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Routine Immunization the ‘Muskan’ Initiative Bihar, India

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Routine Immunization the ‘Muskan’ Initiative Bihar, India Routine Immunization The ‘Muskan’ initiative Bihar, India Aradhana Johri, Joint Secretary, Ministry of Health & Family Welfare Govt. of India India, a changing environment National Rural health Mission, the Flagship program of GoI launched in 2005 Communization – Incentivised ASHA in each village. Village Health Committees set up. Community oversight at every level Decentralized district planning, flexible need based funding by GOI. Funding enhanced.$150 mill to Bihar. Infrastructure strengthening at each facility. IPHS norms made. 2 ANMs at sub health centre. PHCs are 24*7 with 3 nurses. CHCs are First referral unit Converged outreach scheme of monthly Village Health Nutrition Day launched nationally Institutional deliveries increased exponentially due to GOI incentive scheme *ASHA Accredited Social Health Activist; ICDS Worker, **ANM= Auxiliary Nurse Midwife. IPHS= Indian Public Health Standards Immunization Specific Initiatives in India • Decentralized planning & need based funding. • Improving service delivery through: – Alternate vaccinators – Alternate Vaccine Delivery – Increased services through Special immunization drives – Improving mobilization & tracking through community link workers * & vaccinators ** • Improving supervision & monitoring • Intensified session Monitoring by partners • Ongoing training of HWs in immunization – 51% Health Workers trained in India (107,066 / 209,695) – 90.6% in Bihar (11478 / 12675 ) *ASHA Accredited Social Health Activist; ICDS Worker, **ANM= Auxiliary Nurse Midwife. Bihar: A Challenge • State in North India, Jammu & Kashmir bordering Nepal Himachal Pradesh PunjabChandigarh Uttarakhand • Population 93 million Haryana Delhi Arunachal Pradesh Sikkim (9% of total population) Uttar Pradesh Rajasthan Assam Nagaland Bihar Meghalaya •Poor infrastructure and Manipur West Bengal Tripura Madhya Pradesh Jharkhand Mizoram annual floods add to Gujarat Chhattisgarh service delievery Daman & Diu Orissa Dadra & Nagar Haveli challenge Maharashtra •Poor roads and power Andhra Pradesh Goa supply Karnataka Puducherry •Frequent polio SIAs. 15 Lakshadw eep Tamil Nadu Andaman & Nicobar Islands Kerala days / month Bihar: A Challenge ( contd..) Indicator Bihar India MMR 371 301 IMR 58 55 Fully Immunized Children DLHS-2 Data not available Evaluated Coverage 14 to 40 40 to 55 55 to 75 75 - 85 85 - 93.4 India JAMMU & KASHMIR JAMMU & KASHMIR HIMACHAL PRADESH HIMACHAL PRADESH PUNJAB PUNJAB UTTARANCHAL Bihar: 24.4 % UTTARANCHAL Bihar: 41.4 % HARYANA HARYANA ARUNACHAL PR. ARUNACHAL PR. SIKKIM SIKKIM RAJASTHAN UTTAR PRADESH RAJASTHAN UTTAR PRADESH ASSAM ASSAM NAGALAND NAGALAND BIHAR MEGHALAYA BIHAR MEGHALAYA MANIPUR MANIPUR JHARKHAND JHARKHAND GUJARAT MIZORAM GUJARAT MADHYA PRADESH MIZORAM MADHYA PRADESH WEST BENGAL WEST BENGAL CHHATTISGARH CHHATTISGARH ORISSA ORISSA D&N HAVELI D&N HAVELI MAHARASHTRA MAHARASHTRA ANDHRA PRADESH ANDHRA PRADESH GOA GOA KARNATAKA KARNATAKA A&N ISLANDS A&N ISLANDS PONDICHERRY PONDICHERRY TAMIL NADU TAMIL NADU LAKSHADWEEP KERALA LAKSHADWEEP KERALA India: 47.6% DLHS-2 (2002-04) DLHS-3 (2007-08) Source: http://www.mohfw.nic.in/dlhs/dlhs08_release_1.htm MuskanMuskan (In English …Smile) An Innovative Initiative in Bihar • Target children 0-23 months: ~ 4.7 million • Augmentation of immunization efforts started in 2005 through special immunization drives • Later formalized as ‘‘MuskanMuskan ’’ in Oct-2007 • Partners in Implementation : – State Health Society, Bihar – UNICEF – NPSP/WHO • Enhanced Political commitment Enhanced Political Commitment Oversight by the Chief Minister of Bihar Regular Review by the Executive Director State Task force meetings to review the programme & take corrective actions Muskan Strategy Inter - Sectoral Coordination Involvement Identification of village & level Mahila Tracking of Mandal * beneficiaries Muskan Strategy Performance based Review of incentives for Microplan service providers * Local women’s group HowHow ‘‘MuskanMuskan ’’ WorksWorks •• MuskanMuskan RegisterRegister && SurveySurvey – Enlisting of all beneficiaries through h-to-h survey by community link workers (ICDS* & ASHA**) – Regular updating of muskan registration data CHAMPARAN WEST n : 36,980 CHAMPARAN EAST SITAMARHI SHEOHAR Recording & Registering ( Jan-Nov’08) GOPALGANJ MADHUBANI SUPAUL KISHANGANJ ARARIA SIWAN MUZAFFARPUR (>60% Muskan Registers Updated ) DARBHANGA SARAN MADHEPURA SAMASTIPUR SAHARSA PURNIA VAISHALI BUXAR KHAGARIA KATIHAR BHOJPUR PATNA BEGUSARAI MUNGER BHAGALPUR Data not available ARWAL NALANDA JEHANABAD LAKHISARAI ROHTAS SHEIKHPURA Less than 50 % KAMUR JAMUI BANKA AURANGAABAD NAWADA 50 to 79 % GAYA 80% & above * ICDS: Integrated Child Development Scheme Picture> ** ASHA: Accredited Social Health Activist Source: WHO/NPSP & UNICEF RI Monitoring ……HowHow ‘‘MuskanMuskan ’’ WorksWorks • Weekly Muskan sessions – Microplans revised and 6700 additional ANMs hired – Increasing outreach sessions by adding an additional day for immunization (8-10 outreach sessions per each sub-center area per month) – Integrated efforts of ICDS and health department at all levels esp. at imm session CHAMPARAN WEST n : 36,980 CHAMPARAN EAST SITAMARHI SHEOHAR Re-establishing Outreach services (Jan-Nov’08) GOPALGANJ MADHUBANI SUPAUL KISHANGANJ ARARIA SIWAN MUZAFFARPUR DARBHANGA (>90% Sessions Held) SARAN MADHEPURA SAMASTIPUR SAHARSA PURNIA VAISHALI BUXAR KHAGARIA KATIHAR BHOJPUR PATNA BEGUSARAI MUNGER BHAGALPUR ARWAL NALANDA JEHANABAD LAKHISARAI ROHTAS SHEIKHPURA Data not available KAMUR JAMUI BANKA AURANGAABAD NAWADA Less than 50 % GAYA 50 to 79 % 80% & above PictureSource:> WHO/NPSP & Unicef RI Monitoring Improved Micro Planning using GIS • Urban RI initiated in 23 towns and cities of Bihar • Micro-planning and monitoring using GIS technology % Monitored Sessions with Mobilizer Present (Pre & Post Muskan) 100 90 80 88 78 70 74 60 65 50 51 49 40 30 20 10 0 AWW Presence ASHA Presence Any Mobilizer Presence Pre Muskan (n=17910) Post Muskan (n=37134) Pre Muskan : Nov-06 to Oct-07, Post Muskan: Nov-07 to Oct-08 Source: WHO/NPSP & UNICEF RI Monitoring ……HowHow ‘‘MuskanMuskan ’’ WorksWorks •• CoverageCoverage basedbased IncentiveIncentive – Tracking new borns through due list – Performance based monetary incentive to workers for ensuring vaccination of over 80% due for the month CHAMPARAN WEST n : 36,980 Tracking of Beneficiaries (Jan-Nov’08) CHAMPARAN EAST SITAMARHI SHEOHAR GOPALGANJ MADHUBANI SUPAUL KISHANGANJ (>65% Due List Registers Used) ARARIA SIWAN MUZAFFARPUR DARBHANGA SARAN MADHEPURA SAMASTIPUR SAHARSA PURNIA VAISHALI BUXAR KHAGARIA KATIHAR BHOJPUR PATNA BEGUSARAI Data not available MUNGER BHAGALPUR ARWAL NALANDA JEHANABAD LAKHISARAI Less than 50 % ROHTAS SHEIKHPURA KAMUR JAMUI BANKA 50 to 79 % AURANGAABAD NAWADA GAYA 80% & above Picture> Source: WHO/NPSP & Unicef RI Monitoring ……HowHow ‘‘MuskanMuskan ’’ WorksWorks •• LocalLocal womenwomen ’’ss group*group* meetingmeeting – Conducting twice a month meetings – Create awareness on issues related to Health, Nutrition and Immunization. •• SupportiveSupportive SupervisionSupervision – Integrated approach to supervision by MO & ICDS official – Random verification and cross checking of immunized beneficiaries from muskan registers. – This forms the basis for release of monetary incentive to the link workers. *Care givers with vaccinator & community link workers Process Monitoring (Jan 08 to Nov 08) Inter Sectoral Coordination Community participation (>75% ICDS Presence) (>65% Local women’s group meetings held) CHAMPARAN WEST CHAMPARAN WEST CHAMPARAN EAST SITAMARHI SHEOHAR CHAMPARAN EAST GOPALGANJ MADHUBANI SITAMARHI SHEOHAR SUPAUL KISHANGANJ GOPALGANJ MADHUBANI ARARIA SIWAN MUZAFFARPUR SUPAUL KISHANGANJ DARBHANGA ARARIA SIWAN MUZAFFARPUR SARAN DARBHANGA MADHEPURA SARAN SAMASTIPUR SAHARSA PURNIA MADHEPURA VAISHALI SAMASTIPUR SAHARSA PURNIA VAISHALI BUXAR KHAGARIA KATIHAR BHOJPUR PATNA BEGUSARAI BUXAR KHAGARIA KATIHAR BHOJPUR PATNA BEGUSARAI BHAGALPUR MUNGER MUNGER BHAGALPUR ARWAL NALANDA ARWAL NALANDA JEHANABAD LAKHISARAI JEHANABAD LAKHISARAI ROHTAS SHEIKHPURA ROHTAS SHEIKHPURA KAMUR KAMUR JAMUI BANKA JAMUI BANKA AURANGAABAD NAWADA AURANGAABAD NAWADA GAYA GAYA Picture> ure> Data not available Less than 50 % 50 to 79 % 80% & above Source: WHO/NPSP & Unicef RI Monitoring ……HowHow ‘‘MuskanMuskan ’’ WorksWorks •• BudgetaryBudgetary supportsupport – Funding support from Government of India under the National Rural Health Mission (NRHM) – Expenditure in Routine Immunization has increased more than two times in last two years •• RegularRegular ReviewReview – Reviews conducted at all levels – Monitoring by the state and partners holds the key to bridge gaps. HowHow ‘‘MuskanMuskan ’’ WorksWorks SummarySummary M Muskan Register & Survey U Muskan Sessions Coverage Based Incentive S Women group meeting K Supportive Supervision A Budgetary support N Regular Review RIRI StrengtheningStrengthening effortsefforts andand SurveySurvey ResultsResults 100 Launching RI Muskan 90 augmentation Drive Launched (Aug 05) (Oct 07) 80 70 60 50 40 41.4 30 Percent Percent Fully Immunized 20 22.4 24.4 10 0 DLHS-1(1998-00) DLHS-2 (2002-04) DLHS-3 (2007-08) Source: http://www.mohfw.nic.in EvaluatedEvaluated ImmunizationImmunization CoverageCoverage :: BiharBihar % Coverage Challenge is to reduce 100 drop out & left out children 90 80 81.5 70 60 50 54.2 40 46.8 40.8 41.4 30 20 25.6 28.2 22.4 24.4 10 0 BCG Measles Fully Immunized DLHS-1(1998-00) DLHS-2 (2002-04) DLHS-3 (2007-08) Source: http://www.mohfw.nic.in ConclusionsConclusions • Bihar has shown considerable improvement in immunization
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