Addressing equity and reaching the underserved and unreached in

Abstract Introduction: The Maternal and Child Health Integrated Program (MCHIP) is providing technical assistance to the universal immunization programme (UIP) in India with the key objective of improving the coverage and quality of immunization services by adopting best practices through targeted and focused interventions.

Material and Methods: The MCHIP project is aimed at designing and adapting the “Reaching Every District” (RED) approach within the Indian context, with a particular focus on participatory problem identification and solving with government health staff, in collaboration with other development partners. Following a baseline situation analysis to assess immunization service delivery in two poor performing districts of and in the Santhal Parganas division of the state of in India a model on evidence based high impact interventions as Regular Appraisal of Program Implementation in District (RAPID) rounds, establishing Model RI Demonstration Centers to enable cross-visits, improved and comprehensive microplanning, institutionalizing new born vaccinations, strengthening the Maternal and Child Health Tracking System (MCTS) and development of need-based tools and job-aids (e.g. on micro-planning, service delivery, cold chain, communication, etc) for use by the health functionaries was formulated to strengthen immunization services in the two districts. Results: Over a period of 2 years full immunization in improved from 50% in 2010 to 71% in 2012 as per Routine Immunization monitoring data. Repeat Coverage Evaluation Survey (CES) conducted 18 months after the start of the intervention revealed that access to immunization session sites studied through sites located less than 15 minutes from home had improved from 73% in the baseline survey to 87% and availability of immunization cards improved from 56% to 82%. Using the RAPID methodology, health facilities graduated from 36% poor, 55% average and 9% good (during round 1) to 91% good and 9% average (after fourth round). Conclusion: In the two focus districts of Jharkhand, significant improvements in routine immunization quality and coverage were realized with MCHIP’s technical assistance and capacity building activities. The model can be scaled up to other poor performing districts of the state and the country to achieve desirable results. Keywords: Equity, Routine Immunization, Full immunization coverage

1 INTRODUCTION

India’s Universal Immunization Programme (UIP) is one of the largest in the world with an annual target of 30 million pregnant women and 27 million infants (1). The nationwide reported full immunization coverage (FIC) is 61% (2) with wide interstate and inter-district variations. Antigen wise coverage also varies and the country has the highest number of children in the world (7.4 million) who have not received Diphtheria Pertussis Tetanus (DPT) 3 dose. Jharkhand state in India is a success story in its Universal Immunization Program (UIP) performance, given the level of immunization it has achieved and the degree to which it is reaching the target beneficiaries. From a full immunization coverage (FIC) of 8.8% (NFHS-2, 1998-99) (3), the state has achieved FIC of 59.7% (CES, 2009) (2) in the span of a decade. However wide inter-district variations do exist and the Santhal Parganas division comprising the 6 districts of Deoghar, , , Jamtara, and has lower immunization coverage as compared to the state average (4). Key issues identified in the Santhal Parganas Division include lack of awareness and community participation, low utilization of services resulting in high number of drop outs, poor microplanning- sessions not being held as planned, high risk areas (HRA) not included in the work plan, inadequate human resource, irrational deployment of available human resource, weak vaccine and logistics management and poor or lack of monitoring and supportive supervision. United States Agency for International Development’s (USAID; Maternal and Child Health Integrated Program (MCHIP) provides technical support to the UIP in India at the national level, high priority states of Jharkhand and Uttar Pradesh and five focus districts (3 in Uttar Pradesh and 2 in Jharkhand). In developing a model for providing quality immunization coverage, MCHIP initiated its technical assistance in two districts of Santhal Parganas division viz. Deoghar and Jamtara in the state of Jharkhand, with support by state and national governments. The key objective is of improving the coverage and quality of immunization services by adopting best practices through targeted and focused interventions.

2 METHODOLOGY

MCHIP’s approach was based on the experiences of its predecessor project the Immunization Basis (IB) project (5) - that started working from 2005 at national and state levels (UP and Jharkhand). MCHIP helped to further design and adapt the “Reaching Every District” (RED) approach (6) within the Indian context, with a particular focus on participatory problem identification and solving with government health staff, in collaboration with other development partners. The TA to improve routine immunization has been provided by a small team of MCHIP technical staff at different levels: 3 at the national level, 2 at the state and 1 at the district; that facilitate leveraging of government and partner resources for program implementation. As an initial step a baseline situation analysis was conducted to assess the coverage and quality of immunization services in the two districts using the standard WHO 30x7 cluster survey (7) methodology. Following the baseline analysis a model was designed wherein TA was provided through a set of key interventions like the Regular Appraisal of Program Implementation in District (RAPID) rounds, establishing Model RI Demonstration Centers to enable cross-visits to showcase best practices and enable knowledge-sharing among facilities, improved and comprehensive microplanning, institutionalizing new born vaccinations, strengthening the Maternal and Child Health Tracking System (MCTS) and programme review mechanisms under UIP and development of need- based tools and job-aids (e.g. on micro-planning, service delivery, cold chain, communication, etc) for use by the health functionaries. The process adopted in development and application of each of these interventions is as follows:

