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

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.

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

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

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/

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 vaccines, etc.

Key Take-Aways:

The key take-aways of the immunization program, as a health system intervention are the following:

1. A well designed social mobilization plan, if pursued rigorously, can instigate the change process within the communities to motivate them to bring their children and pregnant women for vaccination and dispel myths and superstitions related to immunization, making them initially the first adopters and later change agents of immunization.

2. A well-structured coordination mechanism among different stakeholders of immunization plans can accelerate the immunization activity leading to an increase in coverage. This coordination enables the stakeholders to keep track of their responsibilities. For instance, if vaccinators are unable to perform outreach services, other stakeholders such as RSPN will inform DHO about the absence of vaccinators in the field and subsequently the case will be taken up to be resolved. Hence, coordination helps in improving the efficiency of the activity to be performed. Furthermore duplication of services is also mitigated through well planned coordination procedures.

Introduction

In 2013 a consortium led by JSI and implementing partners Contech International, RSPN and Heartfile began activities to improve the reproductive, maternal, newborn and child health (RMNCH) situation in Sindh province of Pakistan, Health Systems Strengthening Component (HSS Component), as part of USAID’s Maternal & Child Health (MCH) program. As previously stated, the Component’s mandate is to develop and support innovative, cost-effective, integrated, high quality health programs and services. Increased immunization to reduce neonatal, infant, child and mother morbidity and mortality is among the specified milestones that must be achieved as part of this mandate. The rationale to include this milestone is based on the findings of Pakistan Demographic & Health Survey (PDHS), 2012-13 which demonstrated a dismal state of immunization coverage in Sindh. Despite the fact that EPI was launched nationwide in 1978 with the objective of protecting children by immunizing them against childhood Tuberculosis, Poliomyelitis, Diphtheria, Pertussis, Measles and their mothers against Neonatal Tetanus, the PDHS survey found poor coverage and implementation gaps in four provinces: Balochistan, KPK, Punjab and Sindh. Sindh fares slightly better than Balochistan in the status of complete immunization, of 12-23 months children and retaining of vaccination cards but worse in immunization coverage compared to Punjab. In comparison to KPK, Sindh has a lower percentage of children without vaccinations and its performance is poor on both indicators of ‘all basic vaccinations’ and ‘population has seen having vaccination cards.’ (Figure 1).

Figure 1 - Percent of immunized versus non-immunized children (12-23 months) and population with vaccination cards

All basic vaccinations No vaccinations Population has seen having vaccination cards 66

40 41

29 26 21 16 12 8 9 2

Balochistan KPK Punjab Sindh

In addition, the survey findings have also revealed that urban-rural differentials are the highest in Sindh; 52% in urban against 14% in rural areas (Figure 2).

Figure 2 - Percent of 12-23 months children by urban-rural differentials and provinces 74

58 62 52 52 47 47 41 36 39 38 22 22 17 12 13 14 12 12 5 5 2 1 3

Urban Rural Urban Rural Urban Rural Urban Rural Balochistan KPK Punjab Sindh

All basic vaccinations No vaccinations Population seen having vaccination cards

Realizing the dire state of immunization affairs in the province, the provincial Department of Health (DOH) Government of Sindh sought additional external support to strengthen its routine immunization services in the low coverage areas to increase immunity against vaccine-preventable diseases in order to attain 90% vaccination coverage at provincial level along with eradicating polio, measles and tetanus through Supplemental Immunization Activities (SIAs). JSI HSS Component was then, requested to provide technical and financial backstopping in implementing immunization activities in four districts: Jacobabad, Kashmore, Tharparkar and Thatta. DOH Government of Sindh selected these districts using the indicator of low immunization prevalence rate.

Strengthening Immunization Delivery System in Four Target Districts of Sindh:

To address the situation of low routine immunization coverage in the four target districts, JSI HSS Component team, planned to opt for a phased approach:

PHASE I – Conducting Situational Analysis on the State of Immunization in Four Target Districts of Sindh:

Phase I was initiated by conducting a situational analysis in the four target districts, on immunization prevalence and factors that were hampering vaccination adoption. To meet the requisites JSI conducted the following:

1- Initial scoping and briefing meetings 2- Literature review 3- Report submission = presenting key issues attributed to low immunization coverage in the four districts

1. Initial scoping and briefing meetings:

JSI team held consultative sessions with district and provincial EPI staff. Meetings were also held with the Secretary Department of Health Sindh and District Health Officers (DHOs) of each district to understand their expectations from JSI HSS Component team in implementing the immunization services. Detailed meetings were held with the District and Union Councils level EPI staff to understand the current prevailing situation at the grassroots level. During the meetings, discussions were held on challenges that were limiting teams from increasing immunization rates in these districts.

2. Literature review:

Literature review was conducted to review previous relevant reports and documents. Findings from prior studies and surveys were also analyzed to gather insight on the dismal state of immunizations in the province, and specifically the four target districts.

Below is a brief summary of the literature review:

a) Pakistan Social & Living Standard Measurement Survey (PSLM), 2012-13, has found that the immunization coverage, among children aged 12-23 months, have increased, countrywide, from 53% in 2010-11 to 56% in 2012- 13. This increase rate was higher in urban areas (67 percent in 2012-13 as compared to 62 percent in 2010-11) than in rural areas (51 percent in 2012-13 as compared to 49 percent in 2010-11). Sindh lags behind in all antigens and experienced significant fall in coverage against polio and measles. The survey 10

shows a significant variation among four districts in the performance of immunization activities (Figure 3).

Figure 3 - Percent of completely immunized children (12-23) months by vaccine type in four target districts

Jacobabad Kashmore Tharparkar Thatta 76 72 71 71 69 68 66 62 62 62 64 59 59 59

48 44

BCG DPT 3 OPV 3 Measles

b) Pakistan Demographic & Health Survey, 2012-13, has shown the overall low EPI coverage in Sindh. Less than one-third (29.1%) of all children, aged 12-23 months, were reported as fully vaccinated. Furthermore Sindh and Balochistan are the two provinces where immunization rates have declined over the years in contrast to Punjab and KPK province (Figure 4). While 78.5% of children have received BCG vaccination, only 38.6% received DPT- III and 44.6% received measles.

