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PEI-EPI Synergy in Pakistan

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PEI-EPI Synergy in Pakistan Support for Routine Immunization: PEI-EPI Synergy in Sindh, Pakistan 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, Government of Sindh (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 Sujawal Tando Tharparkar Thatta 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
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