2.1 Regular Appraisal of Program Implementation in District (RAPID) RAPID is a supportive supervision model for program improvement that takes the district as a unit and is conducted as a three to four day activity at periodic intervals (e.g. every 4-6 months). Under this approach, a one day orientation and training on routine immunization is facilitated for all stakeholders at the district level. Following that, teams visit all Community Health Centers (CHCs) and Primary Health Centers (PHCs) that are planning units for immunization and have vaccine storage facilities and randomly selected outreach session sites in the district over two to three days. Each team is comprised of a trained supervisor - either from MCHIP or partner organization (WHO, UNICEF), the Medical Officer in-charge of the facility, and a district official. The teams observe key thematic areas of programme management; cold chain and vaccine management; records and reports; and immunization safety and waste disposal practices. Concurrently a standardized checklist is filled by the supervisor, with the PHC head filling the second copy of the checklist. The team discusses program- related issues with facility staff, ensure onsite corrections, and provide training to contribute to the strengthening of skills and service delivery by the PHC staff. Collected data is compiled and analysed, contributing to an analytical report with indicators and grading of PHCs. The findings are shared with the district and PHC officials to develop an action plan for the next six months. Follow-up activities, including capacity building workshops, are conducted by the MCHIP district consultant to ensure corrective actions per plan. Figure 1 summarizes this process. Figure 1: RAPID process (8)

2.2 Establishment of Demonstration sites In addition to RAPID, another key approach adopted by MCHIP was to demonstrate best practices for RI in its focus districts in the key thematic areas of program management, cold chain & vaccine management, recording & reporting and injection safety. This was accomplished by establishing selected facilities as demonstration centres for respective thematic areas. The centres serve as sites for cross learning, enabling on-site trainings and replication of best practices in other health facilities providing RI services. Facilities to be developed as demonstration sites were identified based on an analysis of the key components such as infrastructure, human resources, level of commitment, equipment and logistics, and operational processes. In addition, results from two rounds of RAPID were considered to identify the potential demo-site. After the initial identification of the potential demo-site, focused inputs were provided to strengthen systems, processes, and capacities of health staff at the facility. For readiness assessment as a demonstration site, a stringent objective criteria was laid down in the form of a scoring system, with incorporation of mandatory (30 indicators, with a score of 2) and desirable (40 indicators with a score of 1) attributes. Per this scoring, a facility was considered as ready for organizing a cross-visit for a particular thematic area, when 3 criteria were fulfilled: (a) the total score gained is 80 or more (maximum score 100), (b) all mandatory attributes were fulfilled, and (c) the score was sustained for a period of one month. Cross-learning visits were then organized for staff from other facilities; the entire activity being facilitated through government approved funds.

2.3 Improved and comprehensive microplanning: A review of microplans was undertaken to include all missed out areas within the RI microplan. The primary objective is to increase the access of immunization services to the community and minimize uncovered and underserved areas.

2.4 Institutionalizing New Born Vaccination: The MCHIP project focussed on improving new born vaccination coverage at all the 13 health facilities in the two districts with vaccine storage facilities. A baseline analysis was conducted in June 2011 to assess the coverage of OPV-0 dose, BCG and Hepatitis B birth dose across these facilities followed by advocacy measures to improve and sustain the coverage. A key input was ensuring availability of vaccines round the clock in the labour rooms and streamlining the documentation practices.