Figure 4 - Percent of full immunization coverage by province

PDHS 2006-07 PDHS 2012-13

65.6

52.6 52.7 53.8 46.9 47.3

37 35.2 29.1

16.4

Punjab Sindh KPK Balochistan Pakistan

c) UNICEF, in 2009, conducted a study to explore the reasons why a significant number of 12-23 months age children remained unvaccinated in Sindh. It was reported that 50.3% children were fully immunized in the province while nearly half of the children missed routine immunization services due to a combination of factors, including: poor service delivery, lack of communication, improper management, and community resistance.

d) Aga Khan University carried out a nationwide study titled "A national nutrition survey 2011," under the supervision of Dr. Zulfiqar Bhutta. The validation of child immunization was part of this survey. It was found that the overall immunization coverage has shown improvement, over the preceding years, by antigen i.e. BCG 80%, Pentavalent 52%, OPV 93% and measles 51%.

e) World Bank and Global Alliance for Vaccines Initiative carried out a joint assessment of Pakistan EPI during January-June 2011. The findings of the study revealed that program performance had been stagnant with only 40- 60% children receiving vaccines at the appropriate age interval. Non- immunization of vaccine-preventable diseases is still a major cause of high infant and child mortality in Pakistan. Evidence points out that low achievement of EPI is due to multiple factors such as: inadequate performance in the area of service delivery, suboptimal performance of program management, insufficient supervision and monitoring mechanism, lack of logistic control, inappropriate human resource management and financing, non-serious health seeking behaviour and other demand side related issues.

World Health Organization (WHO) estimates that based on low immunization rates, one in every 11 children dies before five years of age in Pakistan, and one-third of these deaths are due to diseases that are vaccine-preventable. Because of the poor performance by the districts, in implementing routine immunization, have established Sindh as one of the hubs for the highest number of cases and deaths due to polio, neo-natal tetanus and measles in addition to regularly occurring incidences of diphtheria and pertussis.

3. Report submission on key issues attributed to low immunization rate:

Based on the findings of initial scoping, briefing meetings and literature review, the following key issues were identified as reasons for the low immunization coverage in the province: i. Lack of strong political commitment in implementing EPI

There was a weak political commitment behind implementing EPI. Adequate attention has been given to polio eradication activities but a strong emphasis has not

been established for routine immunization. Often, the majority of EPI workforce’s workdays are overridden by with polio eradication campaigns and other disease control activities. As a consequence, there were frequent occurrences of disease outbreaks in Sindh that could have been easily averted. ii. Political interference prohibits the accountability of immunization staff

District health management staff are reluctant to monitor the performance of immunization staff. They are not ready to confront the political pressures that they have to face in cases of scolding or penalizing the immunization staff for their negligence in delivering their professional duties. Mostly, their decisions are either invalidated or they are transferred, if ever they dare to take a professional stand regarding the poor performance of immunization staff at the grassroot level. iii. Absence of reward-based performance system

There is no mechanism to provide performance based management of vaccinators. In addition, there is no recognition or acknowledgement for vaccinators and supervisors who provide services or are dedicated and determined to their work. Instead when vaccinators and supervisors witness the lack of accountability and professional behaviors by some of their colleagues, it affects morale and also impact individual performance, and worker morale. iv. Fragile monitoring system

A routine monitoring system for immunizations is nearly non-existent. If ever monitoring is done, it is carried out on a limited basis under local supervision. Consequently, the data gathered is unreliable. The major reasons identified for lack of efficient monitoring system include: shortage of transport and POL/maintenance; political backing of the vaccinators’ poor performance that hampers punitive action; supervisors’ visits are mostly unstructured, lack of vertical check and balances system as supervisors themselves are often unsupervised. v. Weak reporting system

Sound reporting is essential for monitoring the implementation status of immunization activities. Currently however, the data is reported on an irregular basis due to the lack of a formal reporting mechanism from HFs and subsequently the district health management staff who are unable to perform their responsibilities. If ever at any HF, the mechanism was established, the data compilation was not done following any sort of professional standards. Often the numbers are duplicated and therefore, the accuracy of data cannot be validated.

vi. Unregulated immunization services

The HFs at Basic Health Units (BHUs), operating under PPHI, are providing only curative services rather than preventive ones. Consequently, a large unregulated private sector has emerged that is charging high costs for immunization services. Furthermore, these BHUs’ administration are not accountable to district and provincial health departments. Public authorities must regulate these BHUs to provide both types of services, (preventive and curative) so that women and children can get both health care services under one roof. vii. Immunization is an expensive activity

The high cost of immunization has led to overall low coverage rates. Implementation activities are largely dependent on international funding. Often the provincial government is not found keen to allocate funds for EPI in their annual health budgets which cause delay and/or stagnation of operations at the grass roots level. In the absence of public support to widespread immunization implementation, people rely on limited services available at the static health services. With the increasing and costly commercialization of health services in the private sector, very few can access immunization facilities. viii. Inequitable access to immunization facilities

Currently there is an inadequate number of HFs in the public sector. On average, there is only one public HF per union council, which is capable of providing service to only 20-30% of the population. This number has remained unchanged over decades. In addition, a significant percentage of public sector HFs do not offer regular immunization services. This problem is coupled with irregular outreach of vaccination services, particularly in rural areas and hampered by injudicious distribution of human resources, non-availability of motorcycles, non-availability of timely budgetary support, lack of motivation in vaccinators, absence of strict supervision and accountability.

ix. Non-existence of demand generation for immunization services

At the district level, demand generation for immunization services has always been a low priority. One possible explanation for this is that most people lack knowledge or education about the benefits of immunization and are hesitant to bring their children. In addition, myths are rampant around immunizations, including for example, that “my child got a fever after getting vaccinated”. These myths can be addressed through effective social mobilization campaigns. To date however, no proper social mobilization plan for routine immunization exists in districts. While Lady Health Workers (LHWs) and vaccinators as well as community volunteers are best suited to act as change agents or opinion leaders for practicing social mobilization in union councils, they receive insignificant support from the staff of BHUs. Currently radio

messages and local cable network are the only means of social mobilization in some places, and seldom actually take place.

x. Unsteady supply of vaccines

Provision of vaccines to provinces is the responsibility of the Federal Government. However, during Jan-Jun 2015, there was a glitch in the coordination, on this subject, between federal and provincial governments. Subsequently, the supply of vaccine, OPV 3 and TT, and BCG syringes were often delayed due to insufficient operational resources. The non-availability of vaccine in HFs makes the due population deprived of accessing immunization facilities well in time.

xi. Poor logistical arrangements

There is currently either no, or an extremely limited forecasting system for EPI logistical arrangements (excluding vaccines, diluents and syringes) at the district level. There is no evident control over vaccine wastage at district and service delivery points in HFs and the vaccine wastage is usually high. There is a fragile cold chain system for the required preservation of vaccines at both the district and tehsil levels because the back-up power arrangements are either missing or misused. Furthermore there is no proper inventory maintenance of expensive cold chain equipment at district and union council levels. xii. Technical & human resource capacity issues

The assessments at the district level have indicated inadequate technical capacity of EPI management staff. The posting of vaccinators in union councils is a highly politicized activity. The majority of the vaccinators are posted in urban union councils due to political backing while the remote or rural union councils are often left vacant.

