1.4-6.4 0.1

Zone 7 (Rajasthan) 20.3 12.4-28.1 2.6 17.9 11.7-24.0 0.4 19.8 13.4-26.2 2.2

Zone 8 (Gujarat & Daman & Diu) 32.2 24.2-40.2 1.5 42.6 31.7-53.5 1.0 35.3 28.8-41.8 1.3

Zone 9 (Madhya Pradesh & Chattisgarh) 19.6 12.3-26.9 2.9 23.5 15.6-31.3 0.8 20.4 14.4-26.4 2.4

Zone 10 (Orrisa) 12.1 6.0-18.2 1.9 18.8 11.1-26.4 0.3 13.0 7.6-18.4 1.6

Zone 11 (Maharashtra & Goa) 45.7 36.3-55.1 2.8 51.7 43.3-59.9 2.6 48.9 42.7-55.1 2.6

Zone 12 (Andhra Pradesh) 17.2 10.7-23.7 3.4 19.5 13.3-25.7 1.1 17.9 12.9-22.8 2.7

Zone 13 (Karnataka) 41.5 32.3-50.8 2.7 42.9 35.1-50.8 0.8 41.9 35.0-48.9 2.1

Zone 14 (Tamil Nadu & Pondicherry) 31.9 25.6-38.4 2.0 47.0 40.7-53.4 0.9 37.1 32.2-42.1 1.7

Zone 15 (Kerala & Lakshad Island) 2.6 0.1-5.1 0.7 9.0 2.9-15.2 0.4 4.1 1.6-6.6 0.6

< 1 year 14.1 10.6-17.6 0.1 21.4 18.8-23.9 4.2 20.1 17.0-23.2 0.6

ALL INDIA ≥ 1 year 32.7 26.7-38.7 0.5 33.7 30.6-36.9 1.7 24.7 22.6-26.8 3.4

Total 20.5 18.2-22.8 3.7 33.6 30.8-36.4 1.5 24.1 22.3-25.9 2.9

Table 4.5.8 Proportion of Injections Given by Informally Qualified Practitioners - Community Survey

Rural Urban Total Zone Est 95% CI Deff Est 95% CI Deff Est (%) 95% CI Deff (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 28.3 17.7-39.0 3.1 3.8 0.9-6.6 0.9 17.8 11.5-24.2 2.7 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 35.7 26.9-44.6 5.9 15.5 8.1-22.9 1.8 31.7 24.5-38.8 5.2

Zone 3 (Bihar & Jharkhand) 25.9 12.5-39.2 15.2 4.2 -1.5-9.8 1.6 23.5 11.8-35.2 14.1

Zone 4 (West Bengal & Andaman & Nicobar Islands) 19.9 12.4-27.3 2.2 9.9 1.6-18.3 1.6 17.3 11.3-23.3 2.1

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 3.7 -1.0-8.5 1.7 0.0 0.0-0.0 - 3.3 -0.9-7.5 1.7

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 10.0 3.0-16.9 0.3 1.6 -0.6-3.8 0.1 8.2 2.7-13.7 0.3

Zone 7 (Rajasthan) 7.1 0.4-13.8 4.7 3.4 -0.3-6.9 0.7 6.3 0.9-11.7 4.2

Zone 8 (Gujarat & Daman & Diu) 0.9 -0.4-2.4 1.0 0.6 -0.6-1.8 0.5 0.9 -0.2-1.9 0.9

Zone 9 (Madhya Pradesh & Chattisgarh) 37.6 28.7-46.5 2.9 8.6 3.9-13.4 0.7 31.5 24.2-38.9 2.8

Zone 10 (Orrisa) 4.3 0.1-8.6 2.4 0.4 -0.4-1.3 0.1 3.8 0.1-7.5 2.3

Zone 11 (Maharashtra & Goa) 1.1 -0.2-2.4 1.1 0.9 -0.3-2.2 1.6 10.3 0.1-1.9 1.4

Zone 12 (Andhra Pradesh) 33.3 24.3-42.3 4.2 15.8 8.5-22.9 1.8 28.4 21.6-35.2 3.6

Zone 13 (Karnataka) 15.1 6.4-23.9 4.5 3.6 -0.1-7.3 1.2 11.8 5.4-18.2 4.2

Zone 14 (Tamil Nadu & Pondicherry) 2.9 0.7-5.1 1.9 0.0 0.0-0.0 - 1.9 0.5-3.3 1.8

Zone 15 (Kerala & Lakshad Island) 0.6 -0.6-1.9 0.7 0.0 0.0-0.0 - 0.5 -0.5-1.5 0.7

< 1 year 7.4 3.9-10.9 0.1 21.6 18.4-24.7 6.3 5.6 3.1-7.9 0.1

ALL INDIA ≥ 1 year 1.6 -0.1-3.3 0.1 5.9 4.4-7.6 1.8 17.4 15.1-19.8 5.6

Total 19.8 16.9-22.7 6.0 5.3 3.9-6.7 1.6 15.9 13.7-17.9 5.5

Table 4.5.9 Proportion of Injections given by Practitioners of ISM - Community Survey

Rural Urban Total Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 7.5 2.6-12.4 1.9 7.5 3.1-11.9 1.2 7.5 4.1-10.9 1.6 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 9.5 3.8-15.3 6.7 5.9 0.9-10.9 1.9 8.8 4.1-13.5 5.9

Zone 3 (Bihar & Jharkhand) 2.2 0.2-4.1 3.1 0.5 -0.5-1.6 0.4 1.9 0.2-3.7 2.9

Zone 4 (West Bengal & Andaman & Nicobar Islands) 3.5 0.01-7.1 2.3 0.0 0.0-0.0 - 2.6 0.0-5.3 2.2

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 0 0.0-0.0 - 0.7 -0.7-2.2 0.1 0.1 -0.1-0.3 0.1

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 0 0.0-0.0 - 0.7 -0.7-2.3 0.1 0.2 -0.2-0.5 0.1

Zone 7 (Rajasthan) 3.8 0.9-6.6 1.5 4.5 1.4-7.6 0.4 3.9 1.6-6.3 1.3

Zone 8 (Gujarat & Daman & Diu) 15.1 7.9-22.3 2.0 12.9 7.1-18.8 0.7 14.5 9.2-19.8 1.6

Zone 9 (Madhya Pradesh & Chattisgarh) 7.4 2.9-11.9 2.6 9.3 1.2-17.3 1.8 7.8 3.8-11.8 2.4

Zone 10 (Orrisa) 3.9 0.9-6.8 1.2 0.0 0.0-0.0 - 3.4 0.8-5.9 1.3

Zone 11 (Maharashtra & Goa) 19.9 11.4-28.3 3.5 20.9 12.1-29.6 4.3 20.4 14.3-26.5 3.9

Zone 12 (Andhra Pradesh) 5.0 0.2-9.9 5.6 1.0 -0.05-2.1 0.5 3.9 0.4-7.4 5.3

Zone 13 (Karnataka) 9.5 2.9-16.1 3.8 9.6 2.1-17.1 2.0 9.5 4.4-14.7 3.3

Zone 14 (Tamil Nadu & Pondicherry) 3.2 0.4-5.9 2.6 0.9 -0.4-2.2 1.0 2.4 0.5-4.2 2.4

Zone 15 (Kerala & Lakshad Island) 1.3 -0.5-3.1 0.7 1.5 -0.6-3.7 0.3 1.3 -0.1-2.8 0.6

< 1 year 3.8 1.4-6.2 0.1 7.1 5.4-8.8 4.6 3.9 2.2-5.8 9.6

ALL INDIA ≥ 1 year 4.3 1.9-6.8 0.1 8.7 6.3-11.2 2.9 7.6 6.2-8.9 4.1

Total 6.7 5.2-8.3 4.3 8.1 5.8-10.3 2.9 7.1 5.9-8.3 3.5

Table 4.5.10 Proportion of Injections Given by Others (Self / Friends) - Community Survey

Rural Urban Total Zone Est Est 95% CI Deff Est (%) 95% CI Deff 95% CI Deff (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 0.5 -0.5-1.6 1.2 2.8 0.3-5.4 0.9 1.5 0.3-2.8 1.0 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 0.6 -0.5-1.7 3.7 0.0 0.0-0.0 - 0.5 -0.4-1.4 3.8

Zone 3 (Bihar & Jharkhand) 28.0 6.5-49.5 36.9 10.9 -6.3-28.3 6.2 26.1 6.7-45.6 35.6

Zone 4 (West Bengal & Andaman & Nicobar Islands) 2.1 -0.2-4.5 1.7 2.3 -1.1-5.7 1.1 2.2 0.2-4.1 1.5

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 8.9 0.5-17.5 2.2 24.4 -5.4-54.3 1.2 10.8 2.5-19.1 1.9

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 1.5 -0.7-3.7 0.2 1.6 -0.6-3.8 0.1 1.5 -0.2-0.3 0.2

Zone 7 (Rajasthan) 0.9 -0.9-2.8 2.6 0.0 0.0-0.0 - 0.8 -0.7-2.3 2.6

Zone 8 (Gujarat & Daman & Diu) 0.9 -0.9-2.9 1.9 0.0 0.0-0.0 - 0.7 -0.7-2.0 1.9

Zone 9 (Madhya Pradesh & Chattisgarh) 0.5 -0.5-1.6 1.8 1.2 -0.4-2.9 0.6 0.7 -0.2-1.6 1.4

Zone 10 (Orrisa) 0.9 -0.9-2.8 2.6 0.0 0.0-0.0 - 2.6 -0.3-5.5 2.1

Zone 11 (Maharashtra & Goa) 0.5 -0.5-1.6 1.8 1.2 -0.4-2.9 0.5 0.5 -0.2-1.2 1.7

Zone 12 (Andhra Pradesh) 0.8 -0.8-2.6 1.8 13.9 -3.4-31.3 2.1 3.4 -0.5-7.4 7.6

Zone 13 (Karnataka) 0.0 0.0-0.0 - 0.9 -0.4-2.3 1.7 0.1 -0.1-0.4 0.5

Zone 14 (Tamil Nadu & Pondicherry) 1.8 0.004-3.5 2.0 0.0 0.0-0.0 - 0.1 -0.1-0.3 0.7

Zone 15 (Kerala & Lakshad Island) 0.0 0.0-0.0 - 0.3 -0.3-1.2 0.0 1.2 -0.3-2.6 0.6

< 1 year 0.3 -0.1-0.6 3.9 5.5 1.4-9.6 34.9 0.5 0.4-0.9 0.4

ALL INDIA ≥ 1 year 0.0 -0.2-1.9 4.7 2.8 0.8-4.7 5.4 4.8 1.7-7.8 30.4

Total 4.8 1.2-8.5 32.6 2.5 0.7-4.3 5.7 4.2 1.5-6.9 29.8

Table 4.5.11 Profile of Injection Givers (Proportion of all Health Facilities) – Prescriber Interview *

Injection Giver Government Health Facilities Private Health Facilities Total

Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff (%) (%) (%)

Doctor Rural 22.8 18.7-26.9 2.1 71.2 67.3-75.1 1.6 58.9 56.0-61.9 1.5

Urban 20.2 15.8-24.5 0.9 57.1 52.4-61.7 0.7 47.8 44.0-51.6 0.9

Total 22.1 19.1-25.0 1.6 67.2 63.9-70.5 1.5 55.8 53.3-58.4 1.7

Rural 95.2 93.5-96.9 1.4 31.9 27.4-36.3 1.9 47.9 44.4-51.4 2.1

Paramedic Urban 94.2 91.6-96.7 0.9 50.5 46.0-55.1 0.7 61.5 58.2-64.8 0.8

Total 94.9 93.5-96.4 1.3 37.1 33.8-40.5 1.5 51.7 49.2-54.3 1.6

Rural 10.0 6.6-13.5 2.9 20.7 16.7-24.7 2.1 18.0 14.7-21.3 3.3 Helper/ Urban 6.9 4.9-9.1 0.6 18.2 13.9-22.5 1.0 15.4 12.4-18.5 1.2 Attendant Total 9.2 6.8-11.5 2.1 20.0 17.0-23.0 1.8 17.3 14.9-19.7 2.6

* Multiple answers

Table 4.5.12 Profile Of Injection Givers (Proportion of Health Facilities) – Direct Observation*

Government Health Facilities Private Health Facilities Immunization Clinics Total

Injection Giver Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff (%) (%) (%) (%)

Rural 95.1 93.4-96.8 1.4 29.4 25.6-33.3 1.5 98.1 96.7-99.5 2.3 49.4 46.6-52.3 2.1

Paramedic Urban 94.9 92.1-97.9 1.5 47.5 42.9-52.1 0.7 96.2 94.3-98.1 0.9 61.9 58.7-65.2 1.2

