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USAID's MCH Program Component 5: Health Systems Strengthening

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USAID's MCH Program Component 5: Health Systems Strengthening USAID’s MCH Program Component 5: Health Systems Strengthening EPI Sindh - Strengthening Health System through Improved Immunization Service Delivery USAID Cooperative Agreement: No. AID-391-A-13-00002 Submitted: August 21, 2015 1 USAID’s MCH Program Component 5: Health Systems Strengthening EPI Sindh - Strengthening Health System through Improved Immunization Service Delivery USAID Cooperative Agreement: No. AID-391-A-13-00002 JSI Research & Training Institute, Inc. HSS Component 44 Farnsworth Street House #6, Street No. 5, F-8/3 Boston, MA 02210 Islamabad, Pakistan 44000 +1 617-482-9485 +92 051-111-000-025 www.jsi.com DISCLAIMER This document is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc. and do not necessarily reflect the views of USAID or the United States Government. 2 Table of Contents Acronyms ................................................................................................................... 4 Executive Summary ................................................................................................... 5 Key Take-Aways: ....................................................................................................... 7 Introduction ................................................................................................................ 8 Strengthening Immunization Delivery System in Four Target Districts of Sindh: ...... 10 PHASE I – Conducting Situation Analysis on State of Immunization in Four Target Districts of Sindh: ..................................................................................................... 10 PHASE II – Implementing Strategy for Increased EPI Coverage in Four Districts of Sindh: ....................................................................................................................... 16 Challenges ............................................................................................................... 27 Sustainability ............................................................................................................ 28 Recommendations ................................................................................................... 28 Annexures ................................................................................................................ 31 Annexure I: Work Plan ............................................................................................. 32 Annexure II: Registration Tools ................................................................................ 33 Annexure III: Roles and responsibilities of different stakeholders involved in the design and implementation of immunization program .............................................. 40 Annexure IV: Monitoring and Evaluation Tools ........................................................ 43 3 Acronyms AEFI Adverse Events Following Immunization BCC Behavior Change Communication BHU Basic Health Unit CFP Community Focal Person CO Community Organization DHO District Health Officer DHPMT District Health & Population Management Team DOH Department of Health DPO District Project Officer DSV District Superintendent of Vaccinations EPI Expanded Program on Immunization HF Health Facility HSS Health Systems Strengthening ILR Ice Lined Refrigerator JSO Junior Social Organizer LHW Lady Health Worker LSO Local Support Organization MCH Maternal & Child Health MLM Mid-Level Management NRSP National Rural Support Program PDHS Pakistan Demographic Health Survey PPHI Peoples Primary Health Care Initiative PRSP Punjab Rural Support Program PSLM Pakistan Social & Living Standard Measurement Survey RMNCH Reproductive, Maternal, Neonatal and Child Health RSP Rural Support Program RSPN Rural Support Program Network SRSO Sindh Rural Support Program TRDP Thardeep Rural Development Program TSV Taluka Superintendent of Vaccinations TT Tetanus Toxoid UC Union Council VO Village Organization WHO World Health Organization 4 Executive Summary Health Systems Strengthening (HSS) Component of USAID’s MCH Program, executed through a consortium led by JSI and implementing partners Contech International, RSPN, and Heartfile is mandated to strengthen the Government of Pakistan’s (GOP) health systems, with a particular focus on Sindh province, to enable it to effectively manage the equitable provision of health services to its rapidly growing population. The goal of the Project is to develop and support innovative, cost‐effective, integrated, and quality programs and services to strengthen systems around reproductive, maternal, newborn, and child health services for improved health outcomes. According to the World Health Organization, immunization is among the most successful and cost-effective health interventions worldwide and is considered to be a panacea for preventing between 2 to 3 million deaths every year caused from diseases that are vaccine-preventable1. In Pakistan, the Immunization program was initiated in 1976 as a pilot in major urban areas. In 1978 the Expanded Program on Immunization (EPI) was launched across the country. The program was initiated from all district headquarters through static centers with gradual expansion into rural areas. The program was primarily aimed at protecting children through immunization against childhood tuberculosis, poliomyelitis, diphtheria, pertussis, measles and their mothers from neonatal tetanus. Since its initiation, the program has significantly helped in reducing childhood morbidity and mortality, caused by avoidable preventable diseases. Over the years, new vaccines and technologies have been introduced and as a consequence, the EPI in Pakistan has also evolved, albeit slowly. For example, Hepatitis B, Haemophilus influenza type b (Hib) and Pneumococcal vaccines were introduced in 2002, 2009 and 2012 respectively. Despite the Government of Sindh’s efforts to adapt the goals and strategies for immunization of vaccine-preventable diseases in accordance with regional and global priorities, the prevalence rate of routine immunization remained dangerously low. In order to improve coverage, the Department of Health, Government of Sindh, sought out external assistance. JSI HSS Component team was then requested to provide technical and financial backstopping in four low coverage districts: Jacobabad, Kashmore, Tharparkar and Thatta. At the request of the Department of Health, JSI first provided technical assistance by conducting a situational analysis in the four least performing districts of Sindh. Literature was reviewed, briefing meetings with the district and union council level EPI staff were conducted, and based on those findings, a strategy was developed to improve the deteriorating immunization program. Next HSS Component through the 1 WHO – Immunization Coverage Fact sheet. (April, 2015). Retrieved from http://www.who.int/mediacentre/factsheets/fs378/en/ 5 grassroots level support of RSPN already formed community organizations, implemented this initiative. RSPN began by engaging its rural support programs (RSPs) namely NRSP, SRSO and TRDP to accelerate immunization activities in the target districts through registering children of 0-23 months for immunization against the preventable diseases and pregnant women for vaccination against neonatal tetanus. Two refresher training courses for vaccinators, supervisors and mid-level health management staff were organized to improve their technical knowledge in the field of immunization service delivery. Knowledge of district management was updated through WHO Mid-Level Managers (MLM) training modules. These generic modules were adapted according to Pakistan’s specific needs. In addition, a two day orientation training for the RSPN field staff was conducted to help them understand the importance of routine immunization, cold chains, roles and responsibilities of different stakeholders involved in the design and execution of the immunization process, the vaccine management process, and utilization of supervisory checklists to monitor EPI related activities. The orientation also helped the field staff to learn about the preparation of micro plans for vaccination, linking vaccinators to Local Support Organizations (LSOs) and fostered by RSP organizations who advocated that communities support the vaccination of their children and pregnant women. A door to door strategy was adopted to register the target group(s). While reviewing the mobility situation of Vaccinators, it was discovered that the majority of the Vaccinators were not mobile because they did not have transportation that would allow them to access hard to reach areas. Consequently, all the vaccinators assigned to outreach sites were given motorcycles with the special permission of USAID. For accuracy purposes, RSPN field teams also re-visited areas to verify both due and default children and pregnant women. Spot checking was done to verify the accuracy of target group registration by RSPN and JSI monitoring staff. A social mobilization approach was practiced to sensitize communities about the significance of immunization and retaining the immunization cards. In an effort to demonstrate political will, the provincial EPI Office, Sindh assured the provision of mobility funds required for uninterrupted field activities. In addition, several recommendations were made to endorse the EPI including a strong monitoring and evaluation system, a steady provision of
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