To improve immunization coverage, some other cadres should be engaged. For instance, a trained para-medical staff can provide immunization services in HFs. However, there is no clear course of action established for the districts to utilize the services of other health squads because there is no uniform policy in the province. Given the poor capacity of existing immunization staff; lack of motivation among different stakeholders involved in the planning and execution of immunization programs; vaccinators’ and supervisors’ indifferent attitude towards their jobs all have contributed to low immunization rates.

PHASE II – Implementing Strategy for Increased EPI Coverage in Four Districts of Sindh:

At the conclusion of Phase I, the implementing strategy was designed to improve immunization coverage in four target districts. This strategy was executed through a four-stage process.

1st stage:

HSS Component team, along with the Rural Support Program Network (RSPN) together developed a work plan (Annexure I) to perform the routine immunization services in these districts. The orientation of RSPN staff on EPI was arranged in Crown Hotel, Hyderabad during 24-25 April, 2014. Staff was briefed on EPI and also trained on the registration process of children aged 0-23 months and pregnant women. Registration tools (Annexure II) were then developed and shared for the collection of information on children and pregnant women who were either due or had defaulted on their vaccination schedule.

2nd stage:

RSPN, with the support of Rural Support Program (RSP) organizations began implementation of the immunization activities at the grassroot level. Three RSP organizations supported activities including Sindh Rural Support Organization (SRSO) for Jacobabad and Kashmore districts; National Rural Support Program (NRSP) for Thatta and Thardeep and Rural Development Program (TRDP) for Tharparkar district. Each was primarily responsible for the implementation of EPI activities. In addition, the monitoring officer was hired and based in RSPN’s head office in Islamabad. For implementation of the project activities, the RSP organizations hired Junior Social Organizers (JSOs), two district social mobilizers (one female and one male), one data entry operator and one District Project Officer (DPO) for improved coordination with district EPI staff. One JSO was made responsible for two union councils.

To accelerate the adoption of immunization at grassroots, RSPN has laid a great emphasis on social mobilization at community level. RSPN has, therefore, established the following three-tier mobilization structure that is being implemented by select RSP organizations:

1st tier - Established Community Organizations (COs) will support rural household meetings, at the “Mohalla” or community level.

2nd tier - The COs are clustered into Village Organizations (VOs) at the village level.

3rd tier - Local Support Organizations (LSOs) are formed at Union Council (UC) level through VOs clusters. These LSOs are responsible for working to improve health and education by creating awareness and lobbying with relevant stakeholders.

RSPN is working in a total of 176 UCs, which comprises four districts, 151 UCs have LSOs while in the remaining districts, only the COs exist. If any locations were identified in any UC that didn’t have COs, then RSPN field teams, comprised of RSP organizations, would work with local volunteers, commonly known as Community Focal Persons (CFPs).

3rd stage:

The JSI HSS Component team and RSPN representatives held a brainstorming session in order to develop a work breakdown structure (Figure 5) and a draft of the roles and responsibilities (Annexure III) of different stakeholders involved in delivering the immunization initiative.

Figure 5 – Work breakdown structure

The JSI team provided technical support to train the RSP organization’s staff to perform a cluster of activities (Figure 6) deemed essential for launching the immunization program. The HSS Component’s team sponsored consultant provided the following activities:

1. Organized the orientation sessions and refresher training courses for vaccinators and supervisors;

2. Conducted MLM courses for district health management staff;

3. Developed standardized supervision tools for supervisors; and

4. Designed monitoring and evaluation tools (Annexure IV) to measure overall immunization program progress.

Figure 6 – RSP organizations performing cluster of activities

Meetings of LSOs

Representation in DHPMT Identification Meetings of CFPs

Awareness Text Messages Increased Sessions with for absence of Immunization Parents/ vaccinators Rate Communities

Holding Data Coordination Registration Meetings Vaccination of children & women

4th stage:

To explain the details immunization to staff, RSPN organized a two day orientation session for the field staff. JSI HSS Component’s Immunization Specialist, RSPN’s Social Sector Specialist, Community Outreach Manager and Monitoring Officer briefed the participants about the significance of routine immunization, cold chain equipment for vaccine preservation, the vaccine management process, the use of supervisory checklists to monitor EPI related activities, and the role and responsibilities of district health management teams. Through mock exercises, the staff learned about the registration of target groups and contact tracing for defaults and drop-out cases.

The orientation also helped the field staff to learn about the preparation of micro plans for vaccination and linking LSOs to vaccinators. The staff learned to coordinate with the EPI staff at the district and Health Facility (HF) levels and share issues faced by RSPN field teams in seeking support for vaccinators to provide routine immunization. The DHOs and District Superintendent of Vaccinations (DSVs) were also present during the session. DHOs appreciated the support being provided by HSS Component team. They assured their full support for the provision of immunization services in accordance with micro plans developed jointly by RSPN field staff and vaccinators.

RSPN also organized a one day orientation workshop for the LSOs. The participants were briefed about the situation of EPI coverage, the importance of the vaccination and the role of the community in providing support to EPI for improving routine vaccination coverage. LSOs made assurances to prioritize and support EPI on their agenda. They also committed to assist EPI management staff in registering target groups and tracing of the defaults to reduce drop outs. The LSOs members were provided information on the following:

1) Registration process; and 2) Formats for registering the target groups.

JSI Responsibilities:

1. Refresher Training for Vaccinators and Supervisors:

The orientation sessions and refresher training courses were perceived as vital to initiating the implementation phase. These were done while keeping in consideration the changes which had occurred, overtime, in the immunization system, (e.g. the introduction of new vaccines, new policies or reporting procedures, More than 450 supportive supervision and monitoring techniques, vaccinators were and participatory approaches such as problem trained in all four districts. identification, problem-solving, training adults, time management, two-way communication and coaching of on-site training etc.) and enhanced disease surveillance needs.

The vaccinators’ technical knowledge was improved in the following areas: immunization service delivery techniques, planning the immunization schedule, safety of injections, safe disposal of waste material, proper handling of cold chain equipment, vaccine management, how to create improvement in data quality as well as identifying and providing follow up for children who had defaulted.

The vaccinators were particularly trained on the use of a default tracking system. The vaccinator will be reviewing, on a regular basis the EPI permanent register to identify infants who may have failed to receive the necessary doses of vaccine. The register can also be used to track Tetanus Toxoid (TT) defaults. With the help of a default tracking system, the outreach activities can be intensified and ultimately the districts will be able to bring down the drop out rate below 10% in every union council.

2. Mid-Level Management (MLM) Training for District Health Management Staff:

Two MLM courses for district health management staff were organized to update their knowledge through WHO EPI Mid-Level Managers training modules. These generic 52 District Health modules were amended according to the country’s Managers were specific needs. The two course sessions were held, trained in all comprising 26 managers each, during February 18-22 four districts. and March 10-14, 2014 in Indus Hotel Hyderabad and Inter Pak Inn Hotel Sukkur. The prior session included managers from Thatta and Tharparkar Districts while the latter was designed for the managers of Jacobabad and Kashmore Districts.