Total 95.1 93.5-96.6 1.6 34.5 31.2-37.8 1.5 97.6 96.6-98.6 1.3 52.9 50.6-55.3 2.1

Rural 7.4 4.6-10.2 2.5 22.2 18.2-26.2 2.0 2.4 0.9-3.9 2.1 17.4 14.5-20.2 3.7 Helper/

Attendant Urban 5.4 3.6-7.2 0.5 18.3 14.3-22.2 0.9 3.8 2.4-5.2 0.5 14.3 11.6-17.0 1.5

Total 6.9 4.9-8.8 1.9 21.1 18.0-24.1 1.7 2.8 1.7-3.9 1.3 16.5 14.3-18.7 3.2

Rural 8.6 6.4-10.8 1.3 65.6 61.5-69.7 1.6 2.5 0.9-4.1 2.3 48.0 45.1-50.9 2.3

Doctor Urban 7.1 3.7-10.4 1.4 49.3 44.5-54.2 0.8 3.8 1.6-5.9 1.1 36.3 32.7-39.9 1.5

Total 8.2 6.5-9.8 1.2 61.0 57.7-64.4 1.5 2.8 1.6-4.1 1.8 44.7 42.3-47.2 2.2

* Multiple answers

Table 4.5.13 Profile of Injection Givers for <1 and ≥1 Year Age Group (Proportion of all Injections given) – Community Survey

Rural Urban Total

Type of prescriber Age Groups Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff (%) (%) (%)

<1 yr 14.1 10.6-17.6 0.1 21.4 18.8-23.9 4.2 20.1 17.0 - 23.2 0.6 Allopathic >1 yr 32.7 26.7-38.7 0.5 33.7 30.6-36.9 1.7 24.7 22.6 - 26.8 3.4

<1 yr 7.4 3.9-10.9 0.1 21.6 18.4-24.7 6.3 5.6 3.1 - 7.9 0.1 Informally Qualified >1 yr 1.6 -0.1-3.3 0.1 5.9 4.4-7.6 1.8 17.4 15.1-19.8 5.6

<1 yr 3.8 1.4-6.2 0.1 7.1 5.4-8.8 4.6 3.9 2.2-5.8 9.6 ISM >1 yr 4.3 1.9-6.8 0.1 8.7 6.3-11.2 2.9 7.6 6.2-8.9 4.1

<1 yr 74.9 70.4-79.4 0.8 44.1 40.7-47.5 4.9 70.5 66.8-74.2 0.7 Paramedics & others >1 yr 61.1 54.7-67.5 0.6 49.3 46.7-51.9 1.1 45.5 42.9-48.1 3.9

<1 yr 0.3 -0.1-0.6 3.9 5.5 1.4-9.6 34.9 0.5 0.4-0.9 0.4 Self/ friends >1 yr 0.0 -0.2-1.9 4.7 2.8 0.8-4.7 5.4 4.8 1.7-7.8 30.4

Table 4.5.14 Formal Training Received by Injection Givers (Proportion of Health Facilities) – Prescriber Interview

Type of Training Government Health Facilities Private Health Facilities Total

Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff (%) (%) (%)

Rural 92.1 89.6-94.6 1.9 43.7 39.9-47.4 1.2 55.9 53.1-58.9 1.5 Formal Training

Urban 94.9 92.6-97.2 0.9 62.3 58.5-66.1 0.5 70.5 67.7-73.4 0.7

Total 92.9 90.7-95.0 2.2 48.9 45.4-52.4 1.5 60.0 57.3-62.7 1.9

Rural 8.9 6.1-11.9 2.2 53.9 49.2-58.6 1.9 42.5 38.8-46.3 2.5

On Job Training Urban 6.5 3.7-9.4 1.1 37.1 33.2-41.1 0.6 29.4 26.6-32.3 0.7

Total 8.3 6.1-10.5 1.9 49.2 45.7-52.7 1.5 38.9 36.2-41.6 1.9

Rural 1.8 0.5-3.2 2.1 6.9 4.5-9.4 2.1 5.6 3.6-7.7 3.3

Informal Training Urban 1.5 0.4-2.5 0.6 4.8 2.8-6.9 0.8 3.9 2.4-5.5 1.1

Total 1.7 0.7-2.8 1.9 6.3 4.6-8.1 1.6 5.2 3.8-6.5 2.3

Table 4.5.15 On-The-Job Training Received by Injection Givers (Proportion of Health Facilities) – Prescriber Interview

Government Health Private Health Facilities Total Facilities Zone Est % 95% CI Deff Est % 95% CI Deff Est % 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 3.9 -0.6-8.5 1.1 49.3 38.0-60.6 0.9 37.6 28.9-46.4 1.3 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 11.0 3.0-18.9 3.4 69.5 57.4-81.5 3.6 54.8 45.4-64.1 3.7

Zone 3 (Bihar & Jharkhand) 22.8 11.1-34.5 2.5 76.5 64.8-88.2 2.5 63.0 53.7-72.3 2.4

Zone 4 (West Bengal & Andaman & Nicobar Islands) 9.3 1.9-16.7 1.5 56.3 44.0-68.7 1.5 44.5 34.6-54.4 1.9

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 9.6 0.9-18.3 0.8 31.8 19.0-44.6 0.7 26.4 15.5-37.3 1.1

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 7.5 0.7-14.4 0.2 26.3 14.8-37.7 0.2 21.6 13.1-30.1 0.2

Zone 7 (Rajasthan) 0.6 -0.6-1.7 0.4 30.6 18.7-42.5 1.1 22.8 13.9-31.6 1.5

Zone 8 (Gujarat & Daman & Diu) 0.9 -0.9-2.6 0.5 27.4 16.8-37.9 0.9 20.7 12.8-28.6 1.2

Zone 9 (Madhya Pradesh & Chattisgarh) 3.1 -1.1-7.2 1.4 61.5 49.3-73.7 1.5 46.8 37.4-56.1 1.7

Zone 10 (Orrisa) 11.2 2.2-20.2 0.9 30.1 17.0-43.1 0.9 25.2 15.0-35.3 1.2

Zone 11 (Maharashtra & Goa) 4.0 -0.6-8.6 1.6 18.0 9.1-26.9 1.6 14.5 7.8-21.1 2.1

Zone 12 (Andhra Pradesh) 9.3 1.9-16.6 1.4 65.5 54.6-76.4 1.2 51.3 42.7-59.9 1.3

Zone 13 (Karnataka) 5.9 -0.03-11.8 0.9 25.2 14.6-35.9 0.9 20.3 12.2-28.5 1.3

Zone 14 (Tamil Nadu & Pondicherry) 4.9 -0.6-10.4 1.2 37.2 25.9-48.5 1.0 29.1 20.3-37.8 1.4

Zone 15 (Kerala & Lakshad Island) 6.1 -0.1-12.4 0.7 28.5 17.2-39.8 0.6 22.9 13.9-31.8 0.9

Rural 8.9 6.1-11.9 2.2 53.9 49.2-58.6 1.9 42.5 38.8-46.3 2.5

ALL INDIA Urban 6.5 3.7-9.4 1.1 37.1 33.2-41.1 0.6 29.4 26.6-32.3 0.7

Total 8.3 6.1-10.5 1.9 49.2 45.7-52.7 1.5 38.9 36.2-41.6 1.9

Table 4.5.16 Informally Trained Injection Givers (Proportion of Health Facilities) – Prescriber Interview

Government Health Private Health Facilities Total Facilities Zone Est % 95% CI Deff Est % 95% CI Deff Est % 95% CI Deff

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 3.9 -0.6-8.5 1.1 14.7 6.4-23.1 1.1 11.9 5.5-18.4 1.6 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 1.9 -1.9-5.9 4.2 2.5 -1.6-6.6 3.6 2.4 -0.8-5.6 4.6

Zone 3 (Bihar & Jharkhand) 2.5 -1.9-6.9 2.6 11.5 2.3-20.7 2.7 9.2 2.3-16.2 3.7

Zone 4 (West Bengal & Andaman & Nicobar Islands) 5.7 0.1-11.2 1.4 7.9 0.9-15.1 1.6 7.4 1.9-12.8 2.0

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 0 0-0 - 9.2 0.9-17.5 0.8 6.9 0.7-13.2 1.1

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 5.0 -0.6-10.7 0.2 6.9 0.2-13.6 0.2 6.4 1.3-11.6 0.2

Zone 7 (Rajasthan) 0 0-0 - 12.2 3.6-20.7 1.1 9.0 2.7-15.4 1.6

Zone 8 (Gujarat & Daman & Diu) 1.8 -0.7-4.2 0.5 1.8 -0.7-4.2 0.5 1.8 -0.4-3.9 0.8

Zone 9 (Madhya Pradesh & Chattisgarh) 1.9 -1.9-5.7 1.9 3.1 -1.1-7.2 1.4 2.8 -0.4-6.0 1.9

Zone 10 (Orrisa) 0 0-0 - 11.4 2.1-20.8 0.9 8.5 1.5-15.4 1.3

Zone 11 (Maharashtra & Goa) 0 0-0 - 8.5 2.2-14.8 1.5 6.4 1.6-11.1 2.2

Zone 12 (Andhra Pradesh) 0.7 -0.7-2.0 0.6 3.2 -0.9-7.3 1.2 2.6 -0.5-5.6 1.7

Zone 13 (Karnataka) 1.7 -1.2-5.1 1.1 1.7 -1.6-5.0 1.0 1.7 -0.9-4.3 1.3

Zone 14 (Tamil Nadu & Pondicherry) 0 0-0 - 3.3 -1.3-7.8 1.2 2.4 -0.9-5.8 1.8

Zone 15 (Kerala & Lakshad Island) 0 0-0 - 0 0-0 - 0 0-0 -

Rural 1.8 0.5-3.2 2.1 6.9 4.5-9.4 2.1 5.6 3.6-7.7 3.3

ALL INDIA Urban 1.5 0.4-2.5 0.6 4.8 2.8-6.9 0.8 3.9 2.4-5.5 1.1

Total 1.7 0.7-2.8 1.9 6.3 4.6-8.1 1.6 5.2 3.8-6.5 2.3

Table 4.5.17 Sterilization of Injection Equipment done by Paramedics (Proportion of Health Facilities) – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal 43.6 32.4-54.8 1.0 11.0 3.6-18.4 1.1 45.6 34.5-56.7 0.9 20.9 15.2-26.8 1.2 Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 52.5 39.4-65.6 3.6 11.0 3.0-18.9 3.4 66.9 54.7-79.3 3.6 24.5 18.7-30.3 2.9

Zone 3 (Bihar & Jharkhand) 45.9 32.0-59.9 2.6 19.8 9.1-30.5 2.4 40.2 26.3-54.1 2.6 27.3 17.6-37.0 4.6

Zone 4 (West Bengal & Andaman & Nicobar 82.8 74.1-91.4 1.3 5.0 -0.4-10.4 1.5 88.3 81.8-94.7 0.9 28.9 24.4-33.3 0.7 Islands)

Zone 5 (Assam, Arunachal Pradesh, 70.9 57.9-83.9 0.7 21.6 9.8-33.4 0.7 74.3 61.7-86.9 0.8 36.7 28.2-45.3 0.9 Meghalaya & Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & 52.8 39.9-65.6 0.2 10.3 3.1-17.5 0.1 49.7 36.9-62.6 0.2 22.9 16.9-29.1 0.2 Tripura)

Zone 7 (Rajasthan) 42.5 29.8-55.2 1.1 6.2 0.4-11.9 0.9 54.8 42.3-67.4 1.1 17.9 12.7-23.2 0.9

Zone 8 (Gujarat & Daman & Diu) 57.4 45.8-68.9 0.8 10.7 3.6-17.8 0.8 60.5 48.9-71.9 0.8 24.8 18.3-31.4 1.1

Zone 9 (Madhya Pradesh & Chattisgarh) 53.9 41.4-66.6 1.5 11.2 3.4-18.9 1.5 39.1 26.9-51.3 1.5 23.1 16.5-29.7 1.8

Zone 10 (Orrisa) 33.7 20.4-46.9 0.9 12.8 3.6-22.1 0.8 33.2 20.1-46.3 0.8 19.1 11.1-27.1 1.4

Zone 11 (Maharashtra & Goa) 60.9 50.4-71.5 1.4 18.5 9.6-27.4 1.5 57.5 46.4-68.6 1.5 31.1 24.1-38.0 1.9

Zone 12 (Andhra Pradesh) 84.1 75.6-92.6 1.2 17.3 8.6-25.9 1.2 57.9 45.3-70.4 1.4 35.6 29.2-42.1 1.2

