Post0229 :NIDS & ROUTINE EPI: OPINION IV 24 February 2000 CONTENTS 1. POLIO CAMPAIGNS AND ROUTINE PROGRAMS 1. POLIO CAMPAIGNS AND ROUTINE PROGRAMS Continuing the discussion which began with TECHNET Forum Post0191, with Robert Steinglass, BASICS, in an opinion piece, discussing the relationship between the accelerated polio eradication effort and the routine expanded program on immunization (EPI). Robert originally presented his views at the Global Consultation on Progress towards the Eradication of Poliomyelitis, WHO/Geneva, 2 - 3 June 1999. The discussion continued in Post0220 OPINION PART II on 24 January 20000, and in Post0225 NIDS & EPI: OPINION III on 3 February 2000. In todays postings Modibo Diko, WHO/AFRO and Mary Catlin, PATH, look at the issues of management and support in the current environment and argue that this is not a matter of polio eradication or the routine EPI. There is no choice! Anthony Battersby, FBA, corrects a misunderstanding and argues for building sustainable systems, and supports Coeli Geefhuysen's posting (Post0225) calling for the long term integration of immunisation into primary care and the health services. Action, comments and additions please: [email@example.com]firstname.lastname@example.org[/email] or use your reply button ___________________________________________________________________________ Date: Thu, 03 Feb 2000 16:16:38 +0200 From: "dicko m" To: Dear Allan, I don't want to get involved in the debate on polio versus EPI just because it does not make sense. In a meeting a few weeks ago in Nairobi, UNICEF-ESARO Regional Director said: "Most often life is not "either-or ", but rather "both"! This is so true regarding polio eradication initiative, which bases on 3 equally important strategies: (a) a performing and sustained routine immunization program, (b) NIDs, and (c) AFP surveillance! Everyone knows that? So what is the essence of the discussion "polio versus EPI"? People who promotes such a controversy just miss the point: the guilty is in reality bad management of the EPI program or of the entire health sector! Indeed, there are a few countries, like Cote d'Ivoire and Benin, where routine EPI has improved while NIDs were going on for several consecutive years. Same thing for health sector reforms: while many countries complain about them disrupting EPI, Ghana has succeeded in achieving health sector reform and improving routine coverage! Let us focus our efforts on ways to support countries to improve the management of their health (including immunization) programs and to build human capacities to carry out the complex management tasks at all levels! To give an example of bad management: we know about some countries where using the burden of disease method, districts de-emphasized EPI! Another example is the abandoning of training and supervision living EPI in the hands of untrained staff! Yes, of course, routine immunization does require specially devoted resources! In our Regional Strategic Plan (2000-2004), we estimated resource requirements for strengthening routine EPI to be about 25%, while polio eradication accounts for 28%. Staff cost is estimated at 28% to be covered mainly by national Governments (26%, which they will pay be polio eradication or not!). Who can say that routine is neglected? Shooting on the wheels of polio eradication is not useful and will contribute only to the so-called "donor fatigue"! How could donor be fatigued when we are approaching the goal? They can only be annoyed when knowledgeable people keep on criticizing them of over-focussing on polio! Instead of sterile critics, let us focus on the real things and convince donors that their money will be used efficiently! Failing to do that will only result in more time and more resource requirement for polio eradication! Modibo --- From: "Catlin, Mary" To: "'Technet Moderator'" Subject: Polio campaigns and routine programs Date: Thu, 3 Feb 2000 08:19:54 -0800 Acknowledging that: ? hardworking, creative, courageous and besieged persons of the highest caliber have achieved historic and important impact with the polio control efforts, and that ? for many reasons, this has coincided with an unacceptable and continuing decline in vaccination coverage of other antigens, and ? the commitment to polio eradication must continue the last difficult steps, The question remains: How can we most effectively use the remaining "opportunities" available with Polio funds? to get rid of poliomyelitis AND improve routine immunization. Opportunities: -Pressure donors who are willing to buy cold chain equipment for Polio campaigns to also buy spare parts, and pay for training and/or salaries for cold chain technicians. Otherwise the equipment purchased for Polio will not persist. -Work now within GAVI to ensure that the funds earmarked for "infrastructure improvement" will focus on the actual needs of routine programs, and will have incentives to institute and carry through with the improvements. -Epidemiologists and high-level polio surveillance staff in remote areas can check the cold chain, reinforce VVM use, and answer questions in routine immunization or get them answered. Just as the Sudanese child said he had never seen a health care worker, so will you find workers in remote areas who say they have never seen someone check on their cold chain and vaccine use! -The ICCs should advise that national policies permit opened vials of OPV with VVMs can can be used in subsequent sessions in both NIDs and routine programs. Workers trained in VVMs in campaigns need to be trained to continue to use them in routine programs. -Campaigns should reinforce vaccine accountability. Vaccine arrival reports should be used and at the end of campaigns, the vaccine accumulating at the periphery should be either moved back up the cold chain, subsequent orders be decreased or both. I look forward to working with Technet members to make these opportunities realities. Mary --- Date: Sat, 5 Feb 2000 21:32:20 -0500 From: Anthony Battersby Subject: Misunderstandings To: Michel Zaffran Cc: [email@example.com]firstname.lastname@example.org[/email] Dear Michel, I have just read your response in Technet, I did not reply earlier because the temperature was too hot. I was not trying to denigrate work carried out be anyone. What I wrote was back in November when, from the perspective of people whom I meet in-country, what appeared to them to be happening in Geneva was very confusing and negative. This may be a presentational problem, but the perception was real. What you said about the reorganisation in WHO was a helpful start and I think a detailed presentation would go some way to allay fears. Since I wrote my response to Robert there have been some changes, and GAVI has come into being. Inevitably we have different perspectives, I am almost always in places where things are not going so well, so my perspective may represent one end of the spectrum, but I am sure it does represent how some people feel. I apologise if I have been too blunt but I think it is very important to appreciate that staff working in difficult conditions often for low pay do have a finite level of effort they are prepared to allocate to their job. Right now in places I have visited or been in contact with that effort is mostly going to polio. That is fine if we recognise that that is the case, and do not try to make them undertake other tasks until polio is dealt with. Coeli has made a very good point, for the long term I think we need to see immunisation more integrated into primary care, as EPI evolves it needs to become a more integral part of health services. Campaigns, however worthy are not good for integration. The EPI programme was trying to build sustainable infrastructure both managerial as well as physical. Such infrastructure is the only way to assure sustainable health services, heavy emphasis on a particular aspect however worthwhile runs the risk of taking attention and resources away from services which overall are just as important to the effectiveness of a health service. As countries find it increasing difficult to provide resources for health services, I believe we need to get back to the basic principles of EPI, that is to build infrastructure that is affordable, managerially possible and thus sustainable and can be used by all primary care services. Hans's child quote "The polio teams were the first health workers I have seen in my life." is a dreadful indictment of HFA 2000. We can do better. Anthony ____________________________________*________________________
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