2.5 Strengthening the Maternal and Child Health Tracking System: Pilot of “Tracking Every Newborn” (TEN) was rolled out in 7 selected sub center areas of the two districts from November-December 2011 onwards. The objective of this pilot is to assess feasibility of maintaining computer based database at health facility level and use of auto generated name based due lists for tracking of pregnant women and children beneficiaries for full immunization. The prime objective of this pilot is to gain learning’s to feed into overall MCTS protocol for ensuring more effective functioning, outcome and impact. The approach of TEN initiative was built upon improving capacity of health workers of the identified sub centers in correctly filling and updating the MCH registers through supportive supervision, and enhancing dialogue with other functionaries (ASHA and Anganwadi worker) for triangulating records to identify new, missed and drop out beneficiaries. No new formats were introduced through this initiative and emphasis was on optimal utilization of the available formats. This beneficiary information from MCH registers of villages in catchment area of 7 pilot sub centers was then computerized into specially prepared MS excel based tool (no internet facility required) with feature for auto generation of name based due lists. Name based due lists were then generated in local language and English and shared with respective ANMs once every month on a pre-fixed date. During the session, ANMs used these due lists to track and vaccinate the beneficiaries and added the details of newborns and newly registered pregnant women in coordination with ASHA and Anganwadi worker. After each session the updated due lists were collected and computer database was updated (i.e. beneficiary wise dates of vaccination given and addition of new beneficiaries).

2.6 Development and dissemination of tools and job-aids: A review of the existing immunization-related material in the country and overseas, including several generic job-aids designed by IB, WHO, UNICEF, Program for Appropriate Technology in Health (PATH) and others was conducted by MCHIP. Where appropriate; existing materials were adapted to the current Indian context. The job aids were designed through an interactive process of review and input by end-users, national stakeholders and international experts. The first step in developing these tools and job aids was to assess (with the Ministry of Health and Family Welfare, Government of India and other partners) the kind of technical information required at different levels. Needs were identified for all thematic areas - including guidelines for micro-planning, vaccination schedules, cold chain maintenance, waste disposal, supervision and communication with the community. Design principles, quality graphics and pictures with minimum text (English and ) were incorporated to attract attention and ensure understanding. Thus tools and job-aids were developed for all key thematic areas of routine immunization pertaining to program management, cold chain, immunization safety and waste management that were used in both the focus districts of Jharkhand.

Figure 2: Some examples of Job aids developed by MCHIP. A complete index of tools and job-aids is available at www.mchip.net (7)

Figure 2: Some examples of Job aids developed by MCHIP. A complete index of tools and job-aids is available at www.mchip.net (9)

2.7 Impact of TA on quality and coverage The improvements in the quality of immunization service delivery were captured in the successive rounds of RAPID. To assess the quantitative outcome and impact of the above TA and capacity building activities in terms of coverage, MCHIP conducted a coverage evaluation survey (CES) after approximately 18 months of starting the activity (Sep 2011) in the two focus districts and compared the results with the baseline situation (CES done in Feb 2010).

3 RESULTS

3.1 Improved Quality of Immunization Services through RAPID model Under the RAPID model health facilities are graded as good, average and poor as assessed through a structured checklist and scores generated through an excel based software. Facilities are graded on a total score of 60 across different parameters related to the immunization program; those with a score of more than 50 are graded as good, between 31-50 as average and 30 and below as poor. Table 1 summarizes the results of the four successive rounds of RAPID conducted in the health facilities of the two districts. It is evident from the data that out of 11 health facilities in the focus districts only one was in good category (9%) while 6 (55%) were in average and 4 (36%) in poor in the first round of RAPID. By the fourth round, the status changed to 10 in the good category (91%) and one (9%) in the average category. Table 1: Grading of Health Facilities over 4 rounds of RAPID

Round 1 Round 2 Round 3 Round 4 (Feb 2010) (Nov 2010) (April 2011) (Nov 2011)

District PHC Points Grade Points Grade Points Grade Points Grade

Deoghar Mohanpur 25 Poor 43 Avg 55 Good 59 Good

Deoghar Sarath 47 Avg 41 Avg 53 Good 55 Good

Deoghar Madhupur 36 Avg 41 Avg 50 Avg 55 Good

Deoghar 54 Good 52 Good 52 Good 58 Good

Deoghar Sarwan 47 Avg 53 Good 53 Good 58 Good

Deoghar 37 Avg 50 Avg 50 Avg 53 Good

Deoghar Karon 33 Avg 35 Avg 53 Good 58 Good

Jamtara Kundhit 24 Poor 41 Avg 50 Avg 60 Good

Jamtara Narayanpur 26 Poor 39 Avg 48 Avg 55 Good

Jamtara Nala 27 Poor 40 Avg 56 Good 50 Avg

Jamtara Jamtara 30 Avg 56 Good 58 Good 58 Good

The specific thematic areas that showed improvement in quality of immunization services are as follows: 3.1.1 Program Management A number of programmatic issues were strengthened during the various visits to health facilities at Deoghar and Jamtara. The major areas of concern were inadequate microplanning in terms of estimation of logistics and beneficiaries, unavailability of a map of the catchment area, irregular block meetings, immunization calendar and coverage monitoring charts not being displayed, and an insufficient number of supervisory visits at facility and session sites, as revealed by the first RAPID results. Focussed TA led to improvements in all of these areas by the end of the fourth round of RAPID (Figure 3).

