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  2. Vaccines and delivery technologies
  3. Monday, 26 May 2008
POST 01272E: LOW-TECH SOLUTIONS IMPROVE IMMUNIZATION COVERAGE--THE TRACKING BAG STORY 26 MAY 2008 ******************************************* Tasnim Partapuri and his colleagues from IMMUNIZATIONBasics, India share this story about how tracking bags have enabled health workers in some Indian states to ensure better immunization coverage. Simple innovations like these go a long way in making a success of a programme. It is interesting to observe that, when it came to smallpox eradication in India, one of the factors attributed to the programme’s success was the creativity and ingenuity of the field staff. The other factor was ‘level-jumping’, whereby “junior staff frequently leaped over formal hierarchical levels in order to expedite action”! I invite more readers to share their innovations with us. In addition to posting it on the E-forum, we will also upload these stories and experiences on the TechNet website so that we can build up a library of simple efficient innovations that can be adopted by other countries as well. The text has been condensed and minimally edited for use here. ----------- Follow-up of Vaccination Dropouts: Use of Defaulter Tracking Bags in India The potential “reach” of the immunization program in India, as reflected in BCG coverage¾the first in the series of antigens¾is 78.2% (from the 2006 National Family Health Survey – NFHS3). A continuing concern is the gap between this figure and full immunization coverage (measured at 43.5% by NFHS3). With an annual birth cohort of 26 million in India, a large proportion of children remain who could be fully immunized if they were effectively followed up to complete the immunization schedule. A review of the country’s Universal Immunization Program in 2004 also highlighted this, recommending that all health workers be provided with tools and training on how to track every child. Health workers in India are usually supported at session sites by Anganwadi Workers (AWWs) and Accredited Social Health Activists (ASHAs), who mobilize beneficiaries due for immunization on a particular, fixed day. These beneficiaries are identified with the help of the immunization register and the immunization card counterfoils. The immunization card, updated with the child’s vaccination status and a reminder to return on scheduled dates, is given to the caregiver accompanying the child. The health worker retains a counterfoil of the card to estimate the number of beneficiaries and vaccines required for the next session and to track dropouts. Though immunization registers receive some attention from the health worker, the immunization cards and, in particular, the counterfoils, are often totally neglected. It is quite obvious that health workers have not understood their utility. Printed immunization registers (if available) are bulky, and health workers often prefer not to carry them to outreach sites. As an alternative, tallies of administered doses are noted on a scrap of paper, of course, with the intention to copy the data later into the actual register. The health workers also use hand-made registers to write entries by session. Although the name of every beneficiary receiving a vaccine may be noted down, sometimes the data has no relation to entries from previous sessions. This results in numerous errors in the tracking information, and the registers of the health workers and “mobilizers” (AWWs and ASHAs) rarely match. Some mobilizers do not use the list of due beneficiaries and rely on their memory, and waste time and effort to mobilize beneficiaries who may not be due for vaccination that day, while beneficiaries who are scheduled to receive their shots may be missed. When issued to beneficiaries, all the relevant data is often not entered on the immunization cards. Similarly, the counterfoils retained by health workers are either not filled or not correctly stored or filed based on the recommendation of the Universal Immunization Program Review. But these issues are being addressed in an “Immunization Handbook for Health Workers”, developed in 2006 and currently in use throughout India. It includes instructions to health workers on tracking and follow-up of due beneficiaries and dropouts. A cloth tracking bag, composed of fourteen pockets, is a simple tool that has been developed for follow up of beneficiaries. Twelve pockets in the bag indicate the months of the year. Counterfoils are filed into the pocket indicating the month when the next vaccine is due. The thirteenth pocket is used for counterfoils of beneficiaries who have left the area or have died. The fourteenth pocket contains counterfoils of fully immunized children. Before the session, the health worker prepares a list of beneficiaries due on that day, based on the counterfoils in the pocket for that month. This list is then shared with the AWW or ASHA. As children come for vaccination, their cards and counterfoils are updated, and the counterfoil deposited into the relevant pocket based on when the next vaccination is due. At the end of each month, cards and counterfoils remaining behind represent drop-outs to be followed up. When used correctly, these bags in fact reduce the moblizer’s workload. With a precise list of due beneficiaries, they can focus on visiting the fifteen or so families that are due for vaccinations in the next session. Distribution of these bags has varied, with introduction through some small-scale initiatives, such as hand-made tracking bags by AWWs in Bharatpur (through CARE/Rajasthan) and in a model sub-centre in Agra (with UNICEF/Uttar Pradesh support). To ensure scale and uniformity in their use, one bag each was supplied to all health workers Rajasthan (2005). Other states in India have also followed suit. Costing an average of about 4 US dollars each, the bags have been supplied either in the form of a backpack or as a foldable bag so that it is easy to carry around. But use of the bags remains an issue. Implementation has been limited due to several reasons. Health workers conduct sessions in 5-6 different outreach sites every month. With only one tracking bag, they find it difficult to track children in different session sites. Moreover, the bulky size of the bag discourages them from carrying it on session days. Many health workers have also not yet been trained in their use. In response to these problems, states are devising their own solutions. Uttar Pradesh proposes to distribute tracking bags to all health workers with a “Frequently Asked Questions” guide and instructions on their use, developed by IMMUNIZATIONbasics and WHO-NPSP. UNICEF/Jharkhand has supplied the bags in an innovative, smaller accordion-file design. The bags’ reduced size and their supply for every session site ensure greater use. The tracking bag is still a new innovation in India. Roll-out and implementation take time and effort, particularly to change the health workers’ and mobilizers’ behavior and practices. Distribution and use of the bags need to be ensured and monitored as part of immunization program activities. With new and expensive multi-dose vaccines poised for introduction in the immunization schedule, such low-cost, low-tech solutions can help to reduce the large number of children lost to follow-up in India. Tasnim Partapuri ([email=tasnim@immbasics.org]tasnim@immbasics.org[/email]), IMMUNIZATIONbasics, New Delhi, India Inputs from Manisha Nair ([email=riorajasthan@npsuindia.org]riorajasthan@npsuindia.org[/email]), WHO-NPSP, Rajasthan, Manish Jain ([email=manish@immbasics.org]manish@immbasics.org[/email]), IMMUNIZATIONbasics, Uttar Pradesh, Sumant Mishra ([email=sumant@immbasics.org]sumant@immbasics.org[/email]), IMMUNIZATIONbasics, Jharkhand (Implementation in other states has been undertaken with support from UNICEF and PATH.) Various models of the tracking bags. Post generated using Mail2Forum (http://www.mail2forum.com) http://www.technet21beta.org/components/com_agora/img/members/3149/mini_tracking-bag.png


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