3. Developing Standardized Supervision Tools for Supervisors:

To assist supervisors, tools were developed to standardize the supervision system. These tools included supervisory checklists and learning materials (EPI manuals and guidelines, etc.) to be used by supervisors during supervisory visits.

4. Designing of M&E Tools to measure overall immunization program progress:

To improve the overall quality of the immunization program, a well-designed monitoring and evaluation system is necessary. The JSI team, in close coordination with districts and RSPN field staff, developed the monitoring and evaluation tools to:

• Assess procedures and practices for measuring progress on immunization, identifying problems and solutions and guiding policies and interventions.

• Ensure that all infants and pregnant women are immunized; appropriate quantities of vaccines and safe injection equipment is delivered on time; staff are well trained and adequately supervised; performance of union councils is being reviewed on monthly basis; communities have developed confidence in the quality of vaccines delivered and the immunization services, they have received.

• Analyse immunization data, generated from field, examining disease incidence occurrence and forecasting the happenings of Adverse Events Following Immunization (AEFI).

5. Distribution of 550 Motorcycles to Strengthen EPI Activities

The situational analysis conducted on EPI implementation activities at the grassroots level reiterated that the lack of sufficient means for transportation is a major challenge particularly to those hard-to-reach rural villages. For 550 motorcycles example, Thatta District had a mere nine motorcycles for were distributed in 16 districts 149 vaccinators; Kashmore District had only 29 motorcycles for its 99 vaccinators; Tharparkar District had only two motorcycles for its 101 vaccinators; and Jacobabad District had 20 motorcycles for 80 vaccinators.

Keeping this in mind, USAID donated 550 motorcycles to the DOH to improve EPI coverage across the province. The 15 districts which received motorcycles included Jacobabad, Kashmore, Thatta, Tharparkar, Dadu, Khairpur, Tando Allah Yar, Umerkot, Naushehro Feroze, Sukkur, Mirpurkhas, Mitiari, Shikarpur, Gotki, Sanghar and Sujawal. HSS Component has developed a strong relationship with EPI and DHOs for vaccination activities. This coordination and follow up by HSS Component will help to increase vaccination.

JSI organized a ceremony on November 21 in Karachi to formally hand over the motorcycles to the DOH. Mr. Leon S. Waskin, USAID’s Regional Director for Sindh and Balochistan (on the left in the photo below), and Dr. Jam Mehtab Dahar, Provincial Minister for Health (on the right), gave away keys to motorcycles to DHOs of the aforementioned districts (Figure 7 & 8).

Figure 7 – Motorcycle handing over ceremony

Figure 8 - Opposition Leader National Assembly, Syed Khurshid Shah and EPI Provincial Manager, DR. Khamisani in a motorcycles distribution ceremony in Sukkur

RSP Organizations performed a cluster of activities:

1. Meetings of Local Support Organizations:

These LSOs are mandated to complete the registration of target groups. Through their executive body monthly meetings and general body quarterly meetings, LSOs ensure that monthly targets are achieved and progress is monitored. These meetings also serve as platforms to delegate tasks to the VOs and COs so that the decisions taken at higher levels can be implemented at the grass roots. During these meetings, LSO members discuss the community role in implementing routine vaccination and performance of vaccinators. The LSOs also raise issues related to vaccinators’ performance during the UC level coordination meetings that are being held at BHUs.

2. Identification of Community Focal Persons:

To get vaccinators the support from the community which is required for the smooth execution of immunization activities – LSOs identified Community Focal Persons (CFPs) who would Identified 8, 928 Community Focal serve as community activists and are not paid any Persons to cover 10, 534 honorarium for their services. RSP organizations locations/settlements discuss with LSOs the selection criteria and responsibilities of these CFPs. To date, LSOs have identified 8,928 CFPs to cover 10,534 locations or settlements. Each CFP is responsible for one location. There are only a few CFPs that are responsible for two to three small settlements. Included in the CFPs’ responsibilities are:

• Ensure that immunization cards are retained at the community level • Inform parents and pregnant women about the arrival of the vaccinator • Assist the vaccinator in knowing about new births and new pregnancies in their catchments for vaccination purposes.

3. Awareness Sessions with Parents/Communities:

RSPN field teams, with the help of CFPs, are responsible for informing communities about the importance of immunization (i.e. its types, In total 3, 004 awareness frequencies and retention of immunization cards) sessions with10, 171 as well as mobilizing them to get their children men and 13, 918 women and pregnant women vaccinated. The field teams have been conducted. also inform the communities about the arrival of vaccinators in their respective villages. As of June 12, 2105, a total of 3,004 awareness sessions (Figure 9), consisting of 10,171 men and 13,918 women, have been conducted. These field teams provide participants a pictorial leaflet that contains information on immunization schedules for children and pregnant women.

Figure 9 – Awareness raising sessions in the communities

4. Data Registration:

Data registration is a multi-layered process:

At the initial layer, data registration was performed through CFP’s assistance to JSOs responsible for registering pregnant women and children of 0-23 months. RSPN field teams also coordinated with LHWs to register target groups within their covered areas.

At advanced layers, for accuracy purposes, RSPN monitoring officers verified the gathered data. For non-LHWs’ covered areas, RSPN field staff with support of CFPs, registered the target groups through a door-to-door strategy. The teams re-visited due and default children and registered pregnant women to ensure that no one is missed from the specified villages. RSPN monitoring officer also visited the field to verify the data through spot checking of the registration process. JSI HSS Component Immunization Specialist also provides cross checking the data verified by the monitoring officer for rectifying of any discrepancies. Simultaneously, RSPN representatives are informed regarding the removal of these discrepancies through re-visits of all union councils. This was completed by the end of June 2015.

The registered children and pregnant women data (Table – 1) is being shared with DHO and his 258, 936 children (0-23 vaccination team for the preparation of routine months) and 69, 891 EPI micro-plans. The plan provides information women of reproductive related to: the name of the villages to be covered, age have been targets on the number of children and women to registered. be vaccinated, due and defaults to be covered, new births, name of vaccinator and CFP responsible to provide community support for vaccination, vaccinator’s schedule and suitable place of vaccination within the community. RSPN teams reports the number of uncovered villages on a daily and weekly basis to DHO, DSVs, TSVs and JSI HSS team so that proper measures are undertaken for vaccinators’ presence in the field as per micro plan.

Table - 1: Status of Registration of Target Groups by Districts

Basic Information Target Group Registered Districts UCs Population of 0-23 Months Pregnant District Children Women Tharparkar 44 1,250,404 69,816 23,947 Jacobabad 40 878,412 51,331 13,308 Kashmore 37 823,060 58,675 14,051 Thatta 30 862,088 49,139 10,426 Sujawal* 25 639,321 29,975 8,159 Total 176 4,453,285 258,936 69,891

5. Vaccination of Children and Women:

To execute a smooth and steady implementation of immunizing children and women, field teams are facilitating the vaccinators in developing the micro plans. They are also informed about the names of community focal persons that will support them to accomplish the micro plans. RSP organizations are also actively coordinating with

DSVs and TSVs for the implementation of these plans. The updated antigen-wise performance is shown in Table 2.