Figure 3: Programme Management parameters over four RAPID rounds

3.1.2 Cold chain & vaccine management A cold chain assessment was done based on a set of 25 parameters. The major issues identified were diluents not placed in Ice Lined Refrigerators (ILR) at least 24 hours before reconstitution, improper maintenance of records of defrosting ILRs, records of power failure, and periodic checks of temperature log books by Medical Officer in Charge (MOIC). These aspects were regularly followed up along with strengthening other components of cold chain services (e.g. keeping ILRs and DFs away from direct sunlight and walls and other equipments; maintenance of temperature log books for ILRs and DFs; and routine monitoring of daily temperature). As a result of focussed TA and hands-on training of cold chain handlers on the issues highlighted, across 22 of the 25 parameters, 100% facilities had optimal results (Table 2).

Table 2: Key cold chain parameters assessed over four RAPID rounds Cold Chain Round Round 2 Round Round 1 3 4 All ILRs & DFs placed on blocks 91% 91% 100% 100% All ILRs & DFs at least 10 cm away from walls and 91% 100% 100% 100% surrounding equipment All ILRs & DFs away from direct exposure to sunlight, 100% 100% 100% 100% moisture and rain All ILRs & DFs connected through functional Voltage 82% 91% 100% 91% Stabilizers Temperature Log Books available for every ILR and DF 82% 100% 100% 100% Twice daily monitoring of temperature in respective log 100% 100% 100% 100% books Record of power failures/cuts 27% 64% 100% 100% Record of Defrosting ILRs & DFs 27% 55% 82% 100% Periodic checks of Temperature Log Books by Facility in- 73% 100% 100% 100% charge Functional thermometer placed inside every ILR 91% 100% 100% 100% Cabinet Temperature of ILRs between +2 to +8OC 91% 91% 100% 100% No frost OR frost less than 5mm on inside walls of every 100% 100% 100% 100% ILR All vaccine vials correctly arranged inside labeled cartons 82% 100% 100% 100% No T-series or Hepatitis B vaccine vials placed in the 82% 100% 100% 100% bottom of ILR No items other than vaccines placed inside ILR 91% 100% 100% 100% Vaccines in ILR within expiry dates 100% 100% 100% 100% OPV vials within usable stage of VVM 100% 100% 100% 100% Vaccine vials in ILR with labels 100% 100% 100% 100% No reconstituted BCG & Measles vials 100% 100% 100% 100% Diluents placed in ILR, at least 24 hours before 73% 91% 100% 100% distribution Functional thermometer placed inside every DF 91% 100% 91% 91% Cabinet Temperature of DFs between -15 to -18OC 91% 82% 100% 82% No frost OR frost less than 5mm on inside walls of every 91% 100% 100% 100% DF Correct placement of ice packs inside DF 91% 73% 100% 100% No RI vaccines stored inside DFs 91% 100% 100% 100%

3.1.3 Immunization safety and recording and reporting All aspects of immunization safety & waste management, along with recording and reporting practices showed continuous improvement over the four rounds of RAPID. In the first round, 20% of facilities were reporting VPD and AEFI cases in their monthly performance reports (MPR), chemical disinfection of immunization waste was being performed only at one site and a disposal pit was being used for sharps disposal at four facilities. By the end of the fourth round, all these practices were found to be followed at 100% of facilities.

Figure 4: Reporting and immunization safety parameters over four RAPID rounds

3.2 Improved Quality of Immunization Services through other interventions Two demo-sites (CHC in for the thematic areas of programme management, and Sarwan CHC in Deoghar district for the thematic areas of cold chain and vaccine management and injection safety) were successfully developed and cross learning visits for staff members were organised on 07/12/11 in Jamtara and 14/02/12 in Deoghar district respectively; 49 health functionaries and officials being trained through these cross learning visits. (10). These cross visits helped staff members from other facilities of the two focus districts to update their knowledge and practices related to immunization program. As revealed from subsequent follow-up visits to their facilities by MCHIP technical staff, these staff members have started to apply the acquired knowledge to improve practices in their own facilities. Excel based microplanning software enabled the generation of computerized microplans with improved microplanning resulting in more than 90% of the planned sessions being held every month. Sustained advocacy for new born vaccination in health facilities improved the coverage of OPV-0 and BCG from around an average of 35% from January – June 2011 to an average of 70% for the post intervention period of July 2011 – June 2012. The TEN initiative initiated in December 2011 helped identify drop outs in the 7 selected HSCs areas. Table 3 reflects the additional beneficiaries immunized through this initiative. The learnings from the TEN initiative will help to further refine and strengthen the GOI MCTS.

