For many years it has been the advice to national immunization programmes to have a "supermarket approach" to the delivey of vacines to health care clients. Basically, whenever a child showed up in a health facility, the vaccination would have to be provided, ie. if necessary a vial opened to vaccinate the child, even if it meant wasting the other doses in a multidose vial. With more expensive vaccines, vaccine wastage has become much more problematic, and maybe our advice needs to change. What I am proposing is a "modified supermarket approach", trying to have the best of both worlds, ie both using every opportunity to vaccinate, and keeping vaccine wastage low. As before, children coming to health facilities for other reasons, or without knowing when vaccinations are given would receive the vaccine, and as before a mutlidose vial will be opened and wastefully discarded. However, through increased community information, and the planning of immunization sessions, the vast bulk of vaccinations would be focussed on a regular immunization sessions, planned and announced beforehand, and included in the dates mothers are told to return for subsequent sessions. Taking an example where immunization services are planned once a week, on all the other days (non-immunization days) the health worker would open maybe one vial, and maybe be forced to waste 80% of one vial. The incidental child would not be turned away because it came on a non-immunization day. However, on the immunization day itself one would expect that many more children would have been programmed to come through cooridnated recall dates, that the wastage on these dates should be very small. Thus having wasted a large proportion of very few vials on the non-immunization days, and having wasted almost nothing on the immunization days, the programme would have reached both objectives of still vaccinating every child possible, and reducing wastage. I have no doubt that many programmes have already tried this, and would be very interested what the experience has been with this. What do you think?
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REPORT OF AN IMMUNISATION COVERAGE SURVEY IN TAMIL NADU. MAKKAL NALAVAZHVU IYAKKAM http://www.scribd.com/doc/58794261 BACKGROUND. Immunizations are the single most cost- effective public health intervention1. Universal Childhood immunization has been accepted by world public health leaders as both an affordable and cost effective strategy not only for child survival but also for promoting primary health care2. In India, the UIP was launched in 1985-86 to extend immunization coverage among the eligible children and to improve the quality of services. The target now is to achieve 100 per cent immunization coverage. The immunization coverage of Tamil Nadu, which bagged the award for the best performing state under NRHM, as per DLHS 3 (2007-2008) is shown in Table 1. Table 1. Immunization coverage in Tamil Nadu according to DLHS 3(2007-2008). . Fully immunized 83.2% BCG 99.6% MEASLES 97.6% DPT3 88.9% Though this is the picture on paper there are many differences in the field reality in Tamil Nadu. A major change happened when immunizations were moved from the village sub center level to the primary health centre following the untoward incident of death of two children following measles vaccination. This led to reduction in the coverage rates of measles vaccine and also led to increased indirect costs for immunization. The civil society in Tamil Nadu was increasingly concerned about this and also felt a need to evaluate the true immunization scenario in the state at the field level. This study was conducted by a non-governmental organization in association with its network partners. The objectives of the current study were to evaluate the immunization coverage of children in Tamil Nadu state and to make recommendations regarding strengthening of immunization services based on the study findings. Ten districts in Tamil Nadu were selected randomly. In each district 30 villages were selected by a random process. In each village 14 children were selected-7 between age group 6months to 11months and another 7 between age group 12 months to 17 months. Field workers received training on the sampling procedure and information collection. Information regarding the receipt of BCG vaccine, three doses of OPV and DPT and one dose of measles vaccine were collected from the mothers of the selected children. Characteristics of the study population Among a total of 4096 children, data was incomplete for 589 children. These children were not included in the primary analysis. Table 2. NAME OF DISTRICT No. of children aged 6-11 Months No. of children aged 12-17 months Total Dindikkal 210 190 400 Kanyakumari 113 110 223 Kovai thiruppur 199 206 405 Krishnagiri 170 162 332 Nammakkal 143 115 258 Nilagiri 157 172 329 Perambalore 207 198 405 Theni 213 199 412 Dharmapuri 49 57 106 Thiruchi 109 119 228 Vellore 209 199 408 Total 1780 1727 3507 Data incomplete-589(14.4%) Table 3. Distribution by gender. Sex 6-11months old 12-17months old Total Male 849(50.1%) 791(51.8%) 1640(50.9%) Female 891(47.7%) 894(45.8%) 1786(46.8%) Data missing 40(2.4%) 41(2.4%) 81(2.3%) Total 1780 1727 3507 . Table 4. Overall immunization coverage in Tamil Nadu from the study Vaccine 6-11 months 12-17 months Total coverage BCG 1775(99.7%) 1721(99.7%) 3496(99.7%) DPT 1 1767(99.3%) 1719(99.5%) 3486(99.4%) DPT 2 1751(98.4%) 1689(98.3%) 3449(98.3%) DPT 3 1678(94.3%) 1642(95.1%) 3320(94.7%) POLIO 1729(97.1%) 1683(97.5%) 3412(97.3%) MEASLES - 1505(87.1%) The total BCG immunization coverage according to the current study is 99.70%.The coverage in Tamil Nadu according to the NFHS 3 is 99.5% while according to DLHS 3 the coverage is 99.6%. BCG mark was not present among 1.9% of children among 6-11 months and 3.1% of children among 12-17 months. 