Table – 2: District-wise Details of Vaccination

District Thatta Tharparkar Jacobabad Kashmore Sajawal* Total

BCG 9,775 30,338 8,605 5,128 36 53,882

OPV0 5,405 13,907 3,243 1,885 20 24,460

OPV1 11,705 42,536 18,423 21,811 87 94,562

OPV2 9,948 32,930 14,398 12,253 74 69,603

OPV3 8,638 24,996 10,436 10,384 69 54,523

PENTA1 11,705 42,536 18,423 20,429 87 93,180

PENTA2 9,948 32,90 14,398 12,253 74 69,603

PENTA3 8,638 24,996 10,436 10,384 69 54,523

PCV1 11,705 42,536 18,423 20,429 87 93,180

PCV2 9,948 32,930 14,398 12,253 74 69,603

PCV3 8,638 24,996 10,436 10,384 69 54,523

MEASELS1 6,870 16,134 10,388 13,139 54 46,585

MEASELS2 3,739 5,957 8,996 4,645 36 23,373

TT1 9,753 13,450 7,142 6,209 28 36,582

TT2+3+4+5 4,920 5,991 5,519 1,794 19 18,243

6. Retention of Immunization Cards:

RSPN field teams with the help of LSOs are motivating parents to demand immunization cards from vaccinators to keep them in their homes. LSOs have also assigned CFPs to be custodians of immunization records in each community. They are also responsible to ensure that the children and pregnant women have received their immunization cards during the visit of vaccinators. During the period April–June 2015 RSPN’s field teams physically validated the availability/ retention of vaccination cards. They visited randomly selected 1,407 villages and went door to door and validated the retention of cards for 10,149 children and 4,682 pregnant women. Data showed that care taker of 69% children and 67% women had retained the vaccination card. The caretakers/parents of children were advised to keep the vaccination card of women and children at safe place in their homes.

7. Text messages:

As per recommendations of HSS Component team, RSPN field teams helped LSOs to Text of few messages sent by CFP to DSVs and DPO HSS: develop key text messages for raising awareness and motivating the communities to 1- Vaccinator did not visit our village Jhando get their children vaccinated. LSOs also Khan Jakhrani as per plan shared by RSPN created text messages containing information team, please send him so that vaccination of women and children can be done of registered children and women in their

union council and texted those messages to 2- There is no outreach vaccination activities in District Health Officers, District Union Council Gublow, no vaccinator is Superintendents of Vaccination, Taluka willing to work please send us vaccinator for Superintendent of Vaccinations and vaccination of our children.

demanded to send vaccinators for vaccination 3- Vaccinator is not coming in our village Fateh of registered target groups. Mohd Khoso UC Sodhi as per plan

In addition, text messages were sent to district 4- Vaccinator Mr. Mushtaq is not visiting our EPI managers by the CFPs in cases where village Keetar in UC Khensar please ensure his visit to get our children immunized vaccinators were no-shows based on the micro plan or due to any other operational issue in the field.

8. Coordination Meetings:

Coordination meetings were held on a monthly basis or on an as needed basis, among all the stakeholders of the immunization program. The representatives of RSPN, RSP organizations, and HSS Component met regularly with partners and with DHOs, EPI coordinators, DSVs and TSVs in order to review the progress. These meetings cover a wide range of activities including: preparing and implementing micro-plans, reviewing the performance of vaccinators, following up on registered children and pregnant women for due vaccinations, discussing the number of covered and uncovered villages, devising options to address the key issues and challenges that field teams face, and designing of strategies to reach uncovered villages.

9. Representation in DHPMT Meetings:

The platform of DHPMT meetings is established to review, on a quarterly basis, all the activities performed for the betterment of RMNCH in the province. All three RSP organizations are regularly represented through their DPOs in these meetings. These DPOs apprise DHPMT members on the issues related to: vaccinators’ performance, outreach/social mobilization activities, union councils without vaccinators, areas that vaccinators don’t access due to lack of mobility issues such

26 as they don’t have petrol/gas available for their motorcycles and the reasons of vaccinators’ continuous absence from outreach activities.

Challenges

To ensure the successful implementation of immunization activities, the RSPN field teams had to address the following challenges. To address each challenge, the HSS Component’s team provided guidance to RSPN in design of a suitable strategy:

1. It has been observed that in most of the cases the vaccinators always complain about the non-availability of the mobility costs (POL and DSA). It is partially, because many vaccinators assigned to the UCs (population) are not the residents that UC/population and are unable to visit their UCs. There are many UCs where more than four Vaccinators have been appointed while there are number of UCs without any vaccinator. The vaccinators should be appointed on the basis of an approved criteria i.e. vaccinators must be a local resident. However, in hard to reach UCs, the vaccinators were unable to perform immunization services. They were helped through providing them 4x4 vehicles. Likewise, there were many other areas where vaccinators remained absent for having no means of mobility. They were, therefore, made capable with the provision of motorcycles.

2. Vaccinators are supervised by the TSVs but the TSVs seem reluctant to suggest any action against the non-performing vaccinators. It is due to political pressure and this practice also encourages other vaccinators to remain absent from duty. The TSVs and DSVs being the supervisors must be strengthened to recommend the actions against the non-performing vaccinators.

3. There are many UCs without any EPI centers. It is suggested that EPI centers should be established in the health facilities of each UC. Efforts are also needed to keep all EPI centers functional.

4. The local communities held many beliefs and myths about vaccination and hence the adoption rate of immunization was very low. Parents believed that children would get sick following vaccination intervals and parents refused to receive the remaining doses. To avoid such drop-offs, the community focal persons are engaged to gather such parents for awareness raising sessions, where there myths and beliefs were addressed in a satisfactory manner.

5. Reporting the actual coverage of the performance of vaccinators is critical. A system is developed for the proper monitoring and validation of the implementation of micro plans.

Sustainability

The HSS Component did not create any parallel system to implement this initiative but rather worked with the provincial and district health departments to facilitate the implementation of the EPI program to improve the coverage by collecting 0-23 months’ children and pregnant women data. The data was provided to the relevant vaccinators in order to communicate the required antigen doses.

Based on the HSS Component experience, the program needs sustained attention from province, district and health facility management teams in the following area for the revival of the entire vaccination system:

• MLM training for managers for monitoring and supervision and training of vaccinators on developing micro-plans. • Proper development and implementation of micro-planning and ensure proper supervision of implementation of micro-plans. • Arrangement of mobility and POL for timely support of vaccination team and supervisors. • Uplifting of cold chain system, proper handling and maintaining cold chain system for storage of vaccines. • Improving quality of recording and reporting data. • Create awareness among community for diminishing the refusals. • Ensure quality of EPI service deliveries for program sustainability.

