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Post00245 POLIO NID QUALITY ASSESSMENT GUIDELINES 28 April 2000 CONTENTS 1. DRAFT POLIO NID QUALITY ASSESSMENT GUIDELINES FOR REVIEW AND COMMENT 1. DRAFT POLIO NID QUALITY ASSESSMENT GUIDELINES FOR REVIEW AND COMMENT Bob Davis, UNICEF/ESARO, introduces a draft global guidelines for evaluating polio NIDs from the quality standpoint prepared by Bob and Jane Zucker. Bob requests comments by the weekend if you have the time. * Immediate comments please to: Bob Davis Date: Wed, 26 Apr 2000 11:49:42 -0700 From: [][/email] (Robert Davis) To: [][/email] Subject: DRAFT GUIDELINES FOR REVIEW AND COMMENT Dear Colleagues, As you all know, there are no global guidelines currently in use for evaluating polio NIDs from the quality standpoint. Jane Zucker and I have been asked to present draft guidelines for assessing the quality of polio NIDs at the polio tech consultation to be held in Geneva next month. If any of you have time, could you please review our text below and get me any comments by this weekend. You will find a plain text copy below Best regards, Bob Davis UNICEF/ESARO ___________________________________________________________________________ * DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT DRAFT * * DRAFT FOR COMMENT DRAFT FOR COMMENT DRAFT FOR COMMENT DRAFT FOR COMMENT * ___________________________________________________________________________ Annex: Proposed Indicators to Assess the Quality of Implementation of Supplemental Immunization Activities for Polio Eradication Background: Tremendous progress continues to be made toward the goal of polio eradication -- the total number of polio-infected countries has decreased to 30 from 50 from 1998 to 1999. The number of cases reported so far for 1999 is 6,659. This figure is similar to that of 1998, due in part to improved surveillance, but also to a large outbreak (1,103 cases) which occurred in Angola. The majority of poliovirus transmission continues to be found in South Asia and the African continent. Of these, there are 14 countries which are identified as priorities for success of the initiative - based on size, inaccessibility to children due to conflict, and documented presence of wild poliovirus: DR Congo, Nigeria, Republic of Congo, Chad, Niger, Ethiopia, Somalia, Angola, India, Pakistan, Bangladesh, Afghanistan, Sudan (Khartoum and OLS), and Iraq. Despite the progress being made, wild poliovirus continues to be identified in countries that have conducted multiple rounds of NIDs. Experience in 1999 with conducting house to house strategies for NIDs has consistently demonstrated improved coverage in the range of 10% to 40% with this approach. One dramatic example is the house to house sNIDS that were conducted in Nigeria in the spring of 1999 when 40% more children were immunized than were originally targeted. Similarly, in both India and Pakistan, approximately 10% to 15% of additional children were immunized with house to house polio activities. This has highlighted the fact and led to recognition that the coverage and quality of NIDs has not been sufficiently high to interrupt poliovirus transmission is some highly endemic countries. Two joint strategy meetings between WHO and UNICEF were held in February and March 2000 to address the need for acceleration in polio eradication efforts. The March meeting was convened by the Executive Director of UNICEF and the Director General of WHO with the UNICEF and WHO Representatives of the 14 priority countries listed above. An key recommendation and priority action was the need to improve the quality of implementation of NIDs and to develop indicators to monitor progress and quality. An important vehicle for this improvement is the National Inter-Agency Coordinating Committees (ICCs) through direct involvement of WHO and UNICEF country representatives. Components of quality highlighted were: Better microplanning, mapping, supervision, and monitoring at the district level, especially in high-risk, hard to reach, and conflict areas; Monitoring the total number of children immunized and number of zero-dose children vaccinated in successive rounds; Timely disbursements and accounting for cash advances and local procurements; Enhancing social mobilization efforts; Identifying innovative approaches to sustain motivation; and Developing independent monitoring and evaluation mechanisms and sharing lessons learned widely. Furthermore, it was recommended that indicators to monitor quality if NIDs be developed, field tested, and the results would be used for further improvements. Purpose: To develop and field indicators to monitor quality of NIDs. Proposed indicators: Caveats: focus is on quality of NIDS ? going beyond traditional coverage statistics, looking at process and qualitative assessments, in addition to quantitative assessments. Surveillance is not included. Intended to complement field guides and implementation manuals. 