Support for Routine Immunization: PEI-EPI Synergy in ,

Dr. Tariq Masood, JSI Patricia Taylor, JSI Presenters

Dr. Tariq Masood Sr. Immunization Advisor John Snow, Inc. (JSI)

Patricia Taylor Project Director and Sr. Advisor John Snow, Inc. (JSI) Agenda

Background

Approach

Key Outcomes

Barriers and Solutions

Lessons Learned

Looking Ahead

Q&A BACKGROUND What is PEI/EPI Synergy?

EPI = Expanded Programme on Immunization started in 1978/79 in Pakistan. In this presentation, refers primarily to routine immunization (RI). PEI = Polio Eradication Initiative started 1988 globally. Pakistan is one of only 2 remaining polio endemic countries. Situation improved through 2018, but 2019 saw sharp rise in cases which appears to have continued in 2020. Synergy is aimed to leverage the resources of PEI for improving the coverage of EPI and vice versa Complications of coordination include EPI and PEI having different lines of authority, structure and incentives: • EPI – National Program Manager, Provincial EPI Project Director, District Health Officers • PEI - Emergency Operations Center (EOC) established in 2014; units present at provincial and district levels under EOC coordinators. • Vaccinators have been critical to both EPI/RI and to PEI campaigns (SIA); work on campaigns has been incentivized, on RI has not. Evidence-based approaches to achieving PEI/EPI synergy were few and none at scale before 2016, when the initiative reported here began. PEI-EPI Synergy Background PEI-EPI Synergy in Pakistan

2012: First Meeting of Pakistan’s Technical Advisory Group on Polio Eradication recommended that the PEI explore synergy especially in high-risk districts.

2014: Global Independent Monitoring Board (IMB) made similar recommendations, specifically mentioning need to identify zero dose children during campaigns. PEI/EPI Synergy = 2014: WHO/EMROWorking “urged together [Pakistan] to reach to accelerate additional implementation children of the EPI/PEI synergyfor plan both.” (Summary polio andreport routine on the twenty immunization-eighth meeting of national managers of the Expanded Programme on Immunization. Amman Jordan WHO-EM/EPI/342/E).

2018: National Emergency Action Plan (NEAP) 2017/18 strongly endorsed PEI-EPI synergy, with one of its strategic objectives: “Strengthen routine immunization coverage in core reservoirs,” through “monthly RI outreach delivering all antigens including IPV.”

Despite these endorsements, there continued to be challenges to achieving synergy. Project Background

• 5-year RMNCH strengthening project in 16 districts of Sindh Province (2013-2018).

• Support to Department of Health, (DOH-GoS) in family planning, immunization, MNCH (CHX, HBB, KMC, CEmONC, mobilization) and nutrition services.

• 16 districts participated in the PEI/EPI synergy intervention in some fashion – in 8 districts, the intervention was more intensive.

• Three districts started Feb. 2016; five were added between Aug. and Oct. The intensive PEI/EPI intervention ended in December 2017, spanning approximately 18 months. Pakistan 2020 Population : ~ 221 million Sindh Province 2020 Population : ~ 51 million 2020 Newborns : ~ 1.8 million

Source: Pakistan Demographic and Health Survey 2012-2013 Only 14% of children in rural Sindh were fully immunized, resulting in repeated outbreaks of polio, measles and other VPDs

Source: Pakistan Demographic and Health Survey 2012-2013 Sindh Province Immunization Coverage 2012 – 2014 100 94 90 87 83 84 80 78 76 69 70 65

60 53 53 50 45 39 40 35 29 30

20

10

0 BCG Penta-1 & OPV-1 Penta-3 & OPV-3 Measles FIC

Admin Reports PDHS 2012-13 MICS 2014

PDHS: Pakistan Demographic Health Survey MICS: Multi Indicators Cluster Survey APPROACH Mixed Model for Public Private Partnership

We took a health systems approach to improving routine immunization (RI) through better planning & implementation.