Recommendations

Keeping in view the challenges faced during the implementation in the four pilot target districts, the following recommendations are made for the improvement of the immunization coverage in Sindh:

Overall, substantial political and administrative attention must be given to routine immunization to avoid the re-emergence of preventable disease outbreaks especially diphtheria, pertussis and measles.

A. At provincial level:

1. Provincial government should arrange Ice Lined Refrigerators (ILRs) both electrical and solar, for the replacement of aging cold chain equipment. Uninterrupted supply of vaccines, syringes, safety boxes, vaccination cards and registers will help to prevent disruption in vaccination services and must be ensured at the provincial level.

2. Provincial government should ensure required allocation of funds for EPI operations at the grass root level for the sustainability of the program.

3. Provincial government should assist district administration in the development of a proper social mobilization plan to create demand generation for routine immunization services.

4. Provincial office should review monthly performance of the program and provide feedback to improve the coverage.

5. Provincial office should disseminate the coverage of routine immunization.

B. At district level:

1. The districts should address the existing human resource gap within the urban and rural union councils through minimizing the political intrusion.

2. Districts should also improve their fragile cold chain system with back-up power arrangements and must ensure proper inventory of the costly cold chain equipment at the service delivery and districts level stores.

3. New EPI centers in the HFs, without immunization services, must be established. The vaccinators and supervisors must be trained on necessary intervals whenever, new interventions are introduced in EPI.

4. As vaccinators have to work in community hence they should also be trained on community mobilization process and their linkages must be established with the existing community groups to seek their support for vaccination points and gathering the children and women for vaccination purposes.

5. POL/maintenance of vehicles and DSA related cost should be released in advance to DHO office by the provincial EPI Directorate. It has been observed that if vaccinators have to get the reimbursement of the POL cost then they will not perform.

C. Sound monitoring mechanism:

1. Training of managers on MLM and training of vaccinators on development of micro-plans is critical.

2. The accountability mechanism needs to be institutionalized to evaluate the vaccinators’ performance. There must be a sound monitoring and evaluation

system at the district level to review the vaccine consumption and to control vaccine wastage at service delivery levels.

3. On a monthly basis, the DHO should conduct progress review meetings with TSVs, DSVs and vaccinators. This review meeting should also serve the purpose of developing micro-planning for next month. On a quarterly basis, review meetings should also be attended by representatives from DP EPI office. The vaccinators with best performance should be acknowledged by awarding them with a performance certificate.

4. Daily monitoring visits from DSVs, TSVs and other officials from DHO office are very important as it will help them to know the ground realities and observe the performance of the vaccinators. It will also be useful to improve the quality in service delivery for routine vaccination

Annexures

Annexure I: Work Plan

Activities Weeks No 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 6 1 Review EPI situation and prepare Inception Report

2 Meeting with provincial and districts teams

3 Submission of Inception Report 4 Reviving district monthly meeting on regular basis for performance validation of supervisors and immunization providers

5 Provide technical assistance to reduce default children through capacity building of vaccinators

6 Holding first technical training for vaccinators to refresh technical knowledge and including development of outreach activities, M&E and supportive supervision plans

7 Holding second technical training for vaccinators to refresh technical knowledge and including development of outreach activities, M&E and supportive supervision plans

8 Implementation of developed EPI monitoring and supervisory tools for data quality 9 Submission of second report 10 Holding first Mid-Level Managers training course

11 Holding second Mid-level Managers training course

12 Submission of final report

Annexure II: Registration Tools

Outreach Vaccination Plan

Month/Year: ______Union Council: ______Tehsil/Taluka: ______

District: ______

Person responsible for Center Village Population of Date Annual number of conducting the vaccination Name Name Village session Children Children Pregnant <1 year of (12-23) Women Name Designation age months

Signature and name of the persons responsible for conducting vaccination session according to this plan

1. Signature:______(Name:______) 2.Signature:______(Name:______)

3. Signature:______(Name: _____) 4.Signature:______(Name:______)

Signature of the local facility in-charge: ______

Name of the local facility in-charge: ______

Default Children List

Month/Year: ______Union Council: ______Tehsil/Taluka: ______District: ______

Date(s) of Injections given Sr. Name of Father's Complete No. Child Name Address BCG/Polio OPV-Penta-PCV Measles Zero I II III I II

Vaccinator’s Signature______Health Facility In-charge Signature______

Vaccinator’s Name______Health Facility In-charge Name______

Daily Vaccine Inventory & Temperature Monitoring Chart

Center Name: ______Type of Equipment & Model No: ______

Union Council: ______Tehsil/Taluka: ______District: ______

Diluents 0 Temperature ( C) Number of Doses (number of ampoules)

Date Signature TT PCV OPV BCG BCG Penta Measles Measles Evening Morning

Daily Tally Sheet for Routine immunization (Residents)

Center Name: ______Date: ______

Less than 1 year 12-23 Months 2 Years and above* Vaccine(s) Tally Total Tally Total Tally Total

BCG OPV-0 OPV-1 OPV-2 OPV-3 Penta-1 Penta-2 Penta-3 PCV-1 PCV-2 PCV-3 Measles-1

Measles-2

Child Bearing Age Vaccine Pregnant Women Total Total Women TT-1 TT-2 TT-3 TT-4 TT-5 Vaccines

Doses BCG OPV Penta PCV10 Measles TT

Total doses administered Total doses used

% of vaccine wastage

*As per EPI policy, the government targets children (<1 year) and pregnant women only. Since vaccinators are not able to reach each and every child during his first year, therefore, they cover the back log during 12-23 months. The columns of children belonging to age groups of: 12-23 months and above two years are closed only for BCG and OPV-0 because the BCG and OPV-0 is given at the time of birth. The vaccinators are, however, completing the valid doses required beyond 12-23 months so that the immunization schedule can be completed.

Daily Tally Sheet for Routine Immunization (Non-residents*)

Center Name: ______Date: ______

Less than 1 year 12-23 Months 2 Years and above Vaccine(s) Tally Total Tally Total Tally Total

BCG OPV-0 OPV-1 OPV-2 OPV-3 Penta-1 Penta-2 Penta-3 PCV-1 PCV-2 PCV-3 Measles-1

Measles-2

Pregnant Child Bearing Age Vaccine Total Total Women Women TT-1 TT-2 TT-3 TT-4 TT-5 Vaccines

Doses BCG OPV Pentavalent PCV10 Measles TT

Total doses administered Total doses used

% of vaccine wastage

*The non-resident children are tracked by the vaccinators through preparing their daily reports that are derived from the daily registers, maintained to ensure immunization of children and pregnant women, of their respective union councils. The list of non-resident children and pregnant women, vaccinated, is then shared with the district EPI supervisors so that the record of other union councils is updated.