Table 3: Beneficiaries immunized through the TEN initiative till June 2012 BCG OPV1 OPV 2 OPV3 DPT1 DPT 2 DPT3 Measles DPT B OPV B 210 222 194 208 285 273 288 245 225 173

3.3 Overall Impact of interventions Impact of the above interventions was assessed through the independent RI monitoring conducted by WHO and the CES evaluation surveys conducted by MCHIP. RI monitoring data revealed that in a period of one year full immunization in Deoghar district improved from 50% in December 2010 to 71% in December 2012 and DPT-1 to DPT-3 drop out decreased from 20% to 13%. In addition the repeat CES revealed that access to immunization session sites studied through sites located less than 15 minutes from home had improved from 73% in the baseline survey to 87% in the repeat CES. In the same period availability of immunization cards improved from 56% to 82%. A ranking system based on select RI monitoring indicators was also devised to study the impact. All the 24 districts in the state of Jharkhand were evaluated through a scoring system (Table 4).

Table 4: Ranking system based on RI monitoring indicators Indicator Maximum score allotted Session sites monitored by Government officials 5 Children monitored by Government officials 5 % Session not held 5 % Full Immunization 10 % Drop out (DPT 1- DPT 3) 5 % Drop out (BCG- Measles) 5 % Due list availability at session sites 5 % Hub cutter availability at session sites 5

Deoghar district had a score of 10 and was ranked 20th in 2010; while it had a score of 23 and ranked 10th in 2011. Of all the 24 districts it was the district to show the second most improvement in a span of one year. Similarly Jamtara had a score of 24 in 2010 and was ranked 4th while in 2011 it had a score of 27 and was ranked 5th.

4 DISCUSSION

It is quite evident from the results that the interventions have had a desired impact. Both the quality of services and the coverage has shown an improvement. Key focused interventions definitely have had a positive impact on the overall RI service delivery mechanisms in the two districts. Although training of Medical Officers, health workers and cold chain handlers is an integral part of the government system (11), the trainings often occur in a sporadic manner, are not participatory in nature and are not reinforced. As a result, health workers do not retain the basic concepts for a substantial period of time. Recognition of this gap formed the basis of development of the tools and job aids. Because of their easy to understand and pictorial nature, these aids were easily adapted and served as ready-reference material for the health workers. The job aids included various important aspects of immunization pertaining to the thematic areas of cold chain, immunization safety and waste management, and recording and reporting (9). The basic PHC and district level microplanning tool and compilation software helped program management. This facilitated automatic generation of microplan essentials: e.g. session wise targeting of children and pregnant women and logistics requirement with minimum data entry. Meticulous microplanning was achieved by the continuous use of the tool by the block level program managers. Recognizing the importance of the scale-up of the job aids and tools, buy-in of central and state ministries of health and development partners was achieved after extensive advocacy on the possible uses and thorough research on production and budgeting. As a result, state governments in Jharkhand and Uttar Pradesh have allocated funds for the preparation of plans (based on the micro- planning software) and for the dissemination of the printed job-aids at sub-centre, PHC and district levels. Several of the materials were also included in the Government of India’s plan for the immunization training of 50,000 Medical Officers across the country. The utilization of the materials has transcended local and programmatic boundaries. Reflecting the growing interest in the micro-planning tool job-aids, many state governments have adapted them for use in their routine immunization programs. RAPID is a unique system that enables measurement and quantification of the quality of immunization services. As a result of the RAPID approach, quality improvement of vaccine management and immunization service delivery has been facilitated through joint problem analysis with the health staff. This empowers them in a collaborative way to handle issues by providing on-site demonstrations and capacity building to correct behaviour and follow-up with the health facilities to ensure sustainability. The approach currently undertaken by state governments and partner agencies is to include RAPID as an integral component of the RED strategy and has proved to be an extremely effective tool to improve the quality and coverage of RI services (12, 13). In an effort to achieve RAPID scale-up, MCHIP has shared feedback with program managers, decision makers and donors within the states and nationally to demonstrate the benefits of this approach. Consequently, in 2009-10, RAPID was scaled-up in six districts of Jharkhand state, with concurrence of the government and assistance of partners. In the following years, funds have been allotted for two rounds of RAPID in all 24 districts at approximately 2000 US$ per district (14). Although there could be some bias in the selection of the demo-sites - given infrastructure, commitment of staff members and feasibility of cross visits, it does not influence the result; the main objective of establishing the demo-site was to motivate the health staff to adopt correct practices rather than influencing infrastructural changes. Improved coverage in the two districts can be attributed to the collaborative result of multiple approaches, including RAPID, adopted in the state to enhance routine immunization (RI) and the concerted efforts of all the partners working together in the area (with MCHIP playing a lead role in providing technical assistance).