Our goals were to: • Register every child under 2 years of age and reach every pregnant women • Improve recording, reporting, monitoring and supervisory system • Ensure mobility of vaccinators and their training and supervision • Engage communities through local civil society organizations (CSO), under the umbrella of the Rural Support Programmes Network (RSPN). Key Actors

Provincial level • Project Director EPI Sindh and Team • PEI Emergency Operation Cell Coordinator & Team • JSI Team

District level • District Health Management Team • District Immunization Officers (DIOs) • Vaccinators and Supervisors • MIS Team • Local CSO representatives • Village Volunteers Project Supported Districts and Polio Cases by Date of Onset

Date of onset: 5th Mar & 12th Apr 2016 Date of onset: 10th Feb 2016

Project-supported districts (16)

PEI/EPI intensive districts (8) Date of onset: 17th Jan 2016 Districts with DIOs (16)

WPV1 cases in Sindh in 2016 (8)

Sujawa Date of onset: l 10th & 16th Oct 2016

Date of onset: 3rd Sept & 3rd Nov 2016 Intervention through District Immunization Officers (DIOs) Activities in Intensive PEI/EPI Districts

• Conducted micro-census and used data to update EPI & polio micro-plans – missing populations were included. • Community engagement through: • Village focal person – lists exchanged with EOC & District Polio Control Rooms • Social mobilization thru CSO’s network • Management Information System (MIS) for registration, tracking of due doses & defaulters, monitoring of performance and reminder messages to caregivers. • Advocacy to provincial authorities and DHMTs to make sure vaccinators were released from polio campaigns (SIA) to conduct RI outreach services (by order of EOC, EPI & DG-H). • Capacity building for mid-level managers, vaccinators, supervisors, Lady Health Workers (LHWs), data entry operators and others. Micro-Census Community Mobilization Vaccination in hard to reach areas Vaccination in Hard-to-Reach Areas Activities in Intensive PEI/EPI Districts (continued)

• Prepared plans for outreach during polio campaigns.

• Prepared lists of due & defaulter children by area (using micro-census + PEI zero-dose data).

• Provided petrol, oil, and lubricant (POL) support to vaccinators (in addition to motorbikes) and advocated with state to increase this allowance.

• Monitored & provided supportive supervision during outreach.

• Shared feedback regularly with authorities for corrective measures.

• Continuously advocated for and promoted the synergy approach. SUMMARY PEI – EPI Synergy Activities: Outreach Sessions Carried Out During Campaigns (May 2016-Sept 2017)

3,000 More than 16,835 outreach sessions were conducted 2,767 2,706 during polio days and >300,000 children vaccinated 2,605 2,500 for different antigens including OPV & IPV.

1,974 2,000

1,669

1,500

1,086 1,067 1,044 1,000 888 736 777 536 494 477 499 500 442 278 297 319 320 284 222 246 127 201 177 178 167 211 162 150 149 111 50 52 86 108 99 91128 80 0 NIDs SNID SNID NID SNID SNID NID SNID Feb Mar Apr May Jul Sept May-16 July Aug Sep Oct Nov Dec Jan-17 SNID SNID NID SNID SNID NID # of Union Councils # of vaccinators involved # of outreach sessions conducted KEY OUTCOMES Villages Registered at Start and End of Project in 8 Intervention Districts, Sindh

Total at baseline: 23,694 villages Total by end of project : 28,566 villages 5,500 20% increase in number of villages registered

4,500

3,500

2,500

1,500

500

Jacobabad Kashmore Matiari Tando Umerkot -500 Allahyar Number of Villages Registered at Baseline Number of Villages Counted in MIS at EOP Number of Children Registered (0-23 months) Life of Project, 8 Intensive Districts, Sindh

200,000

180,000 Total registered at baseline: 313,177 children Total registered life of project: 830,610 children 155,511 160,000

140,000 125,962 117,140 120,000 106,870 103,102 100,000

77,151 75,965 80,000 68,909 56,372 60,000 46,292 38,837 38,292 41,636 40,000 35,110 31,653 24,985 20,000

0 Jacobabad Kashmore Matiari Sujawal T. Allahyar Tharparkar Thatta Umerkot

Registered Start of Project Registered End of Project Quarterly Vaccinator Outreach Sessions Conducted Versus Planned in 8 Intervention Districts (Oct-Dec 2016 to Oct-Dec 2017)

100 98 93 92 8989 90 86 87 84 85 82 81 80 80 74 75 71 72 68 69 70 66 67 63 62 61 62 60 59 59 58 57 57

60 55 ercent

P 52 49 50 46 45 41 40 38 34 30 30 28

20

10

0 Thatta Sujawal Kashmore Jacobabad Tharparkar Matiari TAY Umerkot Oct- Dec 16 Jan- Mar 17 April- June 17 July- Sep 17 Oct-Dec 17 Routine Immunization Coverage (Penta 3) Increased Dramatically in the 8 PEI/EPI Intervention Districts, Sindh 100 90 90 88 81 80 80 79 80 71 70 67 62 60