Monthly Vaccination Report and Vaccine Stock Position (Resident)

Month: Year: District: Province:

VACCINATIONS 0-11 MONTHS 12-23 MONTHS TOTAL CHILDREN BCG OPV-O OPV-1 OPV-2 OPV-3 PENTA-1 PENTA-2 PENTA-3 PCV-1 PCV-2 PCV-3 MEASLES-1 MEASLES-2 FULLY IMMUNIZED CHILDREN BEFORE 1ST BIRTH DAY

PREGNANT CHILD BEARING AGE VACCINATIONS TOTAL WOMEN LADIES TT-1 TT-2 TT-3 TT-4 TT-5 CHILDREN PROTECTED AT BIRTH

Vaccines Stock Position

BALANCE (AT BALANCE IN VACCINES RECEIVED USED THE END OF HAND MONTH) BCG OPV PENTA PCV10 MEASLES TT ORS

DSV: DOH/EPI Coordinator EDO(H)

Name: Name: Name:

Signature: Signature: Signature:

Monthly Vaccination Report and Vaccine Stock Position (Non-resident)

Month: Year: District: Province:

0-11 TOTAL VACCINATIONS 12-23 MONTHS MONTHS CHILDREN BCG OPV-O OPV-1 OPV-2 OPV-3 PENTA-1 PENTA-2 PENTA-3 PCV-1 PCV-2 PCV-3 MEASLES-1 MEASLES-2 FULLY IMMUNIZED CHILDREN BEFORE 1ST BIRTH DAY

PREGNANT CHILD BEARING VACCINATIONS TOTAL WOMEN AGE LADIES TT-1 TT-2 TT-3 TT-4 TT-5 CHILDREN PROTECTED AT BIRTH

Vaccines Stock Position

BALANCE BALANCE (AT THE END VACCINES RECEIVED USED IN HAND OF MONTH) BCG OPV PENTA PCV10 MEASLES TT ORS

DSV: DOH/EPI Coordinator EDO(H)

Name: Name: Name:

Signature: Signature: Signature:

Annexure III: Roles and responsibilities of different stakeholders involved in the design and implementation of immunization program

Province:

Provincial EPI office will intimate all DHOs regarding the budget allocations (head wise) of their respective districts to facilitate planning the activities at district level. Provincial EPI office will release funds on quarterly basis for all EPI related activities including mobility of vaccinators and supervisors. This may be subjected to receipt and review of the performance reports from districts. Province will nominate EPI focal person who will be responsible to:

• Ensure that all target districts have prepared their micro plans and submitted to provincial EPI office (specify timeline for submission) • Ensure regular EPI review meetings at district level by UCs (Specify frequency of meetings: monthly, quarterly etc.) • Ensure regular supplies of vaccines, syringes, safety boxes, IEC material etc. • Ensure the provision of cold chain equipment for opening of new centers and replacement of old equipment, through public sector funding and/or donors. • Ensure the supervisory visits to the districts. • Prepare annual plan for on-job training/handholding. The funding may be through public sector spending subjected to provision in PC-1 or through some development partner • Conduct quarterly review meetings to share the progress of previous quarter; identify issues hindering the progress and suggest remedial measures to be taken

District:

• Will ensure preparation and submission of district micro plan (including activities/budget requirements for outreach) at the schedule defined by provincial EPI office. • Will include the registration data of due and default children 0-23 months and pregnant women in the micro-plan given by RSPN/JSI. • Will invite RSPN staff/UC Representative in these meetings. • Pursue provincial EPI office for early release of funds and timely disbursement to all, specifically the vaccinators and outreach supervisory staff. This includes POL, TA/DA, repair and maintenance etc. • Will take effective measures to ensure availability and optimal performance of the vaccinators and supervisory staff. • Will ensure the proper implementation of the micro plans for each UC/Village for vaccination of registered children and pregnant women. • Will ensure the regular monitoring and supervision of EPI activities at UC level and will submit supervisory reports with Provincial Office on monthly basis.

• Will ensure regular EPI review meetings of UC Vaccinators for validation of covering of due and defaults. DHO will ensure that RSPN and PPHI staff will also attend this meeting. • Will submit the requirements of vaccines, syringes, safety boxes, cold chain equipment for opening of new centers and replacement of old equipment, based on proper need assessment in consultation with PPHI to the Provincial EPI Office. • Will ensure the proper maintenance of EPI equipment (Cold chains and supplies) at District, Taulka and BHU level. • Will share the outreach plan of vaccinators with RSPN.

JSI/HSS Component Provincial Office:

• Will coordinate with Provincial EPI office for timely release of funds and that of vaccines, syringes, safety boxes etc. to the district. • Will undertake monitoring visits to target districts to see gaps in implementation of the micro-plans and suggest remedial measures. The detail reports will also be shared with the provincial EPI directorate and respective district health offices. • Advocate with Provincial EPI office to address the Routine Immunization related issues discussed in the DHPMT meetings. • Provide technical support to train mid-level managers and vaccination staff for routine immunization • Conduct follow up visits to the districts and provide status reports, participate in any district EPI monthly review meetings and provide technical assistance in development of realistic micro-plans • Ensure coordination among provincial and district office, RSPN teams, PPHI and other stakeholders

RSPN:

• Create awareness and mobilization about the importance of routine immunization at community level through RSPs fostered Community Institutions i.e. LSOs

RSP Organizations:

• Registration and verification of due and defaults from non LHWs covered areas (0-23 months’ children and pregnant women) from all target UCs. • Update and verify registration by enlisting the new births and pregnancies (and also number of children never immunized).

• Participate in planning and coordination meetings at UC/BHU/EPI Center to share the UC wise registration data of due and default children and pregnant women and give inputs to develop the vaccinator wise outreach plans. • Participate in EPI review meeting at district level to share the overall data of registration and to give inputs in planning for vaccination coverage. In these meetings, RSPN’s district representatives will also share the feedback about the visits of the vaccinators. • Inform the communities about the vaccinators outreach plans for routine immunization and ensure, during the visit of vaccinators to villages, the community support for gathering the target children and pregnant women. • Take feedback of the communities about the visit of the vaccinators as per their approved schedule and if vaccinators does not visit any village as per approved schedule then inform their supervisors and also share this information with DHO, DSV and EPI Coordinator. • Take tally sheet from vaccinators (data of vaccination) on daily basis and compile this data at district level for onward reporting to JSI on weekly basis. • Consolidate the EPI related issues/feedback from communities and share it in coordination and will DHPMT meetings. • Share their monthly activity plan with district health office/EPI focal person and facilitate the vaccinator/supervisor in reaching the targeted village, provided the movement plan of EPI staff matches with that of RSPN staff.