92.4% has reported to have got BCG from Government facilities. Overall DPT 1, DPT 2 and DPT 3 coverage is 99.40%, 98.30% and 94,7% respectively. DPT 3 coverage in NFHS 3 is 95.7% while according to DLHS 3 is only 88.9% 97.3% of children have received 3 doses of OPV. The coverage of measles vaccine among children 12 -17 months in this survey is 87.1%which appears to be much lower than Measles vaccine coverage of Tamil Nadu according to NFHS 3(12-23months) which is 92.5% and DLHS 3 which is 97.6%. District wise vaccine coverage among children 12-17 months is shown in Table 4. Table 5. District wise vaccine coverage among children 12-17 months. District BCG DPT1 DPT2 DPT3 MEASLES Dindikkal 100% 100% 100% 97.9% 87.7% Kanyakumari 99.1% 98.2% 97.3% 93.6% 78.2% Kovai thiruppur 99.5% 99% 98.1% 95.6% 74.3% Krishnagiri 100% 100% 98.1% 93.2% 83.3% Nammakkal 100% 100% 98.3% 94.8% 93.9% Nilagiri 99.4% 100% 99.4% 98.8% 93.6% Perambalore 99.5% 100% 99.5% 92.9% 86.4% Theni 100% 100% 100% 100% 99% Dharmapuri 100% 100% 98.2% 98.2% 87.7% Thiruchi 100% 98% 96.6% 94.1% 79.8% Vellore 99% 99.5% 98.3% 87.9% 83.9% GRAPH1. PROPORTION OF CHILDREN IMMUNISED FROM GOVERNMENT FACILITIES. Among those immunized, proportion of those immunized from Government facilities appears to be decreasing as they are moving towards DPT3 and Measles. 67.2% of mothers want their children to be immunized at the village itself, while others said that they want their children to be immunized in PHCs. Even though around 5% are getting immunized from private sector, only 0.6% of them want to get immunized from there. It appears that they are forced to get immunized from private sector for various reasons. Qualitative analysis of this issue is needed before commenting more. COST OF IMMUNISATION TRAVEL EXPENSES: 30% of them didn’t have any travel expenses for child’s immunization.1 out of 4 spent less than Rs 10, while another 1 out of 4 between Rs 10 and Rs20, while around 2% said that they spent more than Rs 100 towards travel expenses. WAGES LOST: 44.1% had no major loss of wages, 28% had loss less than Rs.100 and rest of them had loss more than Rs.100 because of child’s immunization. FOOD EXPENSES: Around half of the mothers had no expenses towards food, while 30% spent less than Rs 50 and rest reported to have spent more than Rs 50 towards food when they went for immunization. CONCLUSION. The immunization coverage of Tamil Nadu obtained from this survey is almost similar to the results obtained from other surveys like NFHS3 and DLHS3 except for low immunization coverage for measles vaccine. Actions are needed for improving DPT3 and measles vaccine coverage in the state. Certain low performing districts needs focused activities. There was no significant difference in the immunization status of children in the age group 6-11 months and 12-17 months. Around 10% of the families depend on the private sector for immunizing children. Two out of three mothers wish to immunize their children in the village level itself. The indirect amount they spent for immunizing children is not at all ignorable
Comments on Vaccine Wastage Assessment (NRHM) April 2010 http://www.unicef.org/india/Vaccine_Wastage_Assessment_India.pdf Comments on Vaccine Wastage Assessment NRHM April 2010 Comment: Different formulae are being used at Delivery level and Storage level. One refers to usage (labeled “utilization” here) and the other to stock movement. The two formulae have both been called “wastage”. In fact one is 1- stock movement and the other is 1- usage. They should have different names. What happens if returned vaccines expire? Is this a flaw in usage, or in stock management or in supply. Suppose the National store moves vaccine one month before expiry or after the VVM goes into stage 4. Will they be the cause of non-use? Or will the district be held responsible? Again if this stock now moves to the PHC. Is the PHC responsible? And if this goes to the field and is returned by a conscientious field worker? If it is destroyed by the field worker? As you may realize this is a very common scenario- vaccine is shunted to the periphery and the worker disposes of the vials. No child is immunized and the Report blames the periphery and poor “session planning” Comment: As such the conclusions should have taken into account the costs and space issues (which were studied )- and given priority to conclusion d and e. Conclusion (a) Documentation of Stock Movement is of prime importance. This should include reference to expiry date, length of stock stagnation at a given level (including manufacturer), status of VVM. It falls to being part of recommendation 5! Recommendation 3 made on conclusion (d) Size of Vial is important. Conclusion (e) refers to Return of unopened Vials. Not covered separately in recommendations (maybe part of recommendation 5) Conclusion (b) is biased by giving the same name to non-comparable rates (stock movement and usage). This has led to the prominence given to recommendation 1. The study should be published- giving more scope for discussion. Prabir June 2011
http://www.thehindu.com/news/states/tamil-nadu/article1156899.ece is the link to the news report on cost to the patient of facility (level 2 or PHC) based vaccination