50 46 43 40 38 34

30 27 23 20 Percent registered children immunized children registered Percent 13 10 8 4

0 Jacobabad Kashmore Matiari Sujawal T.Allahyar Tharparkar Thatta Umerkot Total Coverage Start of Project Coverage Life of Project Results of PEI/EPI Strategy, Sujawal District Numbers of children <2 years of age vaccinated by antigen Jan-Jun 2016* and Jan-Jun 2017** 16,000 15,200 Total Jan-June 2016 : 13,771 children 14,000 Total Jan-June 2017 : 41,823 children 13,244

12,087 12,111 12,095 11,781 12,000 11,117 11,119 11,120

9,552 9,565 9,554 10,000 9,252

8,000 6,456 6,482 6,454 6,000 4,769 4,640 4,669 4,642 4,260 4,400 4,418 4,403 4,000 2,992 2,579 2,000 1,753 644

0 BCG OPV 0 OPV 1 OPV 2 OPV 3 Penta 1 Penta 2 Penta 3 PCV 1 PCV 2 PCV 3 IPV Measles Measles Jan to Jun 16 Jan to Jun 17 1 2 *Source: Reported Coverage **Source: Project MIS Data PEI/EPI Intervention Districts Reported Fewer VPD Cases than Non-Intervention Districts in the Final Months of the Project

PEI/EPI Intervention Districts

Non-PEI/EPI intervention districts

Source: Sindh Province Surveillance Data, Week 19, May 2017, published jointly by the EPI Cell of the Government of Sindh and WHO EPI Sindh Monthly 550 Children vaccinators motorbikes by 3,557 district registered: outreach JSI-HSS; staff trained/ 830,610 activities POL & 4x4 oriented in 8 PWs: 348,315 reporting vehicles districts Micro support planning & Facilitation of monthly Outcomesvaccinators Capacity outreach with motor Micro- building census Routine Immunization:activities 658,958 bikeschildren & fuel received 3 doses of Pentavalentplan & OPV (79% of eligible) Fully ImmunizedClose monitoring, Children supportive: 434,747 supervision children andreceived BCG + 3 dosesproblem of solvingPenta &at Measles1gross-root level (52% through of eligible) DIOs & HO Immunization Teams of Project & IPs CommunityTetanus elimination: 227,537 pregnant women engagementreceived 2 doses of Tetanus Toxoid (65% of eligible) Outreach Awareness Vaccination activities, PEI- Tracking & messages: of eligible EPI Synergy; caregiver 18,898 village 900,136; children & MNTe/ reminders PWs volunteers/ due dose Measles SIA- CFPs engaged reminders: EPI Synergy 86,681

Source: MIS dated 31st Dec, 2017 BARRIERS AND SOLUTIONS Barriers Faced: Overcome By:

• Involvement of EPI vaccinators in • Continuous advocacy with provincial & repeated anti-polio SIAs district authorities

• Frequent transfer of District Health • Advocacy with Ministry & EOC to retain Officers (DHOs) the DHOs in their posts for longer time

• Inconsistent implementation of • Close monitoring & supervision through microplans/outreach plans DIOs; provision of motorbikes, POL & field assistants

• Low level of awareness of • Organizing awareness sessions with communities in remote villages village focal persons and communities – role of CSO Barriers Faced: Overcome By:

• Initial micro-census and EPI • Triangulated EPI microplans and microplans were not complete micro-census data with polio SIA (villages and families missed) microplans -- found hundreds of villages and thousands of children that were initially missing. • Capacity issues of District Health • Mid Level Managers’ training of Management Team and vaccination managers & Immunization in Practice staff. training of vaccination staff in addition to on-the-job coaching. • District health officers and • Continuously advocated and shared commissioners reluctant to release results with district and provincial- Vaccinators during campaigns – fear level decision-makers of missing polio targets LESSONS LEARNED Lesson Learned

• Target the Highest Decision Maker: Due to high turnover, the team kept losing valuable time engaging with and introducing each new district staffer to the approach. Securing a memorandum of understanding with the province before starting activities would have been more effective and less time-consuming.

• Design for Context: The resources allocated for routine immunization must be reviewed periodically to ascertain requirements and mobilize resources. In our initiative, we used motorcycles, four-by-four vehicles, boats or camel carts to enable quick access to hard-to- reach areas, increasing the number of families that were identified and served. These are missing ingredients in the effort to maximize EPI and PEI results.