Zone 13 (Karnataka) 70.9 60.1-81.7 0.9 9.8 3.6-16.0 0.7 67.8 57.1-78.5 0.8 28.0 22.7-33.4 0.7

Zone 14 (Tamil Nadu & Pondicherry) 72.4 62.0-82.8 1.0 32.7 21.9-43.5 0.9 85.4 79.1-91.6 0.6 45.6 37.2-53.9 1.6

Zone 15 (Kerala & Lakshad Island) 38.7 26.8-50.6 0.6 40.3 28.1-52.5 0.6 71.5 60.2-82.8 0.6 41.9 33.1-50.9 0.9

Rural 59.6 54.5-64.8 2.4 13.6 11.0-16.1 1.2 62.6 57.9-67.2 1.9 27.7 25.2-30.1 1.9

ALL INDIA Urban 54.6 50.2-59.0 0.7 18.6 15.5-21.6 0.5 52.8 48.1-57.5 0.7 29.3 27.3-31.4 0.5

Total 58.2 54.6-61.8 1.7 14.9 12.5-17.5 1.5 59.8 56.3-63.3 1.6 28.1 26.1-30.1 1.8

Table 4.5.18 Sterilization of Injection Equipment done by Paramedics (Proportion of Health Facilities) – Prescriber Interview

Government Health Facilities Private Health Facilities Total Zone Est (%) 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 42.9 31.8-53.9 1.0 7.6 1.5-13.8 1.0 16.7 10.9-22.4 0.9 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 62.5 49.9-75.1 3.5 15.0 5.6-24.4 3.6 26.9 18.8-35.1 3.5

Zone 3 (Bihar & Jharkhand) 42.2 28.3-56.0 2.6 12.5 3.2-21.8 2.6 19.9 11.4-28.6 3.0

Zone 4 (West Bengal & Andaman & Nicobar Islands) 93.7 87.9-99.3 1.3 11.2 3.1-19.2 1.6 31.9 26.1-37.7 0.7

Zone 5 (Assam, Arunachal Pradesh, Meghalaya & Sikkim) 80.9 69.9-91.9 0.7 25.5 13.3-37.6 0.7 38.9 29.2-48.7 0.7

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 54.5 41.7-67.3 0.2 9.6 2.6-16.7 0.1 20.8 13.9-27.7 0.1

Zone 7 (Rajasthan) 52.3 39.9-64.7 1.1 5.7 -0.1-11.5 1.0 17.8 12.4-23.1 0.7

Zone 8 (Gujarat & Daman & Diu) 72.7 63.5-82.0 0.7 14.9 6.3-23.4 0.9 29.4 22.6-36.3 0.7

Zone 9 (Madhya Pradesh & Chattisgarh) 55.9 43.3-68.5 1.6 9.3 2.3-16.2 1.4 21.0 14.3-27.7 1.3

Zone 10 (Orrisa) 24.4 12.4-36.3 0.9 10.9 2.3-19.6 0.8 14.5 7.9-21.0 0.7

Zone 11 (Maharashtra & Goa) 65.5 54.6-76.3 1.5 16.9 8.5-25.5 1.5 29.2 22.2-36.3 1.4

Zone 12 (Andhra Pradesh) 77.5 67.2-87.8 1.4 21.8 11.5-32.1 1.4 35.8 27.8-43.9 1.3

Zone 13 (Karnataka) 74.9 64.4-85.4 0.9 9.7 4.1-15.3 0.6 26.1 21.4-30.8 0.4

Zone 14 (Tamil Nadu & Pondicherry) 74.8 64.9-84.7 0.9 34.0 22.8-45.3 1.1 44.3 35.2-53.4 1.3

Zone 15 (Kerala & Lakshad Island) 65.8 54.1-77.4 0.6 45.1 32.8-57.4 0.6 50.3 40.8-59.8 0.7

Rural 64.0 59.4-68.7 2.1 15.8 12.2-19.4 2.1 27.9 24.8-31.2 2.2

ALL INDIA Urban 59.9 54.6-65.1 0.9 15.4 12.1-18.7 0.7 26.6 23.6-29.6 0.8

Total 62.9 59.4-66.3 1.6 15.7 13.1-18.3 1.6 27.6 25.4-29.8 1.6

Table 4.5.19 Sterilization of Injection Equipment done by Helper/ Attendants (Proportion of Health Facilities) – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities Zone Est. 95% CI Deff Est. 95% CI Deff Est. 95% CI Deff Est. 95% CI Deff (%) (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu & Kashmir & 30.6 20.2-40.9 1.0 17.0 8.3-25.8 1.1 19.5 10.3-28.7 1.1 20.4 13.7-27.0 1.6 Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 24.5 13.1-35.8 3.6 14.0 5.2-22.8 3.3 15.9 6.1-25.9 3.8 16.6 9.0-24.2 6.5 Zone 3 (Bihar & Jharkhand) 12.2 2.9-21.4 2.6 9.7 1.3-18.1 2.6 8.0 0.4-15.6 2.5 10.2 4.0-16.3 4.0 Zone 4 (West Bengal & Andaman & 28.4 17.5-39.3 1.4 14.8 5.7-23.9 1.6 10.9 3.8-17.9 1.2 17.7 11.0-24.4 2.2 Nicobar Islands) Zone 5 (Assam, Arunachal Pradesh, 10.9 2.3-19.4 0.7 16.9 6.2-27.7 0.7 18.1 7.3-28.9 0.7 15.6 7.5-23.7 1.4 Meghalaya & Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & 36.1 23.6-48.7 0.2 10.6 2.8-18.5 0.2 31.1 18.9-43.3 0.2 18.0 11.8-24.2 0.2 Tripura) Zone 7 (Rajasthan) 15.2 5.7-24.7 1.2 2.5 -1.5-6.5 1.1 12.7 3.8-21.6 1.2 6.2 1.9-10.4 1.6 Zone 8 (Gujarat & Daman & Diu) 19.9 10.4-29.4 0.9 13.3 5.7-20.8 0.8 12.7 5.2-20.3 0.8 14.8 8.8-20.7 1.3 Zone 9 (Madhya Pradesh & Chattisgarh) 23.8 12.9-34.8 1.6 13.5 5.5-21.5 1.3 13.8 4.8-22.8 1.6 15.9 9.5-22.4 2.2 Zone 10 (Orrisa) 27.2 14.7-39.6 0.9 13.2 3.9-22.4 0.8 16.8 6.2-27.4 0.9 16.7 10.1-23.3 1.0 Zone 11 (Maharashtra & Goa) 24.0 14.2-33.8 1.6 13.9 6.3-21.7 1.4 22.5 12.8-32.2 1.6 16.9 10.7-23.2 2.5 Zone 12 (Andhra Pradesh) 16.1 6.9-25.4 1.4 19.6 9.3-29.8 1.5 2.9 0.1-5.6 0.6 17.7 10.1-25.2 2.6 Zone 13 (Karnataka) 15.1 6.3-23.9 0.9 13.3 5.3-21.3 0.9 17.4 8.6-26.2 0.9 13.9 7.6-20.4 1.6 Zone 14 (Tamil Nadu & Pondicherry) 25.8 15.4-36.1 1.1 24.9 14.6-35.2 1.1 7.7 2.4-13.0 0.7 23.9 16.2-31.7 1.9 Zone 15 (Kerala & Lakshad Island) 41.4 29.2-53.7 0.6 12.9 4.3-21.6 0.6 22.4 12.0-32.7 0.6 20.3 13.8-26.8 0.8 Rural 23.2 19.4-26.9 1.7 14.5 10.7-18.2 2.5 12.9 9.8-16.1 1.9 16.4 13.6-19.3 3.9 Urban 20.1 15.7-24.4 0.9 13.2 9.8-16.7 0.9 17.1 13.4-20.7 0.8 15.1 12.4-17.8 1.4 ALL INDIA Total 22.3 19.2-25.4 1.7 14.1 11.6-16.7 1.6 14.1 11.6-16.7 1.7 16.1 14.0-18.1 2.8

Table 4.5.20 Sterilization of Injection Equipment done by Helper/ Paramedics (Proportion of Health Facilities) - Prescriber Interview

Government Health facilities Private Health Facilities Total Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%)

Zone 1(Chandigarh, Delhi, Punjab, Himachal Pradesh, 29.1 18.7-39.6 1.1 9.7 2.6-16.7 1.1 14.7 8.7-20.6 1.1 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 30.5 18.5-42.6 3.6 9.5 2.4-16.6 3.1 14.8 8.6-20.9 3.1

Zone 3 (Bihar & Jharkhand) 15.3 5.3-25.3 2.5 5.0 -1.1-11.1 2.6 7.6 2.6-12.6 2.3

Zone 4 (West Bengal & Andaman & Nicobar Islands) 24.3 13.6-35.0 1.5 11.6 3.2-20.1 1.7 14.8 7.4-22.2 2.1

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 9.6 9.7-18.3 0.8 9.2 0.9-17.5 0.8 9.3 2.4-16.3 1.1

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 34.9 22.5-47.4 0.2 10.5 2.7-18.2 0.2 16.6 10.6-22.6 0.1

Zone 7 (Rajasthan) 14.2 5.2-23.1 1.1 5.7 -0.1-11.5 1.0 7.9 2.6-13.1 1.3

Zone 8 (Gujarat & Daman & Diu) 15.0 6.6-23.4 0.8 5.0 -0.1-10.1 0.8 7.5 3.2-11.9 0.8

Zone 9 (Madhya Pradesh & Chattisgarh) 35.3 22.9-47.6 1.6 9.3 2.3-16.2 1.4 15.8 9.8-21.8 1.3

Zone 10 (Orrisa) 26.8 14.5-39.2 0.9 9.6 1.0-18.1 0.9 14.1 6.1-22.1 1.1

Zone 11 (Maharashtra & Goa) 21.9 12.9-31.1 1.4 9.5 2.9-16.1 1.5 12.6 7.2-18.1 1.6

Zone 12 (Andhra Pradesh) 27.3 16.1-38.5 1.4 10.0 2.6-17.4 1.4 14.4 8.1-20.6 1.4

Zone 13 (Karnataka) 18.4 8.9-27.8 0.9 11.7 3.9-19.5 0.9 13.4 6.9-19.8 1.1

Zone 14 (Tamil Nadu & Pondicherry) 28.6 18.3-38.8 0.9 13.4 5.4-21.3 1.0 17.2 10.7-23.7 1.1

Zone 15 (Kerala & Lakshadweep Island) 41.4 29.2-53.7 0.6 8.1 1.5-14.7 0.6 16.5 11.2-21.8 0.4

Rural 26.2 22.2-30.1 1.8 9.0 6.3-11.8 2.0 13.4 10.9-15.8 2.2

ALL INDIA Urban 21.2 17.0-25.5 0.9 9.3 6.1-12.5 1.0 12.3 9.7-14.9 1.1

Total 24.8 21.6-28.0 1.7 9.1 7.0-11.2 1.6 13.1 11.3-14.8 1.7

Table 4.5.21 Availability of Written Guidelines for Sterilization of Injection Equipment (Proportion of Health Facility) -- Prescriber Interview

Government Health Facilities Private Health Facilities Total

Zone Est 95% CI Deff Est 95% CI Deff Est (%) 95% CI Deff (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 20.2 10.9-29.5 1.1 6.1 0.7-11.5 1.0 9.7 4.8-14.7 1.1 Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 23.9 12.5-35.5 3.8 0.5 -0.5-1.5 1.0 6.4 3.4-9.4 1.6

Zone 3 (Bihar & Jharkhand) 13.8 4.5-23.1 2.4 0.3 -0.3-0.9 0.4 3.7 1.3-6.1 1.1

Zone 4 (West Bengal & Andaman & Nicobar Islands) 7.7 1.8-13.6 1.2 1.3 -0.5-3.2 0.6 2.9 0.9-4.9 0.7

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 12.5 2.9-22.0 0.7 2.2 -2.1-6.5 0.8 4.7 0.8-8.6 0.6

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 5.6 -0.2-11.3 0.2 1.6 -0.2-3.5 0.1 2.6 0.7-4.6 0.1

Zone 7 (Rajasthan) 23.8 13.1-34.5 1.1 6.1 1.2-10.9 0.7 10.7 6.2-15.1 0.7

Zone 8 (Gujarat & Daman & Diu) 20.0 10.6-29.4 0.8 4.3 -0.1-8.6 0.7 8.2 4.4-12.1 0.6

Zone 9 (Madhya Pradesh & Chattisgarh) 21.0 11.1-30.9 1.4 2.4 0.1-4.6 0.5 7.1 4.2-9.9 0.6