1) COVERAGE OF TARGET POPULATION ? disaggregated by district Note: population-based estimates are the most available and most often quoted, but lack in reliability in those countries which have not had a good recent census. Recommended to use indicators based on year to year and round to rounds comparisons. At all levels, and especially in pinpointing districts, the crude vaccination statistics, if kept in the same way from round to round, avoid the pitfalls of demographics. One can reliably say that if District X halved (or doubled) its NIDs vaccinations between 1999 and 2000, this is statistically significant. Another, related indicator, again based on available data, is performance over time in districts where the door to door strategy has been introduced. If house to house starts in 2000, then 2000 vaccinations should, district by district, exceed 1999 vaccinations. If they don't, something went wrong. 2) ZERO DOSE MONITORING Zero dose reporting as a proportion of the total is useful if and only if infant vaccinations are excluded. It should be based on 12- to 59-month- olds; otherwise, you are mixing kids who should have been vaccinated with those who were too young to have been. Zero dose reporting is most useful in doing district to district comparisons. 3) INDICATORS BASED ON IDENTIFICATION OF UNDERPERFORMING DISTRICTS This is the heart of the matter. If you want to make an impact, you find the underperformers and send in the marines. How to identify? Informal polls of nationals. Better yet, meetings of district NIDs managers after the first round of NIDs to prepare (by secret ballot) a list of the underperfomers. Anonymous postcard polls are the ideal way to identify underperforming districts, especially when done among peripheral health workers, who know in more detail than their superiors what went wrong. Here is my anonymous ballot paper for NIDs performance. ANONYMOUS BALLOT PAPER, DISTRICT ..........., STATE OF ............ PLEASE RETURN THIS PAPER UNSIGNED TO YOUR MEDICAL OFFICER OF HEALTH, CIRCLING FOR EACH OF THE QUALITY INDICATORS LISTED HOW YOU PERCEIVE THE PERFORMANCE OF THE MOST RECENT POLIO CAMPAIGN IN YOUR DISTRICT. 4) COLD CHAIN AND LOGISTICS VERY GOOD GOOD MEDIOCRE POOR VERY POOR Was the cold chain implemented and managed according to standards Were VVMs still showing potent vaccine when examined by supervisors was there sufficient quantity of OPV for each team 5) PLANNING and TRAINING VERY GOOD GOOD MEDIOCRE POOR VERY POOR were microplans developed at the district level 6) SOCIAL MOBILIZATION VERY GOOD GOOD MEDIOCRE POOR VERY POOR timely distribution of materials strategies to identify minority or unreached population employed were additional strategies besides posters/banners/T- shirts used were special efforts undertaken in underperforming districts 7) CASH ADVANCES VERY GOOD GOOD MEDIOCRE POOR VERY POOR available in a timely way not to disrupt or delay activities 8) IMPLEMENTATION VERY GOOD GOOD MEDIOCRE POOR VERY POOR were maps used for house to house activities were special plans made for "border" areas in urban areas were there plans to go to everyone floor in high rise buildings? was supervision sufficient (numbers, checklists completed, results reviewed) were independent monitors used were specific efforts to target low performing and/or "high" risk areas were special plans undertaken to immunize "unreached", hard to reach communities (for example, displaced communities, nomads, urban slums) for house to house activities, were children (or houses) who were immunized "marked" 9) OVERALL MANAGEMENT VERY GOOD GOOD MEDIOCRE POOR VERY POOR Proposed Timeline, Plans, and Use of Indicators: 1) Timeline: Review proposed indictors in UNICEF April 28 Circulate proposed indicators among partners May 1 Present to TCG May 9 Field test June/August Revise for use in Autumn NIDs September/October 2) Disseminate at appropriate meetings: TCGs for EMRO - June, SEARO - August, AFRO ? December and respective UNICEF meetings 3) UNICEF and WHO will test these indicators in a sample of the 14 priority countries (to be decided) 4) UNICEF and WHO will use the (ICCs) to establish consensus on the quality of each NID round by using the indictors. The ICC should use the information to advocate with the government for necessary support to improve quality. ____________________________________*______________________________________ Selected items reprinted under the fair use doctrine of international copyright law: ____________________________________*________________________

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