• The same approach will give you the same results. Gaining acceptance for innovations or even minimal change was difficult in our context, even though existing methods hadn’t yet achieved the target of polio eradication. With the new synergistic approach – both RI and polio vaccination coverage increased. Looking Ahead Way Forward

• In transitioning this successful package of interventions, we ensured that the details of the PEI-EPI synergy approach were shared with the Federal/Provincial EPI teams, EOCs and District Authorities, and with WHO, UNICEF and donors (Gavi, BMGF, World Bank and USAID). • Many of the project’s interventions were adopted and continue to be implemented with support from the partners. • Government of Sindh recruited 1,808 additional EPI vaccinators, purchased additional motorbikes for vaccinators, and increased their monthly allowance for Petrol Oil Lubricant. • WHO initiated "Enhanced Outreach" activities (with Gavi funding) throughout the country, focusing on special micro planning and outreach plan preparation. • DIO monitoring model was adopted by UNICEF and funded by Gavi -- third- party monitors are working in & Hyderabad and UNICEF is supporting Government to scale up the approach to all of Sindh province. Advice for Others Facing Similar Barriers

• Achieving and sustaining polio eradication requires a strong EPI program. The resource requirements of both programs—PEI and EPI—must be met to achieve and sustain results.

• Longstanding endorsements for PEI/EPI synergy must be operationalized and put into action on the ground in all districts.

• Be Bold! Try something new, measure your results, share them with key decision makers and don’t give up. Your innovations can help save the lives of women and children. THANK YOU

THANK YOU Sustainability

• Department of Health, Government of Sindh agreed to recruit District Immunization Officers for all the districts of Sindh province. Notification of nomination was issued at district and sub-district level, although there were problems with implementation.

• Majority of the Project’s interventions were adopted by WHO, UNICEF, Acasus & IRD and implemented after the project ended.

• Based on the experience & recommendations of the project, Government of Sindh recruited 1,808 additional EPI vaccinators.

• Motor bikes and additional support for Petrol Oil Lubricant (POL) and lobbied for Government to increase this to PKRupees 4,000/vaccinator per month for all vaccinators doing outreach.

• Monitoring model through DIOs adopted by UNICEF, who used Gavi funding to hire third-party monitors in Karachi & Hyderabad and is in the process of scaling the approach up to all of Sindh province. Sustainability (continued)

• Based on shared project experience and findings, WHO initiated "Enhanced Outreach" activities (with Gavi funding) throughout the country focusing on special micro planning and outreach plan preparation, monitoring & supervision and provision of additional resources for transportation, etc.

• Community mobilization: More than 16,000 village volunteers were informed and guided about vaccination; many continue promoting vaccination in rural Sindh.

• Cohort of children & women vaccinated with support from the project (more than a million) and protected against vaccine preventable diseases.

• Subsequent to the project reported here, Gavi has utilized the services of our JSI team to develop the Urban Immunization Roadmap for Karachi. Vaccination Coverage at End of Project among Children Registered in the 8 PEI/EPI Intervention Districts, Sindh Children Fully Children Children Vaccinated Children Vaccinated Immunized Districts Registered by from Penta 1 - 3 from BCG - Penta3 BCG - Measles1 the Project Number % Number % Number % Jacobabad 117,140 94,034 80 66,888 57 56,653 48 Kashmore 125,962 102,177 81 72,726 58 62,668 50 Matiari 77,151 47,468 62 42,352 55 31,115 40 Sujawal 68,909 46,086 67 41,268 60 29,199 42 T.Allahyar 75,965 53,792 71 47,187 62 35,043 46

Tharparkar 155,511 136,838 88 103,834 67 89,838 58

Thatta 106,870 96,554 90 84,618 79 69,536 65 Umerkot 103,102 82,009 80 74,503 72 60,695 59

Total 830,610 658,958 79 533,376 64 434,747 52 TT Vaccination Coverage among Registered PWs at End of Project in 8 Intervention Districts, Sindh Registered Pregnant TT 1 TT 2 District Women # % # % Jacobabad 56,412 53,295 94 39,271 70 Kashmore 47,711 43,129 90 27,525 58 Matiari 23,659 20,275 86 11,941 50 Sujawal 30,029 27,293 91 18,058 60 T.Allahyar 24,486 20,778 85 13,070 53 Tharparkar 82,239 81,511 99 62,863 76 Thatta 38,515 37,900 98 25,070 65 Umerkot 45,264 40,893 90 29,739 66

Total 348,315 325,074 93 227,537 65