5 CONCLUSION

Approaches like utilization of tools and job aids, organization of RAPID rounds at regular intervals, and establishment of demonstration sites led to overall improvement in quality of immunization services in the two focus districts of Jharkhand. While better programming led to overall increases in coverage, emphasis on improving equity in service delivery led to improved coverage amongst marginalized populations and rural communities. Training of front line workers in interpersonal communication through regular visits to session sites translated into behaviour change in the community that was evident in better upkeep of records and improved knowledge. These simple approaches promoted through MCHIP technical assistance and capacity building in a 1.5 year time period can easily be generalised to wider geographic areas within the existing resources. This has been demonstrated by the successful adaptation of RAPID by all the districts of Jharkhand and 32 districts of UP; and the utilization of microplanning software by states like Haryana and Madhya Pradesh. REFERENCES 1. Ministry of Health and Family Welfare. National Vaccine Policy. Government of India; April 2011. 2. UNICEF Coverage Evaluation Survey, 2009 National Fact Sheet. 3. International Institute for Population Sciences (IIPS) and ORC Macro, 2000. National Family Health Survey (NFHS 2), 1998-99:India:Mumbai:IIPS 4. International Institute for Population Sciences (IIPS), 2010. District Level Household and Facility Survey (DLHS-3), 2007-08: India: Key Indicators: States and Districts, Mumbai: IIPS. Available from: http://www.rchiips.org/pdf/DLHS-3_KI.pdf. Accessed on: 14/08/12. 5. Periodic Intensification of Routine Immunization (PIRI) Monograph. 2009 . Available from: http://www.immunizationbasics.jsi.com/Docs/ PIRImonograph_Feb09.pdf. Accessed on: 14/08/12. 6. Vandelaer J, Bilous J, Nshimirimana D. Reaching Every District (RED) approach: a way to improve immunization performance. Bull World Health Organ. 2008;86(3). 7. Howshaw W.S. Description and comparison of the methods of cluster sampling and lot quality assurance sampling to assess immunization coverage. Department of Vaccines and Biologicals. World Health Organization: 2001 8. Supportive Supervision for Strengtening Immunization in India. Guidelines for Program Managers. 2009. Available from: http://www.immunizationbasics.jsi.com/Docs/ IMMbasics_India_Supportive_Supervision_Concept_Note_2009.pdf. Accessed on: 14/08/12. 9. Revised Index of Tools and Job-aids [database on the Internet] 2010. Available from: http://www.mchip.net/sites/default/files/revised%20index%20 for%20tools%20&% 20job% 20aids_2.pdf. Accessed on: 12/08/12. 10. Establishing Model Routine Immunization Demonstration Center: Experience from Jharkhand, India. Jan 2012. Available from: http://www.mchip.net/sites/default/files/demo%20site%20Jamtara_one%20pager.pdf. Accessed on: 12/08/12. 11. Ministry of Health and Family Welfare. Government of India. Immunization Handbook for Medical Officers; 2009. 12. Improving immunization through supportive supervision. Program for Appropriate Technology in Health (PATH) document.. Available from: http://www.path.org/publications/detail.php?i=1443. Accessed on: 14/08/12.

13. Andhra Pradesh: Building a Model Immunization System. Indian state protects millions and demonstrates what new vaccines and technologies can achieve. Program for Appropriate Technology in Health (PATH); December 2004. 14. Jharkhand State Program Implementation Plan 2012-13 [database on the Internet]. Available from: http://pipnrhm-mohfw.nic.in/PIP2012-13.htm. Accessed on: 14/08/12.