Hello, I had difficulty posting a link to a file a couple of week ago and the TechNet Administrator said that it was caused by the .xlx file format, He fixed the problem the following day. I can open your file OK so I guess the problem remains fixed. Please let us know of any similar difficulties with the TechNet site. There is a place to reports bugs right at the bottom of the Forum page: Website Support and FAQ. Each of the yellow sticky symbols has a section "report a bug". I hope this helps
Hi Rudi, the feature to post file on technet does not seem that great indeed. I am trying again to attach the excel spreadsheet. Open-vial-wastage-modeling-with-session-pooling.xlsx The link there should work http://db.tt/hnZY6jw.
Hi letallec - I tried looking at your spreadsheet, but am finding only a zipped file with what looks to me like MS Project files. Can you repost the modelling Excel sheet, or explain how I can get this zipped file to work? Thanks Rudi
Please can you provide links to the studies that you are referring to.
Hi Ranjit, could you make sure your link works. It would be great to see the document you are referring to from India. Thanks!
I could not resist doing a quick analysis to investigate the effect of pooling immunization session given some subtle counter-acting effects involved. Attached is a quick excel model to analyze the impact on wastage of varying session size in different demand environment and vial size. The impact of doing major immunization sessions will demand on the setting of the site, in particular the intensity of its demand - with lower volume site benefiting most (daily demand < 50% vial size or daily demand less than 3 children per day). The main wastage reduction is obtained by shifting demand away from certain days into major sessions such that vial opening is avoided outside of them and hence wastage. Vial size does play a role as well since larger vial give an advantage to demand pooling to a level such that on average ~50-90% of a vial is consumed. Since in reality there are more than one vaccine on the immunization schedule, this thinking should factor in the characteristics of the different ones, notably vial size and cost of wastage. But since newer vaccines are typically much more expensive (and with fewer doses per vial), the sessions should probably be optimized for their characteristics. The philosophy of concentrating demand while never denying immunization seems attractive and should be investigated further. However, advertising to the community less frequent but larger immunization session could reduce access by decreasing convenience. It seems that only a proper study could really check if coverage would be hurt. This loops back to the initial question of Rudi: is there any real-world data point to inform that decision?Open-vial-wastage-modeling-with-session-pooling.xlsx
Hi - thanks for all your comments. Just to clarify, Prabir, my approach was meant to never turn away any child, but to have the maximum bulk of children coming one a specific day. Clearly, should a child come outside the immunization day, I am *not* suggesting that this child remains unvaccinated.
Interesting discussion. Of course the child who is turned away pays a price too. One is the repeat visit- it has been costed at up to Rs 167 in TN recently (a study on centralizing the vaccination at hospital by Rakhal Gaitonde and others). And if the child never gets the vaccine- the risk of disease (which is not small for Measles). Given that a 5 dose vial does not cost Rs 167 in India, I think planners need to compute the cost to the child too. Coverage is the driving concept. The TB study (1960s?) of Halfdahn Mahler, Anderson and Banerjee showed how many TB patients were turned away by doctors without a test. Computing the total cost benefit instead of dwelling on rationing laws of is very good health economics
Reducing wastage is indeed a key opportunity to improve EPI efficiency. One key challenge is to align the incentives of stakeholders to do so. Most people would agree that reducing closed-vial wastage would not impact coverage, but it is usually not tracked such that it can be ascertained and reduced. I would agree with Rudi that reducing even open-vial wastage without hurting coverage is a sizable opportunity. For example, product and vial size decision could impact the open-vial wastage significantly but again incentives might not be aligned for efficiency as long as MoH only co-pay a small fraction of the vaccine cost. Rudi's question is theoretically approachable by modeling. One could fairly easily model the expected wastage per site assuming some distribution of visits for each day under the 2 scenarios. Intuitively though, reduced wastage might not follow from this approach, unless it creates days where no kids come for immunization, which might not be a desirable model if we factor in the convenience of clients. Indeed, if the operations has only one immunization nurse and one assumes that each day at most one vial is opened and wasted, the intuition would say that every day, with small or large session, one vial remains opened and generates waste. For the large session, the wastage will be on average vial size divided by two, which might be an improvement, but for the other days, if someone comes, the wastage is likely to increase. Thus the net balance might not be that advantageous. The interplay between vial size and daily patient cohort size is subtle though and would require simulation. If I have time, I might put together a small excel to check this.