Zone 10 (Orrisa) 20.2 9.1-31.2 0.8 15.7 5.5-25.9 0.8 16.9 8.0-25.7 1.2

Zone 11 (Maharashtra & Goa) 46.5 35.1-57.9 1.5 15.0 6.8-23.2 1.6 22.9 15.9-30.0 1.7

Zone 12 (Andhra Pradesh) 26.4 15.6-37.2 1.4 7.0 1.2-12.9 1.2 11.9 6.1-17.8 1.5

Zone 13 (Karnataka) 36.5 25.1-47.8 0.9 4.2 -0.8-9.2 0.9 12.3 7.9-16.7 0.6

Zone 14 (Tamil Nadu & Pondicherry) 26.9 17.0-36.9 0.9 8.5 2.5-14.5 0.9 13.1 7.5-18.8 1.1

Zone 15 (Kerala & Lakshadweep Island) 28.1 17.2-38.9 0.7 26.0 15.0-37.0 0.6 26.5 18.1-35.0 0.7

Rural 20.9 17.1-24.8 1.9 3.9 2.7-5.1 0.9 8.2 6.8-9.6 1.2

ALL INDIA Urban 30.5 26.2-34.7 0.7 9.8 6.4-13.1 1.1 14.9 12.2-17.8 1.0

Total 23.6 20.5-26.7 1.6 5.5 4.3-6.8 0.9 10.1 8.8-11.4 1.1

Table 4.5.22 Proportion of Health Facilities where Sterilization Equipment was Available – Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu & Kashmir & 85.0 76.8-93.2 1.0 63.5 52.4-74.6 1.0 84.0 75.6-92.4 1.0 69.9 61.1-78.8 2.2 Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 75.0 63.6-86.4 3.6 48.9 35.9-62.1 3.6 81.9 72.4-91.5 3.2 57.3 47.2-67.4 6.5

Zone 3 (Bihar & Jharkhand) 77.2 65.5-88.9 2.5 57.5 43.6-71.4 2.6 67.9 54.9-81.1 2.5 62.8 52.2-73.5 4.7

Zone 4 (West Bengal & Andaman & 87.7 79.2-96.2 1.6 30.2 18.9-41.4 1.4 86.8 78.5-95.1 1.4 47.5 39.1-55.9 2.0 Nicobar Islands)

Zone 5 (Assam, Arunchal Pradesh, 91.6 84.1-99.1 0.7 54.4 40.3-68.5 0.7 87.8 78.4-97.2 0.7 65.4 54.7-76.1 1.4 Meghalaya & Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & 93.3 87.5-99.2 0.1 48.0 35.3-60.7 0.2 87.5 78.9-96.0 0.2 61.3 51.9-70.7 0.3 Tripura)

Zone 7 (Rajasthan) 75.6 64.5-86.6 1.1 61.2 48.6-73.7 1.1 76.5 66.1-86.9 1.0 65.6 56.2-74.9 1.9

Zone 8 (Gujarat & Daman & Diu) 95.6 91.9-99.3 0.5 63.2 52.1-74.3 0.8 76.6 66.5-86.7 0.9 71.6 63.6-79.7 1.5

Zone 9 (Madhya Pradesh & Chattisgarh) 90.6 83.0-98.2 1.6 67.1 55.3-78.8 1.5 64.3 51.9-76.6 1.6 72.4 64.0-80.8 2.6

Zone 10 (Orrisa) 77.8 66.2-89.5 0.9 47.7 33.8-61.6 0.8 59.0 45.2-72.8 0.9 55.5 43.9-67.2 1.8

Zone 11 (Maharashtra & Goa) 76.5 67.1-85.9 1.4 50.5 39.0-61.9 1.5 67.0 56.3-77.7 1.5 57.7 48.9-66.6 2.8

Zone 12 (Andhra Pradesh) 91.1 84.4-97.9 1.3 66.1 54.5-77.8 1.4 70.6 58.9-82.3 1.4 72.3 63.6-81.0 2.5

Zone 13 (Karnataka) 94.2 88.8-99.6 0.9 72.0 61.9-82.1 0.8 88.6 82.1-95.1 0.7 78.3 71.3-85.3 1.4

Zone 14 (Tamil Nadu & Pondicherry) 94.1 88.7-99.5 0.9 79.2 69.6-88.9 1.1 85.8 77.7-93.8 1.0 83.2 76.3-90.1 1.9

Zone 15 (Kerala & Lakshadweep Island) 98.7 96.9-100.5 0.2 76.9 66.6-87.4 0.6 89.3 82.3-96.3 0.5 82.9 75.5-90.3 1.1

Rural 83.8 79.6-88.1 2.9 57.6 52.3-62.9 2.5 77.8 72.9-82.6 2.9 65.1 61.1-69.1 4.6

ALL INDIA Urban 85.3 82.6-87.9 0.5 57.9 52.6-63.1 0.9 74.9 71.1-78.6 0.6 65.4 61.6-69.3 1.7

Total 84.2 81.4-87.1 1.9 57.7 54.1-61.3 1.7 76.9 73.9-80.0 1.6 65.2 62.5-67.9 3.1

Table 4.5.23 Proportion of Health Facilities where Available Sterilization Equipment was Found Functional – Direct Observation

Government Health Private Health Immunization Clinic Total Facilities Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu & Kashmir & 78.9 69.5-88.4 0.9 76.4 64.1-88.6 1.0 77.9 67.2-88.8 1.0 77.2 68.3-86.1 1.8 Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 75.3 60.8-89.8 3.6 73.5 53.7-93.3 3.9 85.9 73.8-98.2 3.9 75.3 62.4-88.1 6.2

Zone 3 (Bihar & Jharkhand) 62.8 47.3-78.4 2.6 70.1 53.1-87.1 2.6 54.1 36.8-71.3 2.6 66.9 53.2-80.5 5.2

Zone 4 (West Bengal & Andaman & Nicobar 91.4 84.0-98.9 1.5 78.3 62.8-93.9 1.0 94.0 83.8-104.3 1.3 85.9 78.4-93.5 1.4 Islands)

Zone 5 (Assam, Arunachal Pradesh, 86.4 76.2-96.5 0.7 85.1 71.8-98.5 0.7 82.1 70.1-94.1 0.8 85.3 77.1-93.4 0.9 Meghalaya & Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & 76.8 65.7-87.9 0.2 62.4 44.9-79.9 0.2 76.6 64.5-88.6 0.2 68.9 57.5-80.3 0.3 Tripura)

Zone 7 (Rajasthan) 53.7 39.0-68.3 1.1 54.1 37.9-70.3 1.1 50.0 35.1-64.9 1.1 53.7 40.5-66.9 2.3

Zone 8 (Gujarat & Daman & Diu) 80.1 70.3-89.9 0.9 78.9 67.5-90.4 0.8 95.7 89.8-101.6 0.9 80.5 72.7-88.4 1.3

Zone 9 (Madhya Pradesh & Chattisgarh) 77.1 64.5-89.7 1.7 83.9 72.1-95.9 1.7 74.6 60.6-88.6 1.6 81.4 72.2-90.7 2.8

Zone 10 (Orrisa) 57.8 42.2-73.4 0.8 61.9 42.6-81.1 0.8 62.1 41.5-82.8 0.8 60.6 47.6-73.5 1.2

Zone 11 (Maharashtra & Goa) 77.8 66.6-88.9 1.6 61.4 45.8-76.9 1.5 84.3 71.7-96.9 1.6 68.3 56.6-79.9 3.1

Zone 12 (Andhra Pradesh) 89.8 81.8-97.8 1.4 82.1 68.3-95.9 1.5 62.0 47.2-76.9 1.3 83.1 73.9-92.4 2.5

Zone 13 (Karnataka) 94.8 89.9-99.6 0.7 82.6 71.9-93.4 0.9 83.1 73.5-92.6 0.9 86.1 79.0-93.2 1.6

Zone 14 (Tamil Nadu & Pondicherry) 94.5 90.3-98.7 0.6 76.9 65.7-88.2 1.1 78.6 68.2-88.9 1.0 81.7 73.9-89.6 1.9

Zone 15 (Kerala & Lakshad Island) 86.2 77.4-95.0 0.6 70.9 58.1-83.8 0.6 86.2 76.6-95.9 0.6 76.3 66.9-85.7 1.2

Rural 79.7 74.4-84.9 2.9 75.2 69.4-81.1 2.1 76.9 71.2-82.8 2.8 76.7 72.5-80.9 3.8

ALL INDIA Urban 77.5 72.2-82.7 1.2 71.1 64.8-77.4 0.9 79.2 74.9-83.6 0.6 73.7 68.9-78.4 1.9

Total 79.0 75.6-82.5 1.8 74.1 69.6-78.6 1.8 77.6 73.8-81.4 1.7 75.9 72.7-79.0 3.2

Table 4.5.24 Proportion of Health Facilities where Fuel for Sterilization was Available - Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu & Kashmir & 94.5 89.7-99.4 0.9 79.0 69.7-88.3 1.0 86.9 79.1-94.8 1.1 83.2 76.3-90.1 2.0 Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 83.5 74.0-92.9 3.4 61.5 48.8-74.2 3.6 85.5 76.7-94.3 3.3 68.3 58.7-77.9 6.6

Zone 3 (Bihar & Jharkhand) 75.3 63.2-87.5 2.6 76.5 64.8-88.2 2.5 73.9 62.0-85.9 2.4 76.1 66.9-85.3 4.5

Zone 4 (West Bengal & Andaman & 93.8 87.6-100.1 1.6 41.3 29.2-53.5 1.5 94.8 90.2-99.4 1.0 57.3 48.5-66.0 2.2 Nicobar Islands)

Zone 5 (Assam, Arunchal Pradesh, 92.2 84.7-99.7 0.7 64.1 50.6-77.7 0.7 92.5 85.0-99.9 0.7 72.6 62.9-82.4 1.3 Meghalaya & Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & 96.4 92.1-100.7 0.1 46.1 33.4-58.7 0.2 91.9 85.1-98.8 0.2 60.9 51.9-69.9 0.3 Tripura)

Zone 7 (Rajasthan) 82.7 73.4-92.0 1.0 63.7 51.3-76.0 1.1 82.7 73.4-92.0 1.0 69.4 60.3-78.5 1.9

Zone 8 (Gujarat & Daman & Diu) 90.7 84.2-97.3 0.8 63.9 52.6-75.3 0.9 84.9 76.4-93.3 0.8 71.6 63.1-80.0 1.6

Zone 9 (Madhya Pradesh & Chattisgarh) 95.6 90.1-101.0 1.7 82.1 72.7-91.4 1.4 71.2 59.5-82.8 1.6 84.5 78.1-90.9 2.3

Zone 10 (Orrisa) 91.0 82.7-99.3 0.9 75.7 63.6-87.7 0.9 89.2 80.0-98.3 0.9 80.2 71.2-89.2 1.6

Zone 11 (Maharashtra & Goa) 95.5 90.5-100.5 1.7 67.9 57.2-78.7 1.6 89.5 82.3-96.7 1.6 75.9 68.0-83.8 2.9

Zone 12 (Andhra Pradesh) 95.5 90.9-99.9 1.0 69.8 58.6-80.9 1.3 65.3 53.1-77.5 1.4 75.5 67.4-83.7 2.4

Zone 13 (Karnataka) 97.6 94.9-100.3 0.5 75.1 64.9-85.3 0.9 89.4 83.0-95.8 0.7 81.3 74.2-88.5 1.6

Zone 14 (Tamil Nadu & Pondicherry) 99.1 97.4-100.9 0.7 91.6 85.2-98.0 1.0 97.4 94.5-100.3 0.6 93.8 89.3-98.3 1.9

Zone 15 (Kerala & Lakshadweep Island) 98.7 96.9-100.5 0.2 92.4 86.5-98.3 0.5 95.7 90.4-100.9 0.6 94.1 89.8-98.4 0.9

Rural 90.6 87.1-94.0 3.1 70.7 65.5-75.9 2.9 85.1 81.6-88.6 2.1 76.4 72.4-80.3 5.6

ALL INDIA Urban 89.6 86.5-92.7 0.9 67.4 62.4-72.4 0.9 82.6 79.2-85.9 0.7 73.6 69.8-77.4 1.9

Total 90.3 87.9-92.7 2.0 69.8 66.4-73.2 1.7 84.4 81.7-87.1 1.7 75.6 73.1-78.1 3.2

Table 4.5.25 Proportion of Prescribers who had Incorrect Knowledge of Sterilization Process – Prescriber Interview

Government Health Private Health Facilities Total Facilities Zone Est 95% CI Deff Est 95% CI Deff Est (%) 95% CI Deff (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu 44.9 29.7-60.2 1.0 50.0 28.1-71.9 1.0 47.9 33.4-62.5 1.3 & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 25.3 11.7-38.9 3.5 52.1 32.5-71.6 3.6 43.0 30.1-55.9 4.3

