Addressing equity and reaching the underserved and unreached in India Abstract Introduction: The Maternal and Child Health Integrated Program (MCHIP) is providing technical assistance to the universal immunization programme (UIP) in India with the key objective of improving the coverage and quality of immunization services by adopting best practices through targeted and focused interventions. Material and Methods: The MCHIP project is aimed at designing and adapting the “Reaching Every District” (RED) approach within the Indian context, with a particular focus on participatory problem identification and solving with government health staff, in collaboration with other development partners. Following a baseline situation analysis to assess immunization service delivery in two poor performing districts of Deoghar and Jamtara in the Santhal Parganas division of the state of Jharkhand in India a model on evidence based high impact interventions as Regular Appraisal of Program Implementation in District (RAPID) rounds, establishing Model RI Demonstration Centers to enable cross-visits, improved and comprehensive microplanning, institutionalizing new born vaccinations, strengthening the Maternal and Child Health Tracking System (MCTS) and development of need-based tools and job-aids (e.g. on micro-planning, service delivery, cold chain, communication, etc) for use by the health functionaries was formulated to strengthen immunization services in the two districts. Results: Over a period of 2 years full immunization in Deoghar district improved from 50% in 2010 to 71% in 2012 as per Routine Immunization monitoring data. Repeat Coverage Evaluation Survey (CES) conducted 18 months after the start of the intervention revealed that access to immunization session sites studied through sites located less than 15 minutes from home had improved from 73% in the baseline survey to 87% and availability of immunization cards improved from 56% to 82%. Using the RAPID methodology, health facilities graduated from 36% poor, 55% average and 9% good (during round 1) to 91% good and 9% average (after fourth round). Conclusion: In the two focus districts of Jharkhand, significant improvements in routine immunization quality and coverage were realized with MCHIP’s technical assistance and capacity building activities. The model can be scaled up to other poor performing districts of the state and the country to achieve desirable results. Keywords: Equity, Routine Immunization, Full immunization coverage 1 INTRODUCTION India’s Universal Immunization Programme (UIP) is one of the largest in the world with an annual target of 30 million pregnant women and 27 million infants (1). The nationwide reported full immunization coverage (FIC) is 61% (2) with wide interstate and inter-district variations. Antigen wise coverage also varies and the country has the highest number of children in the world (7.4 million) who have not received Diphtheria Pertussis Tetanus (DPT) 3 dose. Jharkhand state in India is a success story in its Universal Immunization Program (UIP) performance, given the level of immunization it has achieved and the degree to which it is reaching the target beneficiaries. From a full immunization coverage (FIC) of 8.8% (NFHS-2, 1998-99) (3), the state has achieved FIC of 59.7% (CES, 2009) (2) in the span of a decade. However wide inter-district variations do exist and the Santhal Parganas division comprising the 6 districts of Deoghar, Dumka, Godda, Jamtara, Pakur and Sahebganj has lower immunization coverage as compared to the state average (4). Key issues identified in the Santhal Parganas Division include lack of awareness and community participation, low utilization of services resulting in high number of drop outs, poor microplanning- sessions not being held as planned, high risk areas (HRA) not included in the work plan, inadequate human resource, irrational deployment of available human resource, weak vaccine and logistics management and poor or lack of monitoring and supportive supervision. United States Agency for International Development’s (USAID; Maternal and Child Health Integrated Program (MCHIP) provides technical support to the UIP in India at the national level, high priority states of Jharkhand and Uttar Pradesh and five focus districts (3 in Uttar Pradesh and 2 in Jharkhand). In developing a model for providing quality immunization coverage, MCHIP initiated its technical assistance in two districts of Santhal Parganas division viz. Deoghar and Jamtara in the state of Jharkhand, with support by state and national governments. The key objective is of improving the coverage and quality of immunization services by adopting best practices through targeted and focused interventions. 2 METHODOLOGY MCHIP’s approach was based on the experiences of its predecessor project the Immunization Basis (IB) project (5) - that started working from 2005 at national and state levels (UP and Jharkhand). MCHIP helped to further design and adapt the “Reaching Every District” (RED) approach (6) within the Indian context, with a particular focus on participatory problem identification and solving with government health staff, in collaboration with other development partners. The TA to improve routine immunization has been provided by a small team of MCHIP technical staff at different levels: 3 at the national level, 2 at the state and 1 at the district; that facilitate leveraging of government and partner resources for program implementation. As an initial step a baseline situation analysis was conducted to assess the coverage and quality of immunization services in the two districts using the standard WHO 30x7 cluster survey (7) methodology. Following the baseline analysis a model was designed wherein TA was provided through a set of key interventions like the Regular Appraisal of Program Implementation in District (RAPID) rounds, establishing Model RI Demonstration Centers to enable cross-visits to showcase best practices and enable knowledge-sharing among facilities, improved and comprehensive microplanning, institutionalizing new born vaccinations, strengthening the Maternal and Child Health Tracking System (MCTS) and programme review mechanisms under UIP and development of need- based tools and job-aids (e.g. on micro-planning, service delivery, cold chain, communication, etc) for use by the health functionaries. The process adopted in development and application of each of these interventions is as follows: 2.1 Regular Appraisal of Program Implementation in District (RAPID) RAPID is a supportive supervision model for program improvement that takes the district as a unit and is conducted as a three to four day activity at periodic intervals (e.g. every 4-6 months). Under this approach, a one day orientation and training on routine immunization is facilitated for all stakeholders at the district level. Following that, teams visit all Community Health Centers (CHCs) and Primary Health Centers (PHCs) that are planning units for immunization and have vaccine storage facilities and randomly selected outreach session sites in the district over two to three days. Each team is comprised of a trained supervisor - either from MCHIP or partner organization (WHO, UNICEF), the Medical Officer in-charge of the facility, and a district official. The teams observe key thematic areas of programme management; cold chain and vaccine management; records and reports; and immunization safety and waste disposal practices. Concurrently a standardized checklist is filled by the supervisor, with the PHC head filling the second copy of the checklist. The team discusses program- related issues with facility staff, ensure onsite corrections, and provide training to contribute to the strengthening of skills and service delivery by the PHC staff. Collected data is compiled and analysed, contributing to an analytical report with indicators and grading of PHCs. The findings are shared with the district and PHC officials to develop an action plan for the next six months. Follow-up activities, including capacity building workshops, are conducted by the MCHIP district consultant to ensure corrective actions per plan. Figure 1 summarizes this process. Figure 1: RAPID process (8) 2.2 Establishment of Demonstration sites In addition to RAPID, another key approach adopted by MCHIP was to demonstrate best practices for RI in its focus districts in the key thematic areas of program management, cold chain & vaccine management, recording & reporting and injection safety. This was accomplished by establishing selected facilities as demonstration centres for respective thematic areas. The centres serve as sites for cross learning, enabling on-site trainings and replication of best practices in other health facilities providing RI services. Facilities to be developed as demonstration sites were identified based on an analysis of the key components such as infrastructure, human resources, level of commitment, equipment and logistics, and operational processes. In addition, results from two rounds of RAPID were considered to identify the potential demo-site. After the initial identification of the potential demo-site, focused inputs were provided to strengthen systems, processes, and capacities of health staff at the facility. For readiness assessment as a demonstration site, a stringent objective criteria was laid down in the form of a scoring system, with incorporation of mandatory (30 indicators, with a score of 2) and desirable (40 indicators with a score of 1) attributes. Per this scoring,