Rudi, this is a very interesting topic I think and I like the analogy. Immunization programs are indeed often ran as supermarkets: we try to keep the shelves stocked at all times and wait for the customers to show up. This approach requires fair amounts of buffer stock and leads to higher wastage where an open vial policy cannot be implemented. But it also often means that programs fail to capture information about the people they serve and are thus not able to make sure that they all get the vaccines they deserve. As Ranjit pointed out, National Immunization Days can help with stock management aspects, but they also often translate into fewer vaccination opportunities and thus lower service levels, especially if mobilization around these days is less than perfect. We at Optimize are trying to demonstrate electronic registry solutions to see if we can help shift the system from a “supermarket approach” to an “Amazon approach” because we think that tracking individual information will allow us to deliver vaccines just at the time they are needed while following up with patients to make sure they don’t fall behind the schedule. Of course we also realize that sophisticated registries may not be feasible in the short term for many countries, so the question is whether technology could provide intermediary, practical solutions, such as simple SMS reminder systems. The reminder system would then group children who need the same vaccines and schedule them for the same session. The idea is a bit general, but maybe it is good to start thinking about such systems and how they would work. On the incentives scheme Toryalai mentioned, I also think that is something worth thinking about. Staying in the supermarket analogy, one could imagine a customer loyalty card scheme. A filled immunization card would then be linked to certain perks and advantages. Being immunized is already a criterion in conditional cash transfer schemes such as Brasil’s Bolsa Familia. Looking forward to see what other people think about this topic!
Interesting concepts, Tory... I know that the malaria programme had (for a while and in some countries) used vouchers for persons to receive bednets, but I understand this was abandoned after a while as being too complicated. The intent in my posting was rather to refer to the feature of supermarkets that always need everything to be on the shelf, as customers may at any given time demand a product. By modifying this "always available" approach to an "always available, but the bulk very much focussed on one day" approach I was proposing a dramatic reduction in wastage.
Supermarkets are driven by profits, and losses of opening one package to serve one customer are made up for overall with sales volume and product margin, which are taken into account when choosing to carry and sell a particular perishable product. When the product (vaccine) is donated to a government, and then simply given to a clinic who then has to ration it out to meet targets without any incentive to be efficient or serve every "customer", the premise upon which supermarkets operate breaks down. If financial support to clinics from Ministries of Health were given in proportion to the number of children vaccinated, and the per capita vaccination "price" were set as if the operation were a business (factoring in losses for particular vaccines, transportation distances, storage and personnel overheads etc), maybe such a model could in time course correct itself to work the same way that supermarkets do. In the supermarket model, the consumer is rewarded with their purchase, something that they want. People are told that vaccines are important, but that's their only motivation to bring their children in. If the population were given the equivalent of "food-stamps", and required to use those for payment at clinics for vaccines, and given a token cash kickback in addition to their child getting a shot, not only would they bring their children in for immunizations but those same tickets could then be used by the clinic to claim their vaccination payment from the ministry of health or even the NGO that supports them or provided the vaccine. Such tickets would also provide excellent data about coverage rates, especially if you had infant/child/adult and male/female versions of them. In such a setting, we really are replicating a supermarket model. Taking things a step further, donor funding for the purchase of vaccines could in part be placed in an escrow account, thus requiring the country to temporarily co-pay for the vaccine shipment. As tickets make it back to the donor and are processed, funds are released from escrow and given to the country, who then issue payment to the clinic whence the ticket came. Tickets themselves could be like phone cards with a scratch off area and a number to call, at which time the money is released then and there at the clinic, doing away with long paper trails and complexities/delays arising from collecting and mass processing "vaccine-tickets". Such an approach would also provide real time vaccination data, which when combined with GIS technology, would finally give a very clear picture to everyone from ministries of health to donors and implementing partners.
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