Zone 3 (Bihar & Jharkhand) 40.8 19.3-62.4 2.3 65.1 37.9-92.3 2.6 56.9 36.3-77.6 3.7

Zone 4 (West Bengal & Andaman & Nicobar Islands) 52.3 39.7-64.9 1.4 57.2 35.4-79.0 1.5 54.9 41.7-68.1 1.8

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 21.6 9.8-33.5 0.6 36.6 15.6-57.7 0.7 30.5 16.4-44.6 1.1

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 59.4 43.4-75.5 0.2 72.3 54.5-90.1 0.1 66.5 53.1-79.9 0.2

Zone 7 (Rajasthan) 52.8 36.6-69.1 1.1 56.0 30.9-81.2 1.1 54.6 38.6-70.6 1.4

Zone 8 (Gujarat & Daman & Diu) 54.6 40.9-68.4 0.8 53.1 34.4-71.8 0.9 53.7 41.3-66.1 1.1

Zone 9 (Madhya Pradesh & Chattisgarh) 50.5 36.4-64.7 1.5 63.5 48.5-78.6 1.5 59.8 48.3-71.4 2.1

Zone 10 (Orrisa) 66.4 45.2-87.5 0.8 72.9 52.8-93.1 0.9 71.4 56.2-86.6 1.1

Zone 11 (Maharashtra & Goa) 53.2 40.7-65.6 1.4 71.2 54.6-87.9 1.4 63.6 52.1-75.1 1.8

Zone 12 (Andhra Pradesh) 55.7 43.0-68.3 1.3 68.2 51.3-85.1 1.4 63.2 51.5-74.9 1.8

Zone 13 (Karnataka) 50.8 38.2-63.5 0.9 78.8 65.9-92.2 0.9 68.8 57.7-79.8 1.3

Zone 14 (Tamil Nadu & Pondicherry) 49.8 38.1-61.5 0.9 65.9 49.9-81.9 1.1 59.6 49.3-70.0 1.2

Zone 15 (Kerala & Lakshadweep Island) 57.4 43.7-71.2 0.6 57.4 35.9-78.8 0.6 57.4 43.7-71.1 0.8

Rural 45.3 40.5-50.0 1.4 60.1 52.3-67.9 2.5 54.9 49.4-60.3 3.2

ALL INDIA Urban 49.1 43.9-54.2 0.6 65.8 55.8-75.8 1.1 58.3 52.2-64.5 1.2

Total 46.3 42.2-50.3 1.5 61.2 55.5-67.0 1.8 55.6 51.7-59.5 2.1

Table 4.5.26 Unhygienic “Injection Environment” (Proportion of Health Facilities): Direct Observation

Government Health Private Health Immunization Clinic Total Facilities Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%)

Zone 1 (Chandigarh, Delhi, Punjab, Himachal 61.5 50.3-72.7 1.0 50.9 39.5-62.5 1.0 83.5 75.3-91.8 0.9 55.6 46.9-64.4 1.8 Pradesh, Jammu & Kashmir & Haryana)

Zone 2 (Uttaranchal & Uttar Pradesh) 69.9 58.2-81.8 3.4 65.5 53.1-77.8 3.5 68.9 56.9-81.1 3.5 66.8 57.5-76.0 6.0

Zone 3 (Bihar & Jharkhand) 81.5 70.8-92.2 2.5 75.5 63.8-87.3 2.4 74.4 62.1-86.8 2.6 76.9 68.1-85.6 4.2

Zone 4 (West Bengal & Andaman & Nicobar 87.9 80.3-95.7 1.3 54.1 41.9-66.4 1.5 90.9 84.8-97.1 1.1 64.6 55.4-73.7 2.6 Islands)

Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 83.8 73.7-93.9 0.7 57.1 43.2-70.9 0.7 93.5 87.2-99.8 0.6 65.8 55.5-76.0 1.3 Sikkim)

Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 75.0 64.5-85.6 0.2 40.8 28.3-53.3 0.2 78.3 67.9-88.8 0.2 51.4 41.4-61.3 0.3

Zone 7 (Rajasthan) 51.3 38.6-64.1 1.1 58.7 46.4-70.9 1.0 63.3 51.0-75.5 1.1 57.3 48.1-66.4 1.7

Zone 8 (Gujarat & Daman & Diu) 75.5 65.9-85.0 0.7 62.7 51.5-73.9 0.8 84.8 76.5-93.0 0.8 67.1 58.8-75.4 1.4

Zone 9 (Madhya Pradesh & Chattisgarh) 91.9 85.1-98.7 1.5 86.5 78.5-94.5 1.3 78.1 67.5-88.7 1.6 87.2 80.8-93.6 2.7

Zone 10 (Orrisa) 63.3 49.9-76.7 0.8 66.2 53.1-79.3 0.8 65.8 52.7-78.9 0.8 65.5 53.6-77.3 2.0

Zone 11 (Maharashtra & Goa) 74.9 65.1-84.9 1.5 54.9 44.2-65.8 1.4 78.9 69.6-88.4 1.6 61.3 52.8-69.8 2.7

Zone 12 (Andhra Pradesh) 80.5 70.9-90.0 1.3 71.1 60.0-82.3 1.4 62.7 50.3-75.0 1.4 72.8 64.3-81.3 2.4

Zone 13 (Karnataka) 88.4 80.9-95.9 0.9 83.5 75.1-91.9 0.8 80.8 71.3-90.3 0.9 84.5 78.1-90.8 1.5

Zone 14 (Tamil Nadu & Pondicherry) 76.6 66.7-86.6 1.0 79.7 71.0-88.4 0.9 63.2 51.9-74.4 1.0 77.9 70.4-85.3 1.8

Zone 15 (Kerala & Lakshadweep Island) 85.6 77.2-94.0 0.5 63.1 51.4-74.9 0.6 93.9 87.6-100.1 0.7 70.5 62.2-78.8 0.9

Rural 79.1 75.0-83.3 2.2 71.4 66.8-76.1 2.3 77.2 72.8-81.5 2.3 73.6 70.2-77.0 3.9

ALL INDIA Urban 69.5 64.9-74.0 0.8 54.2 47.9-60.3 1.3 72.1 68.1-76.1 0.7 58.9 54.1-63.8 2.5

Total 76.4 73.4-79.5 1.6 66.6 63.2-69.9 1.6 75.7 72.5-78.9 1.7 69.5 66.9-72.1 2.9

Table 4.5.27 Contents of Injection Tray: Number of Syringes Vs. Number of Needles – Direct Observation

Government Health Facilities Private Health Facilities Immunization Clinic Total Contents of Injection Tray Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff Estimate 95% CI Deff (%) (%) (%) (%)

Rural 50.1 45.5-54.8 1.9 41.6 37.0-46.2 1.9 52.2 47.5-56.9 1.9 44.3 40.9-47.7 2.9 Needles more than Urban 48.3 43.4-53.1 0.8 28.3 23.8-32.7 0.9 45.9 40.9-50.8 0.8 34.1 30.5-37.8 1.5 Syringes Total 49.6 46.1-53.2 1.6 37.9 34.3-41.4 1.7 50.4 46.8-54.1 1.6 41.5 38.8-44.2 2.8

Rural 7.3 4.7-9.9 2.2 3.2 1.9-4.5 1.2 3.8 1.8-5.8 2.3 4.2 2.9-5.4 2.4 Needles less than Urban 5.7 3.6-7.8 0.7 2.2 0.9-3.4 0.6 1.7 0.5-3.0 0.8 3.0 2.1-3.9 0.8 Syringes Total 6.9 5.0-8.7 1.7 2.9 1.9-3.9 1.1 3.2 1.9-4.5 1.6 3.9 3.0-4.7 1.8

Rural 41.8 38.0-45.5 1.3 54.1 49.4-58.8 1.9 43.6 38.9-48.2 1.9 50.5 47.1-53.9 3.0 Needles same as Urban 45.5 40.9-50.0 0.7 68.9 64.3-73.5 0.8 52.2 46.9-57.5 0.9 62.3 58.6-66.0 1.5 Syringes Total 42.8 39.3-46.3 1.6 58.2 54.7-61.8 1.6 45.9 42.4-49.6 1.6 53.8 51.0-56.6 2.9

Table 4.6.1 Availability of Written Guidelines for Waste Disposal (Proportion of Health Facilities) – Prescriber Interview

Government Health Private Health Total Facilities Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 45.3 33.8-56.8 1.1 23.3 14.0-32.6 0.9 28.9 20.9-37.0 1.2 Pradesh, Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 16.5 6.6-26.4 3.7 1.5 -0.2-3.2 0.9 5.3 2.5-8.0 1.6 Zone 3 (Bihar & Jharkhand) 10.9 2.5-19.4 2.4 0 0-0 - 2.8 0.6-4.9 1.1 Zone 4 (West Bengal & Andaman & Nicobar Islands) 27.9 17.3-38.5 1.3 5.9 1.1-10.6 0.9 11.4 6.9-15.8 0.9 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 6.3 -0.1-12.7 0.6 4.9 -1.2-10.9 0.7 5.2 0.5-10.0 0.8 Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 6.1 0.3-11.9 0.1 6.6 0.8-12.5 0.1 6.5 1.9-11.0 0.2 Zone 7 (Rajasthan) 15.5 7.4-23.5 0.9 6.7 1.7-11.6 0.6 8.9 4.9-13.0 0.7 Zone 8 (Gujarat & Daman & Diu) 28.0 18.4-37.7 0.7 16.8 8.1-25.4 0.8 19.6 12.3-26.9 1.0 Zone 9 (Madhya Pradesh & Chattisgarh) 20.1 11.3-29.0 1.2 6.6 1.8-11.5 0.9 10.0 5.2-14.9 1.3 Zone 10 (Orrisa) 33.7 20.2-47.1 0.9 12.9 4.3-21.7 0.7 18.4 9.6-27.2 1.1 Zone 11 (Maharashtra & Goa) 45.5 34.2-56.8 1.5 28.0 17.6-38.4 1.6 32.4 24.1-40.7 1.9 Zone 12 (Andhra Pradesh) 26.4 15.6-37.2 1.4 4.8 1.5-8.1 0.5 10.2 6.5-13.9 0.7 Zone 13 (Karnataka) 50.8 38.8-62.8 0.9 19.9 10.8-29.0 0.8 27.7 20.3-35.1 0.9 Zone 14 (Tamil Nadu & Pondicherry) 17.7 9.2-26.2 0.9 10.3 4.5-16.1 0.7 12.2 7.0-17.3 0.9 Zone 15 (Kerala & Lakshadweep Island) 31.1 19.7-42.5 0.6 28.9 18.3-39.5 0.5 29.4 20.9-38.0 0.7 Rural 20.8 17.1-24.5 1.8 5.8 4.2-7.4 1.1 9.6 8.0-11.2 1.3 ALL INDIA Urban 38.0 33.1-42.9 0.9 21.8 17.5-26.1 0.9 25.9 22.6-29.1 0.9 Total 25.6 22.6-28.6 1.4 10.3 8.6-11.9 0.9 14.2 12.6-15.7 1.2