Annexure IV: Monitoring and Evaluation Tools

Stock (Inward & Outward) Register

Article: ______

Center Name: ______UC: ______District: ______

Bill No. Quantity or Cash Date Article Particulars Remarks Memo No. Receipts Issued Balance

Basic information on program structure

Number of health Number of Total Number facilities in Functional EPI Number of UC of outreach

the district Fixed Center sessions with types

District

Name

Number of Taluka of Number plan center district Private Government session held held session in the district the in Inthe District working days working Where regular regular Where GAVI)is posted according to micro micro to according Where vaccination vaccination Where Where at least one least at Where functionalfixed EPI Having at least one least at Having vaccinator (Govt. or (Govt. vaccinator outreach vaccination vaccination outreach Actually held in 2013 in held Actually session held on every every on held session Planned in 2013 in the the in 2013 in Planned Jacobabad Kashmore Tharparkar Thatta

Human Resource

the

district district district district (Yes/No) in the district the in designation? District Name District independently Number of LHW in the the in LHW of Number Had s/he ever had any any had ever s/he Had trained on EPI and canand EPI on trained mber of LHS in the district the in LHS of mber by GAVI support, in the the in support, byGAVI Number of LHW who're who're LHW of Number and can perform all EPI EPI all perform can and training(Yes/No) EPI on If Yes, If What's the official including vaccinators and and vaccinators including vaccination independently vaccination Total number of personnel personnel of number Total by Govt. Resources, in the the in Resources, byGovt. Is there a EPI focal person person focal EPI a there Is Numberof ASV/TSV in perform all EPI vaccination vaccination EPI all perform Number of Vaccinator, paid paid Vaccinator, of Number paid Vaccinator, of Number LHWs who're trained on EPI EPI on trained who're LHWs Nu Number of LHV in the district the in LHV of Number Jacobabad

Kashmore

Tharparkar

Thatta

Cold Chain Equipment

vaccine?

in the district the in room? district Yes/No Yes/No Yes/No vaccine? the district the the district the in the district the in transportation? Name of district of Name Mention number Mention s the district have its own own its have district sthe available available available in the district the in available Total No. of functioning functioning of No. Total (medium size) large and (medium Total No. of functioning ILR ILR functioning of No. Total refrigerated van for vaccine vaccine for van refrigerated have store district the Does Total No. of functioning ILR ILR functioning of No. Total Refrigerator available in the the in available Refrigerator month supply of routine EPI EPI routine of supply month capacity to store one month month one store to capacity enough capacity to store two two store to capacity enough Total No. of standard vaccine vaccine standard of No. Total Doe enough have UCs many How Does the district has any cold cold any has district the Does (small, 2 in 1 type) available in in available type) 1 in 2 (small, supply of routine EPI routine of supply Total No. of functioning Freezer Freezer functioning of No. Total carrier with 4 ice packs available available icepacks 4 with carrier Total No. of cold box available in in available box cold of No. Total

Jacobabad Kashmore Tharparkar Thatta

Surveillance

How many health How many health How many health facilities (public & How many health facilities (public & facilities (Public & private) were facilities (public & private) send private) send designated for private) send Name of district regular regular regular regular weekly monthly/weekly monthly/weekly monthly/weekly zero report for VPD surveillance AEFI surveillance VPD surveillance AFP surveillance? report? report? reporting?

Jacobabad Kashmore Tharparkar Thatta

Transport

Total No. No. of No. of No. of Total No. of Name of of EPI functional vehicles, with motorcycles, motorcycles in district vehicles in vehicles in minor repair, functional, in the the district the district the district in the district district

Jacobabad Kashmore Tharparkar Thatta

Financial Requirement

visits paid paid visits TSV 2013 2013 2013 GAVI during 2013 during during 2013 during No of outreach outreach Noof Name of district of Name vaccinators during during vaccinators byDSV, TSV ASV, Total EPI operational operational EPI Total POL paid (in liters) to to liters) (in paid POL POL paid (in liters) to to liters) (in paid POL the vaccinators during during vaccinators the NumberASV, of DSV, budget received, both, both, received, budget both, Government and Government both, Supervisory Supervisory Government and GAVI and GAVI Government sessions conducted by by conducted sessions DSV,TSV ASV, during Number of Vaccinators, Vaccinators, of Number Jacobabad Kashmore Tharparkar Thatta

Monthly Checklist for the Cold Chain Equipment

Issues to observe Response Remarks The equipment is clean inside and outside Yes No Functional Voltage Stabilizer is available with the equipment Yes No

No mechanical fault of the equipment Yes No Thermostat is working Yes No Ice accumulation on the inner wall is not more than 5 mm thick Yes No Working dial thermometer is placed inside Yes No Vaccines are stored at the right place in the right way Yes No No other items except vaccines and diluents are kept inside the Yes No equipment Tubes in the inner wall of the ILR are not empty Yes No

Local Health Facility In-charge’s Signature:______

Local Health Facility In-charge’s Name: ______

Supervisory Checklist

Sr. Question Yes No # 1 Is the session organized efficiently? 2 Are immunization cards in use for every infant and pregnant woman? 3 Is the register used for each child/mother/pregnant woman? 4 Are parents advised on when to return?

5 Does the health facility have a monitoring chart displayed? Does the health facility have a map of the catchments area 6 displayed? 7 Does the health facility have a work-plan for the quarter?

8 Are planned sessions monitored for completeness/timeliness?

9 Is there a system for tracking defaults? 10 Does the health facility display a spot map of Measles & NNT cases

11 Is Vaccine Monitoring Chart in use? 12 Is temperature monitoring chart in use? 13 Are the vaccines stacked properly inside the ILR/refrigerator?

14 Are there any expired vaccines inside the ILR/refrigerator? 15 Is there any vaccine stock out? 16 Are there any vaccines with VVM reaching the discard point?

Do the health workers know how to read and interpret the VVM? Ask 17 them to describe the stages of the VVM and what they mean.

Does the staff member know WHEN to perform the shake test, and 18 can he/she correctly perform the shake test? (Ask them to demonstrate how they would do it) 19 Is there an adequate supply of AD syringes for the planned sessions? 20 Are AD syringes used for every immunization? 21 Is the injection technique appropriate? Are diluents stored with BCG and Measles vaccines for next day 22 use? Are vaccinators using same manufactured BCG diluents with BCG 23 and Measles diluents with Measles vaccines? 24 Are safety boxes used for each AD syringe and needle?

25 Is vaccinator storing filled safety boxes in safe place?

26 Is health facility has a facility of burn and bury in its premises? 27 Are immunization posters displayed on the health facility wall? 28 Is there a schedule of community meetings? 29 Is there a community volunteer involved with immunization? 30 Is there a stock register? 31 Does the stock register show adequate vaccines and supplies?

Disclaimer: “This study/report 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.”