Table 4.6.2 ‘Satisfactory’** Disposal of Used Plastic Syringes at Health Facility Level (Proportion of Health Facilities) - Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu & Kashmir & 81.9 72.8-91.0 1.1 87.6 79.5-95.6 1.1 71.4 59.9-82.9 1.0 85.3 78.7-91.9 1.8 Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 72.8 60.9-84.6 3.6 62.2 48.8-75.5 3.7 57.1 41.7-72.6 3.4 64.5 53.4-75.6 7.2 Zone 3 (Bihar & Jharkhand) 44.8 30.8-58.8 2.6 47.5 33.3-61.6 2.6 27.5 14.9-40.1 2.5 45.5 33.5-57.6 5.2 Zone 4 (West Bengal & Andaman & 62.2 48.0-76.4 1.4 66.8 54.7-78.9 1.5 48.3 28.3-68.3 1.3 65.4 55.6-75.2 2.4 Nicobar Islands) Zone 5 (Assam, Arunchal Pradesh, 63.4 48.7-78.1 0.7 77.3 64.2-90.4 0.8 40.8 23.7-58.0 0.7 71.9 61.1-82.8 1.2 Meghalaya & Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & 49.2 35.8-62.5 0.2 78.3 67.2-89.4 0.2 61.7 47.6-75.8 0.2 70.6 61.9-79.2 0.2 Tripura) Zone 7 (Rajasthan) 70.4 58.5-82.3 1.1 70.2 58.1-82.2 1.2 69.6 57.6-81.6 1.1 70.2 61.1-79.3 1.8 Zone 8 (Gujarat & Daman & Diu) 44.7 33.1-56.4 0.8 55.1 42.9-67.4 0.9 42.9 29.6-56.3 0.9 51.9 41.9-61.9 1.6 Zone 9 (Madhya Pradesh & Chattisgarh) 68.8 56.6-80.9 1.6 66.2 53.2-79.1 1.6 49.7 36.4-62.9 1.6 65.7 56.3-75.1 2.4 Zone 10 (Orrisa) 89.3 80.9-97.8 0.8 73.5 61.1-85.9 0.9 81.4 70.3-92.4 0.8 77.7 68.8-86.7 1.4 Zone 11 (Maharashtra & Goa) 41.3 28.4-54.3 1.5 52.4 41.7-63.1 1.3 43.9 28.2-59.6 1.6 49.8 41.6-57.9 1.9 Zone 12 (Andhra Pradesh) 54.7 41.4-67.9 1.4 62.5 50.4-74.6 1.4 64.5 51.6-77.3 1.4 60.9 51.2-70.7 2.4 Zone 13 (Karnataka) 36.5 24.7-48.2 0.8 37.6 26.4-48.8 0.8 22.9 12.7-33.2 0.8 36.5 27.9-45.0 1.3 Zone 14 (Tamil Nadu & Pondicherry) 38.5 24.0-52.9 0.9 61.8 49.9-73.6 1.0 43.2 27.1-59.2 0.9 57.2 46.7-67.7 1.9 Zone 15 (Kerala & Lakshadweep Island) 78.2 66.8-89.5 0.6 80.1 70.2-90.0 0.6 76.4 58.4-94.5 0.5 79.7 71.3-88.0 1.0 Rural 59.3 55.3-63.3 1.3 58.1 53.2-63.1 2.1 48.6 42.6-54.6 2.2 57.9 53.8-62.0 3.8 ALL INDIA Urban 63.4 58.3-68.4 0.8 72.6 68.1-77.1 0.8 56.2 50.7-61.8 0.8 69.6 66.0-73.1 1.3 Total 60.5 56.7-64.2 1.7 62.3 58.6-65.9 1.7 50.9 46.7-55.2 1.6 61.3 58.2-64.3 3.1 ** If disposed as any one of the following: a. Put in a jar containing hypochlorite solution, b. Collected in a dustbin, c. Broke the syringe and threw away into dustbin

Table 4.6.3 Proportion of Health Facilities where Waste was Segregated by Using Colour-Coded Bags – Prescriber Interview

Government Health Private Health Facilities Total Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 1.3 -0.5-3.0 0.6 3.8 -0.4-7.9 0.8 2.3 0.3-4.3 0.7 Pradesh, Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 11.9 3.9-19.8 5.0 13.7 4.2-23.3 1.6 12.2 5.6-18.9 4.3 Zone 3 (Bihar & Jharkhand) 13.1 3.5-22.7 4.6 3.1 -0.9-7.2 0.5 11.8 3.5-20.2 4.4 Zone 4 (West Bengal & Andaman & Nicobar Islands) 5.6 1.1-10.2 1.4 6.9 2.2-11.6 0.4 5.9 2.4-9.5 1.1 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 4.9 -1.2-11.1 1.3 3.1 -0.9-7.2 0.1 4.7 -0.7-10.2 1.2 Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 1.9 -1.9-5.6 0.3 9.9 1.5-18.3 0.1 3.6 0.2-7.1 0.2 Zone 7 (Rajasthan) 8.9 0.3-17.4 2.3 6.2 -0.1-12.6 0.5 8.2 1.5-14.9 1.9 Zone 8 (Gujarat & Daman & Diu) 1.3 -0.5-3.0 0.5 3.1 -0.9-7.2 0.6 1.9 0.1-3.7 0.5 Zone 9 (Madhya Pradesh & Chattisgarh) 0.6 -0.6-1.9 0.9 0.6 -0.6-1.9 0.3 0.6 -0.4-1.6 0.8 Zone 10 (Orrisa) 0 0-0 - 1.9 -1.9-5.7 0.2 0.3 -0.3-0.8 0.2 Zone 11 (Maharashtra & Goa) 4.4 0.1-8.7 1.0 8.2 3.3-13.0 1.1 6.7 3.3-10.0 1.1 Zone 12 (Andhra Pradesh) 3.7 -1.5-8.9 2.5 7.5 0.3-14.6 0.9 4.8 0.5-9.0 1.8 Zone 13 (Karnataka) 0.6 -0.6-1.9 0.6 2.5 -1.4-6.4 1.2 -0.3-2.8 0.6 Zone 14 (Tamil Nadu & Pondicherry) 4.4 -1.8-10.5 2.2 0.6 -0.6-1.9 0.3 3.1 -0.9-7.1 2.1 Zone 15 (Kerala & Lakshadweep Island) 1.9 -1.9-5.6 1.1 10.4 2.6-18.1 0.3 4.1 0.7-7.6 0.6 Rural 7.0 4.5-9.5 2.1 5.9 3.2-8.6 2.9 6.2 4.1-8.3 3.3 ALL INDIA Urban 9.1 5.7-12.6 1.2 5.1 2.9-7.3 0.8 6.1 4.5-7.8 0.8 Total 7.6 5.5-9.8 2.0 5.7 3.7-7.6 2.3 6.2 4.5-7.8 2.8

Table 4.6.4 ‘Satisfactory’** Terminal Level Disposal of Used Plastic Syringes/Needles (Proportion of Health Facilities) - Direct Observation

Government Health Private Health Facilities Immunization Clinic Total Facilities Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 70.0 59.4-80.7 1.0 59.9 48.5-71.2 1.0 69.8 58.7-80.9 1.0 62.9 54.6-71.1 1.6 Pradesh, Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 53.3 39.7-66.8 3.5 40.5 27.5-53.4 3.6 35.4 21.8-48.9 3.4 43.1 32.8-53.3 6.4 Zone 3 (Bihar & Jharkhand) 35.0 21.6-48.4 2.6 31.4 18.3-44.5 2.6 33.6 19.9-47.3 2.6 32.4 21.5-43.4 5.1 Zone 4 (West Bengal & Andaman & Nicobar 40.7 28.4-52.9 1.4 36.2 24.2-48.1 1.5 39.1 26.1-52.2 1.4 37.3 27.3-47.3 2.9 Islands) Zone 5 (Assam, Arunchal Pradesh, Meghalaya 59.6 45.6-73.6 0.7 48.1 33.3-62.9 0.7 58.9 44.5-73.3 0.7 51.6 40.1-63.1 1.3 & Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & 34.2 21.8-46.6 0.2 27.7 16.1-39.3 0.2 37.3 24.5-50.1 0.2 29.9 20.4-39.4 0.3 Tripura) Zone 7 (Rajasthan) 53.8 41.1-66.6 1.1 34.0 22.4-45.6 1.0 50.5 37.3-63.7 1.1 39.8 30.0-49.5 1.9 Zone 8 (Gujarat & Daman & Diu) 60.5 48.8-72.3 0.9 36.6 25.4-47.8 0.8 64.7 52.8-76.6 0.9 43.8 34.2-53.4 1.7 Zone 9 (Madhya Pradesh & Chattisgarh) 45.7 32.9-58.5 1.6 32.9 20.9-44.9 1.5 48.0 34.3-61.7 1.6 36.9 27.4-46.5 2.6 Zone 10 (Orrisa) 27.0 14.9-39.1 0.8 26.4 14.3-38.6 0.8 29.3 16.9-41.7 0.8 26.8 16.2-37.3 1.8 Zone 11 (Maharashtra & Goa) 63.6 53.7-73.6 1.2 47.0 35.6-58.5 1.6 67.4 56.9-77.8 1.4 52.2 43.6-60.7 2.5 Zone 12 (Andhra Pradesh) 69.9 58.6-81.2 1.4 40.1 28.1-52.1 1.3 58.1 45.0-71.2 1.4 48.3 39.1-57.6 2.2 Zone 13 (Karnataka) 69.3 58.4-80.2 0.9 49.2 37.0-61.4 0.9 55.8 43.7-67.8 0.9 54.5 45.3-63.7 1.5 Zone 14 (Tamil Nadu & Pondicherry) 48.5 36.6-60.5 1.0 46.6 34.9-58.4 1.1 45.5 33.4-57.7 1.0 47.0 37.8-56.2 1.8 Zone 15 (Kerala & Lakshadweep Island) 66.4 54.6-78.2 0.6 78.4 67.9-88.9 0.6 65.4 51.0-79.8 0.6 74.9 66.5-83.3 1.0 Rural 50.6 45.4-55.7 2.2 39.3 34.9-43.7 1.7 43.6 38.5-48.7 1.9 42.2 38.5-45.9 3.6 ALL INDIA Urban 60.8 56.6-64.9 0.6 47.1 41.3-52.8 1.1 61.9 57.2-66.6 0.8 51.2 46.9-55.5 1.8 Total 53.5 49.8-57.2 1.6 41.5 37.9-45.2 1.7 49.1 45.3-52.9 1.6 44.8 41.9-47.7 3.0 ** If disposed as any one of the following: a. Buried in a pit b. Carried away by municipality/Panchayat workers c. Sent to incinerators

Table 4.6.5 Prescribers’ Knowledge of ‘Satisfactory’ Waste Disposal Methods at Health Facility Level (Proportion of Prescribers) – Prescriber Interview

Government Health Facilities Private Health Facilities Total Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, Jammu & 100 100-100 - 100 100-100 - 100 100-100 - Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 92.7 85.7-99.8 3.7 92.3 85.2-99.4 3.6 92.4 86.4-98.4 5.2 Zone 3 (Bihar & Jharkhand) 85.9 75.7-96.1 2.7 77.3 65.0-89.5 2.6 79.5 69.3-89.7 3.9 Zone 4 (West Bengal & Andaman & Nicobar Islands) 91.5 84.6-98.4 1.4 83.7 74.1-93.4 1.5 85.7 78.5-92.9 1.9 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 89.9 80.7-99.2 0.8 92.4 84.2-100.6 0.8 91.8 85.4-98.1 0.9 Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 80.0 68.8-91.2 0.2 81.9 71.5-92.2 0.2 81.4 72.2-90.6 0.3 Zone 7 (Rajasthan) 95.5 90.0-101.1 1.2 93.5 86.8-100.2 1.2 94.0 88.9-99.1 1.5 Zone 8 (Gujarat & Daman & Diu) 82.5 73.3-91.7 0.8 84.5 75.6-93.4 0.9 83.9 76.9-91.1 1.1 Zone 9 (Madhya Pradesh & Chattisgarh) 89.2 80.6-97.8 1.7 83.8 73.8-93.9 1.7 85.2 77.3-93.1 2.2 Zone 10 (Orrisa) 95.2 89.0-101.4 0.9 74.1 61.2-87.1 0.9 79.6 69.6-89.5 1.2 Zone 11 (Maharashtra & Goa) 83.9 74.8-92.9 1.4 81.3 73.4-89.3 1.2 81.9 75.1-88.6 1.6 Zone 12 (Andhra Pradesh) 85.8 76.4-95.2 1.5 80.4 70.1-90.6 1.4 81.7 74.1-89.4 1.7 Zone 13 (Karnataka) 86.6 77.9-95.3 0.9 83.0 73.8-92.2 0.9 83.9 76.3-91.5 1.3 Zone 14 (Tamil Nadu & Pondicherry) 91.6 84.2-99.1 1.1 93.0 87.2-98.8 0.9 92.7 87.5-97.9 1.4 Zone 15 (Kerala & Lakshadweep Island) 96.2 91.4-101.1 0.5 93.3 86.4-100.1 0.7 93.9 88.1-99.8 1.0 Rural 88.8 85.8-91.7 1.8 84.4 81.1-87.8 1.8 85.5 82.8-88.3 2.5 ALL INDIA Urban 93.7 91.1-96.3 0.9 91.5 88.7-94.3 0.8 92.0 89.9-94.1 0.9 Total 90.1 87.8-92.5 1.8 86.4 83.9-88.9 1.7 87.3 85.3-89.4 2.3

Table 4.6.6 Prescribers’ Knowledge of ‘Satisfactory’ Terminal Disposal Methods (Proportion of Prescribers) – Prescriber Interview

Government Health Facilities Private Health Facilities Total Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 71.5 60.9-82.2 1.0 75.6 65.6-85.6 1.0 74.6 66.6-82.6 1.3 Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 77.1 65.6-88.6 3.6 53.8 40.6-66.9 3.6 59.4 49.6-69.2 3.9 Zone 3 (Bihar & Jharkhand) 48.2 33.9-62.5 2.5 42.2 27.9-56.4 2.5 43.7 31.3-56.1 3.7 Zone 4 (West Bengal & Andaman & Nicobar Islands) 68.9 56.6-81.1 1.5 47.8 35.4-60.2 1.4 52.9 42.4-63.5 1.9 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 24.7 12.3-37.1 0.7 38.5 24.9-52.1 0.7 35.1 24.1-46.1 0.9 Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 61.4 48.1-74.7 0.2 63.3 50.5-76.0 0.2 62.8 52.2-73.4 0.2 Zone 7 (Rajasthan) 69.4 57.3-81.6 1.1 46.7 33.9-59.5 1.0 52.6 42.2-63.1 1.4 Zone 8 (Gujarat & Daman & Diu) 82.8 73.3-92.4 0.9 63.1 51.5-74.6 0.8 67.8 58.3-77.3 1.2 Zone 9 (Madhya Pradesh & Chattisgarh) 60.4 47.8-73.0 1.6 43.1 30.8-55.5 1.5 47.5 37.8-57.3 1.8 Zone 10 (Orrisa) 53.0 38.2-67.8 0.9 43.9 29.9-57.8 0.8 46.2 34.3-58.1 1.2 Zone 11 (Maharashtra & Goa) 73.6 63.2-84.0 1.4 70.1 59.8-80.3 1.4 70.9 62.8-78.9 1.8 Zone 12 (Andhra Pradesh) 83.6 74.7-92.6 1.3 62.2 50.0-74.4 1.4 67.7 58.0-77.3 1.9 Zone 13 (Karnataka) 84.2 75.8-92.6 0.8 67.4 55.9-78.8 0.9 71.6 62.5-80.7 1.3 Zone 14 (Tamil Nadu & Pondicherry) 73.6 62.7-84.4 1.1 84.7 75.9-93.5 1.1 81.9 74.3-89.7 1.5 Zone 15 (Kerala & Lakshadweep Island) 90.5 82.7-98.4 0.5 89.3 80.5-98.2 0.6 89.6 82.5-96.7 0.8 Rural 66.2 61.8-70.7 1.8 52.8 47.3-58.2 2.5 56.1 51.9-60.4 3.0 ALL INDIA Urban 78.5 74.8-82.1 0.6 70.9 66.4-75.6 0.9 72.8 69.2-76.4 1.1 Total 69.6 66.1-73.0 1.7 57.9 54.2-61.6 1.7 60.8 57.8-63.7 2.2

Table 4.6.7 Stakeholders’ Perception of Dangers of Improper Disposal of Used Plastic Syringes/ Needles: Community Perception vs. Prescribers’ Perception (Community Survey and Prescriber Interview)*

Community Perception Exit Interviews Prescriber’s Perception

Potential Dangers Estimate 95% CI Deff Estimate 95 % CI Deff Estimate 95% CI Deff

(%) (%) (%)

Don’t know/ not 8.3 7.5-8.9 4.3 14.5 13.2-15.8 4.2 4.1 3.1 - 5.0 1.5 sure

Injury/ Spread of 58.6 56.9-60.2 6.4 82.2 80.8-83.7 4.4 93.6 92.4 - 94.8 1.5 Disease

Recycling by waste- 5.0 4.4-5.5 3.4 4.8 4.2-5.4 2.5 26.2 23.8 – 28.5 1.7 pickers

Environmental 16.6 15.4 – 17.8 6.0 14.1 12.9-15.3 3.8 21.5 19.1 – 23.9 2.2 Damage

* Multiple responses

Table 4.6.8 Selling of Injection Waste to Waste Pickers - According to Type of Health Facility

Type of Health Facility Prescriber Perception Direct Observation

Est (%) 95 % CI Deff Est (%) 95 % CI Deff

Rural 2.4 1.3-3.6 1.1 3.3 1.5-5.2 2.4 Government Health Urban 3.5 1.6-5.4 8.3 2.9 1.2-4.6 2.1 Facility

Total 2.7 1.7-3.8 1.2 3.2 1.9-4.5 1.8

Rural 13.3 9.7-16.9 2.4 15.9 12.6-19.3 1.8 Private Health Urban 8.8 6.0-11.5 0.6 13.1 9.8-16.5 0.8 Facility

Total 12.0 9.3-14.8 2.1 15.2 12.3-17.9 1.9

Rural 2.9 1.3-4.6 2.1 Immunization Urban * 3.1 1.6-4.5 0.6 Clinic

Total 2.9 1.7-4.3 1.8

Rural 10.6 7.9-13.4 3.2 12.1 9.7-14.5 3.5

All India Urban 7.5 5.3-9.7 1.2 10.1 7.7-12.4 1.5

Total 9.7 7.7-11.8 2.9 11.5 9.5-13.6 3.7 * Prescriber Interview not taken in immunization clinics

Table 4.7.1 Profile of Presenting Complaints at Outpatient Clinics [Exit Interview]

Fever/Cough/Diarrhoea Only Weakness Other Symptoms * Zone Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 46.5 41.3-51.6 2.1 0.7 0.00-1.4 1.4 52.8 47.8-57.9 2.0 Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 66.8 62.2-71.4 5.0 0 0-0 - 33.2 28.6-37.8 5.0 Zone 3 (Bihar & Jharkhand) 66.0 59.3-72.7 6.5 1.6 0.5-2.8 2.7 32.4 25.7-38.9 6.6 Zone 4 (West Bengal & Andaman & Nicobar Islands) 38.4 33.5-43.2 2.4 0.8 0.03-1.6 1.9 60.8 55.9-65.6 2.3 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 52.8 45.2-60.4 2.1 1.6 0.3-2.9 0.9 45.6 38.3-52.8 1.9 Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 47.6 42.9-52.2 0.2 0.4 -0.2-0.1 0.2 52.1 47.4-56.7 0.2 Zone 7 (Rajasthan) 59.3 54.8-63.8 1.4 0.9 0.2-1.6 0.1 39.6 34.9-44.2 1.5 Zone 8 (Gujarat & Daman & Diu) 61.8 56.9-66.8 1.6 1.4 0.4-2.5 1.2 36.7 31.8-41.6 1.6 Zone 9 (Madhya Pradesh & Chattisgarh) 55.1 48.9-61.2 3.6 0.9 0.1-1.8 1.9 43.9 37.8-50.0 3.6 Zone 10 (Orrisa) 48.0 41.6-54.5 1.8 3.8 2.1-5.5 0.9 47.8 41.4-54.3 1.8 Zone 11 (Maharashtra & Goa) 44.9 39.7-50.0 3.2 1.7 0.6-2.8 2.2 53.5 48.2-58.8 3.3 Zone 12 (Andhra Pradesh) 43.5 38.0-48.9 2.7 2.6 1.1-3.1 1.9 53.1 48.2-59.8 3.0 Zone 13 (Karnataka) 47.1 40.9-53.1 2.3 0.9 0.6-1.8 1.3 51.9 45.9-57.8 2.2 Zone 14 (Tamil Nadu & Pondicherry) 47.7 42.7-52.8 1.9 0.8 0.1-1.5 1.1 51.4 46.3-56.5 1.9 Zone 15 (Kerala & Lakshadweep Island) 37.6 33.1-42.0 0.8 0.5 -0.1-1.1 0.8 61.6 57.1-66.1 0.8

Rural 54.7 52.6-56.8 3.9 1.2 0.9-1.5 1.6 44.1 42.0-46.1 3.7

ALL INDIA Urban 49.7 47.8-51.8 1.5 1.0 0.6-1.4 1.5 49.3 47.1-51.5 1.7

Total 53.3 51.7-54.9 3.3 1.1 0.9-1.4 1.7 45.5 43.9-47.2 3.4 * Other Symptoms: Swelling/Pain/Vomiting/Restlessness

Table 4.7.2 Reasons for Receiving Last Injection – Community Survey

Fever/Cough/Diarrhoea Only Weakness Other Symptoms* Zone Est 95% CI (Deff) Est 95% CI (Deff) Esti 95% CI (Deff) (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 50.7 44.1-57.2 (1.1) 7.3 4.4-10.2 (0.8) 42.0 35.6-48.4 (1.1) Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 55.9 49.1-62.8 (2.7) 2.7 0.3-5.0 (3.3) 40.5 32.7-48.3 (3.7) Zone 3 (Bihar & Jharkhand) 45.3 38.6-51.9 (1.9) 1.3 0.02-2.6 (1.5) 52.8 45.9-59.7 (2.2)

Zone 4 (West Bengal & Andaman & Nicobar Islands) 18.9 10.7-27.2 (1.5) 0.4 -0.4-1.3 (0.6) 78.4 69.7-87.1 (1.6) Zone 5 (Assam, Arunchal Pradesh, Meghalaya & Sikkim) 38.3 24.5-52.1 (1.2) 3.7 -0.1-7.5 (0.7) 52.7 38.9-66.5 (1.2) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 33.0 24.5-41.5 (0.1) 3.5 0.4-6.6 (0.2) 45.9 32.2-59.6 (0.5) Zone 7 (Rajasthan) 70.8 64.4-77.2 (1.1) 1.9 0.3-3.5 (0.8) 26.8 20.2-33.3 (1.3) Zone 8 (Gujarat & Daman & Diu) 60.2 53.6-66.9 (0.9) 1.2 -0.2-2.7 (0.9) 38.2 31.5-44.9 (0.9) Zone 9 (Madhya Pradesh & Chattisgarh) 60.1 53.7-66.5 (1.5) 2.8 0.6-5.0 (1.6) 37.0 30.7-43.3 (1.5) Zone 10 (Orrisa) 33.8 26.5-41.0 (1.1) 8.7 3.9-13.5 (1.5) 55.1 47.9-62.3 (1.0) Zone 11 (Maharashtra & Goa) 48.2 42.3-54.2 (1.6) 3.7 1.6-5.9 (1.5) 46.2 39.7-52.7 (2.0) Zone 12 (Andhra Pradesh) 53.2 45.7-60.6 (2.7) 3.4 1.4-5.4 (1.5) 43.1 36.1-50.1 (2.5) Zone 13 (Karnataka) 49.1 43.3-54.8 (1.1) 2.9 1.3-4.5 (0.8) 47.7 42.1-53.3 (1.0) Zone 14 (Tamil Nadu & Pondicherry) 60.6 56.2-64.9 (0.9) 2.2 0.9-3.5 (1.0) 37.2 33.0-41.5 (1.0) Zone 15 (Kerala & Lakshadweep Island) 27.1 18.2-35.9 (0.8) 1.7 -0.7-3.9 (0.7) 68.9 59.9-77.9 (0.8) Rural 53.0 50.5-55.4 (1.9) 2.6 1.9-3.4 (1.7) 43.9 41.4-46.3 (1.9) ALL INDIA Urban 48.3 45.0-51.6 (1.2) 4.3 3.3-5.4 (0.8) 45.9 42.7-49.1 (1.2) Total 51.7 49.8-53.7 (1.7) 3.1 2.4-3.7 (1.5) 44.4 42.4-46.4 (1.9) * Other symptoms: Swelling/Pain/Vomiting/Restlessness

Table 4.7.3 Reasons for Receiving Last Injection [Exit Interview]

Fever/Cough/Diarrhoea Only Weakness Other Symptoms* Zone Est 95% CI Deff Est 95% CI Deff Esti 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal 40.3 32.5-48.2 1.7 1.3 -0.04-3.2 1.7 58.3 50.8-65.8 1.5 Pradesh, Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 65.6 58.4-72.8 5.5 0 0-0 - 34.4 27.2-41.6 5.5 Zone 3 (Bihar & Jharkhand) 66.8 58.2-75.4 4.0 1.0 -0.07-2.8 3.7 32.2 24.1-40.3 3.7 Zone 4 (West Bengal & Andaman & Nicobar 24.7 17.5-31.9 1.9 1.3 -0.07-3.2 2.1 74.0 66.4-81.7 2.2 Islands) Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 37.5 27.9-47.1 0.9 2.7 -0.08-6.2 1.1 59.8 50.9-68.6 0.8 Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 34.8 25.8-43.7 0.2 1.4 -0.09-3.7 0.2 63.8 55.1-72.5 0.2 Zone 7 (Rajasthan) 58.4 53.4-63.5 1.1 1.1 0.01-2.1 1.1 38.8 31.2-46.3 1.5 Zone 8 (Gujarat & Daman & Diu) 59.5 52.1-66.8 1.4 1.8 0.06-3.5 1.1 38.8 31.2-46.3 1.5 Zone 9 (Madhya Pradesh & Chattisgarh) 56.9 50.3-63.6 2.5 1.4 -0.05-2.9 2.1 41.7 34.9-48.3 2.5 Zone 10 (Orrisa) 43.7 34.6-52.8 1.6 2.9 0.04-5.4 1.1 53.4 44.5-62.4 1.6 Zone 11 (Maharashtra & Goa) 41.4 34.5-48.2 2.6 1.1 -0.02-2.5 2.1 57.5 50.6-64.4 2.6 Zone 12 (Andhra Pradesh) 42.4 36.1-48.6 2.6 2.3 0.08-3.7 1.5 55.4 48.8-61.9 2.8 Zone 13 (Karnataka) 49.6 42.9-56.3 1.9 1.1 -0.06-2.3 1.3 49.3 42.8-55.7 1.8 Zone 14 (Tamil Nadu & Pondicherry) 46.8 41.3-52.3 1.7 1.0 0.09-1.9 1.2 52.1 46.6-57.7 1.7 Zone 15 (Kerala & Lakshadweep Island) 32.6 25.5-39.7 0.8 0.07 -0.07-2.3 1.0 66.6 58.9-74.3 0.9 Rural 52.6 50.3-54.9 2.3 1.2 .8-1.6 1.2 46.2 43.8-48.5 2.4 ALL INDIA Urban 46.5 43.2-49.8 1.6 1.2 0.6-1.8 1.1 52.3 48.9-55.6 1.6 Total 51.1 48.9-53.3 2.9 1.2 0.8-1.6 1.7 47.7 45.5-49.9 2.8 *Other Symptoms: Swelling/Pain/Vomiting/Restlessness

Table 4.7.4 Reasons for Receiving Last Injection: Community Recall vs. Exit Interview

Community Exit Interviews

Rural Urban Total Rural Urban Total Health Conditions

Esti. 95% CI Esti. 95% CI Esti. 95% CI Esti. 95% CI Esti. 95% CI Esti. 95% CI

(%) Deff (%) Deff (%) Deff (%) Deff (%) Deff (%) Deff

50.5-55.4 45.0-51.6 49.8-53.7 50.3-54.9 43.2-49.8 48.9-53.3 Fever/Cough/ 53.0 48.3 51.7 52.6 46.5 51.1 Diarrhoea (1.9) (1.2) (1.7) (2.3) (1.6) (2.9)

1.9-3.4 3.3-5.4 2.4-3.7 0.8-1.6 0.6-1.8 0.8-1.6 Only Weakness 2.6 4.3 3.1 1.2 1.2 1.2 (1.7) (0.8) (1.5) (1.2) (1.1) (1.7)

Other Symptoms 41.4-46.3 42.7-49.1 42.4-46.4 43.8-48.5 48.9-55.6 45.5-49.9 (Swelling/Pain/ 43.9 45.9 44.4 46.2 52.3 47.7 Vomiting/Restlessness) (1.9) (1.2) (1.9) (2.4) (1.6) (2.8)

Table 4.7.5 Injection Prescription Rate@ for Indicator Conditions [Community Survey]

Fever/Cough/Diarrhoea Weakness Other Symptoms * Zone Est 95% CI Deff Est 95% CI Deff Esti 95% CI Deff (%) (%) (%) Zone 1 (Chandigarh, Delhi, Punjab, Himachal Pradesh, 61.4 51.8-71.0 1.5 36.2 28.2-44.2 0.8 50.7 44.1-57.2 1.1 Jammu & Kashmir & Haryana) Zone 2 (Uttaranchal & Uttar Pradesh) 56.2 48.1-64.2 3.1 54.8 45.5-64.1 0.9 56.0 49.1-62.8 2.7 Zone 3 (Bihar & Jharkhand) 46.4 38.8-54.0 2.2 37.1 28.3-45.9 0.4 45.3 38.6-52.0 1.9 Zone 4 (West Bengal & Andaman & Nicobar Islands) 19.0 7.9-30.1 1.9 18.8 9.2-28.5 0.6 18.9 10.7-27.2 1.5 Zone 5 (Assam, Arunchal Pradesh, Meghalaya & 40.6 25.0-56.1 1.3 20.8 11.4-30.4 0.1 38.3 24.5-52.1 1.2 Sikkim) Zone 6 (Manipur, Nagaland, Mizoram & Tripura) 34.2 24.3-44.2 0.2 28.6 13.2-43.9 0.1 33.0 24.5-41.5 1.4 Zone 7 (Rajasthan) 71.8 64.3-79.3 1.2 66.4 56.7-76.0 0.4 70.8 64.4-77.1 1.1 Zone 8 (Gujarat & Daman & Diu) 60.1 48.8-71.6 0.7 61.4 53.8-64.0 1.7 60.2 53.6-66.9 0.9 Zone 9 (Madhya Pradesh & Chattisgarh) 61.4 53.8-69.0 1.6 55.2 44.2-66.2 0.9 60.1 53.7-66.5 1.5 Zone 10 (Orrisa) 35.1 27.1-43.0 1.2 22.3 15.9-28.9 0.1 33.8 26.5-41.0 1.1 Zone 11 (Maharashtra & Goa) 51.0 43.2-58.8 1.4 45.3 36.3-54.3 1.8 48.2 42.3-54.2 1.6 Zone 12 (Andhra Pradesh) 54.0 44.1-63.8 3.5 50.9 44.3-57.4 0.6 53.1 45.7-60.6 2.7 Zone 13 (Karnataka) 50.0 43.0-57.0 1.2 46.5 37.1-55.8 0.8 49.0 43.3-54.8 1.0 Zone 14 (Tamil Nadu & Pondicherry) 60.2 54.6-65.8 1.1 61.2 54.7-67.7 0.8 60.6 56.2-64.9 1.0 Zone 15 (Kerala & Lakshadweep Island) 28.1 17.7-38.6 0.9 22.4 10.0-34.8 0.4 27.1 18.2-36.0 0.8 ALL INDIA Total 53.0 50.5-55.3 1.9 48.3 45.0-51.6 1.2 51.7 49.8-53.7 1.7 * Other Symptoms: Swelling/Pain/Vomiting/Restlessness @ Injection Prescription rate= (Individuals with indicator condition who received injection/Total with indicator condition x 100)

Table 4.7.6 Injection Prescription Rate@ for Indicator Conditions [Exit Interview]

Health conditions

Fever/Cough/Diarrhoea Only Weakness Other Symptoms * Type of Health Facilities Est 95% CI Deff Est 95% CI Deff Est 95% CI Deff (%) (%) (%)

Rural 36.1 32.6-39.6 2.8 42.2 23.2-61.3 1.8 46.9 43.3-50.4 2.8

Government Urban 28.4 24.1-32.8 2.3 34.2 10.7-57.7 0.7 45.5 41.8-49.1 1.3

Total 34.2 31.3-37.1 2.7 40.6 25.7-55.6 1.5 46.4 43.7-49.1 2.4

Rural 51.5 48.5-54.6 2.3 52.8 35.1-70.4 1.6 51.9 49.3-54.6 1.9

Private Urban 47.5 44.7-50.9 1.7 55.4 37.8-72.9 0.6 54.6 50.8-58.4 2.6

Total 49.4 46.7-52.2 2.7 53.5 40.1-66.9 1.3 52.0 49.3-54.6 1.9

Rural 48.1 45.6-50.6 3.0 50.3 38.3-62.2 1.5 52.4 49.3-55.5 3.7

Both Urban 40.4 36.9-43.8 2.1 51.7 35.8-67.6 0.9 48.5 45.2-51.3 2.1

Total 46.1 43.7-48.4 3.7 50.6 39.7-61.6 1.7 50.4 48.2-52.5 2.7

* Other Symptoms: Swelling/Pain/Vomiting/Restlessness @ Injection Prescription rate= (Individuals with indicator condition who received injection/Total with indicator condition x 100)

Table 4.7.7 Reasons for Receiving Last Injection: Age Related Differences- [Community Survey]

< 1 Year Age Category ≥ 1 Year Age Category Total

Health Conditions Estimate Estimate Estimate 95% CI Deff 95% CI Deff 95% CI Deff (%) (%) (%)

Fever/Cough/Diarrhoea 85.4 79.1-91.7 0.07 50.2 48.3-52.2 1.7 51.7 49.8-53.7 1.7

Only Weakness 0.5 -0.5-1.5 0.04 3.3 2.6-3.9 1.6 3.1 2.5-3.8 1.5

Other Symptoms (Swelling/Pain/Vomiting/ 14.1 7.8-20.3 0.07 46.5 44.5-48.5 1.8 45.1 43.1-47.1 1.8 Restlessness)

Table 4.7.8 Decision about Injection: Dynamics of Prescriber-Client Interaction [Direct Observation]

Government Health Facilities Private Health Facilities Total

Interaction Characteristics Esti. Esti. Esti. 95% CI Deff 95% CI Deff 95% CI Deff (%) (%) (%)

Rural 48.2 43.8-52.7 6.5 39.5 35.3-43.6 6.9 41.4 37.9-44.9 9.1 Prescription Without Urban 47.9 43.3-52.5 2.2 40.1 35.3-44.9 2.9 41.9 37.5-46.2 4.4 Discussion with Client Total 48.1 44.4-51.8 6.1 39.6 36.4-42.8 5.7 41.5 38.7-44.3 7.8

Rural 23.8 19.9-27.6 6.4 30.8 27.9-33.8 4.0 29.3 26.6-31.9 6.3 Prescriber Insisted on Urban 23.6 20.0-27.2 1.9 29.8 25.6-33.9 2.6 28.4 24.7-32.1 3.8 Injection Total 23.7 20.8-26.7 5.3 30.6 27.7-33.5 5.2 29.1 26.6-31.6 7.3

Rural 19.5 16.6-22.4 4.4 19.3 16.3-22.2 5.3 19.3 16.8-21.8 7.2 Client Demanded Urban 19.5 15.5-23.5 2.7 18.6 14.9-22.2 2.6 18.8 15.5-22.1 3.9 Injection Total 19.5 17.0-21.9 4.2 19.1 16.8-21.4 4.4 19.2 17.2-21.2 6.2

Rural 2.2 1.3-3.1 3.1 4.5 3.2-5.8 4.0 3.9 2.9-5.1 5.7 Prescription Discussed Urban 1.9 0.9-3.0 1.4 4.6 2.3-6.9 3.7 4.0 2.2-5.8 4.8 with Client Total 2.1 1.4-2.8 2.6 4.5 3.3-5.7 4.4 3.9 3.0-4.9 6.0

Rural 2.5 1.2-3.7 5.1 1.1 0.6-1.5 2.2 1.4 0.8-1.9 3.6 Prescriber Discouraged Urban 5.2 3.2-7.1 2.1 3.1 1.0-5.1 4.3 3.6 1.9-5.2 4.5 Injection Total 3.1 2.1-4.1 3.9 1.5 0.9-2.1 3.2 1.9 1.3-2.5 4.2

Rural 3.0 1.7-4.3 4.9 2.5 1.3-3.6 5.3 2.6 1.6-3.6 7.6 Client Demanded Oral Urban 5.3 2.5-8.0 4.1 5.1 2.6-7.5 3.8 5.1 2.9-7.3 5.7 Medicine Total 3.6 2.4-4.7 4.5 3.1 2.1-4.1 4.2 3.2 2.3-4.0 5.7

Table 4.7.9 Determinants of Injection: Stakeholders Perspective

Prescribers’ Clients perspective about Prescribers’ reasons for understanding of client Injection * prescribing injections ** perspective ** Interaction Characteristics Est. Est. Est. 95% CI Deff 95% CI Deff 95% CI Deff (%) (%) (%)

A Doctors’ decision accepted @ 44.1 42.7-45.6 4.4 31.0 28.1-33.9 2.4 95.3 94.1-96.5 1.9

A1 No Preference for/against injection 10.7 9.8-11.6 4.9 1.6 0.7-2.5 3.1 7.4 5.9-8.8 1.9

A2 Rational reasons for injection 21.4 20.4-22.5 3.4 12.0 9.9-14.2 2.7 92.6 91.2-94.1 1.9

A3 Doctors’ Push 16.2 15.0-17.4 5.9 18.8 16.5-21.5 2.1 5.7 4.2-7.2 2.5

B Irrational medical reasons @ 73.8 72.5-75.1 4.6 88.6 86.8-90.5 2.2 32.8 30.0-35.6 2.2

B1 Expectation from injection 70.3 68.9-71.6 4.5 49.7 46.8-52.6 2.0 18.1 15.7-20.5 2.4

B2 Patient’s demand 0.8 0.6-0.1 3.0 3.9 2.8-5.0 1.9 14.8 12.7-16.9 2.1

B3 Psychological relief to patients 6.0 5.4-6.6 3.4 53.8 50.8-56.8 2.3 4.7 3.5-6.0 2.2

@ Row estimates are cumulative of sub domains under the broad domain. (Respondents gave multiple responses) * Data from community survey ** data from Prescriber Interview

Assessment of Injection Practices in India

References

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