By supporting government mechanisms, SCLTI ensures sustainable improvement in immunization service delivery
Ms. Shubhangi, an auxiliary nurse midwife (ANM), has been providing vaccination services to villages in Madhya Pradesh’s Gwalior district for 22 years now. Up until a few months ago, she used to transport the vaccines from the closest storage center to the villages. She would do this by either hitching rides or by walking the entire way—a time-consuming and exhausting activity, since the storage center and the various villages she attends to are separated by large distances. Because of the amount of time it took her, Ms. Shubhangi would invariably start late if she picked up the vaccines the morning of the session. However, if she picked up the vaccines the evening before the session, the efficacy of the vaccines would be seriously compromised. “I had to choose between not being able to cover all the villages on the assigned day or take a chance with the quality of the vaccines. It was awful. But I had to choose one or the other every time there was a vaccination session day,” says Ms. Shubhangi.
Fortunately, Ms. Shubhangi doesn’t have to make that choice anymore. In recent months, the SCLTI project has helped implement the government’s alternate vaccine delivery plan in many villages in rural Gwalior and other areas of Madhya Pradesh. Under this plan, a courier picks up the vaccines early in the morning and delivers them to all the villages that are slated to hold an immunization session that day. The worker receives Rs. 50 for each drop-off, the efficacy of the vaccines is not compromised, the sessions begin on time, and the ANM is able to focus on the immunization process instead of logistics—the alternate vaccine delivery system is truly a win-win development for the immunization process. Till date, around 97% sessions have been linked with alternate vaccine delivery.
Lending a hand up, not a handout
The SCLTI project is in complete synchronization with flagship programs of the Indian government, including the National Rural Health Mission. It works within the existing health system and infrastructure to strengthen immunization service delivery through systematic support—this will ensure that quality immunization services continue being delivered long after the SCLTI project concludes.
Dr. Hema, a PATH supervisor, explains, “We don’t do things for the communities or the health workers. Instead, we provide “supportive supervision.” In other words, we help them do their jobs better. Take, for instance, microplans, which are detailed plans for conducting immunization sessions. They deal with logistics, supervision, and alternate vaccine delivery, and are imperative for things to function smoothly. We don’t make the plans for the health workers; we assist them in the planning, provide feedback, and review the completed microplans. So the assistance isn’t just theoretical—it’s practical. This ensures that the improvements last.”
To date, PATH has reviewed microplans in 120 blocks across Madhya Pradesh. These microplans have been finalized and submitted to the state government. PATH is also facilitating the implementation of these plans. The intensive efforts have certainly paid off. The numbers speak for themselves: In PATH project areas, ANM availability at session sites has increased from 84.97% in March 2010 to 90.37% in July 2010. Additionally, in March 2010, vaccines were distributed for 89.29% of total planned sessions, which increased to 95.52% of sessions in July 2010 due to better microplanning, including alternate vaccine delivery.
Strengthening immunization delivery processes through supervision and feedback
Beyond the statistics, it is the stories that help understand how SCLTI’s efforts are bringing about tangible improvements. Ms. Reena, an accredited social health activist (ASHA) in Manhar village, says, “Himanshu Sir and Satyaprakash Sir [PATH field coordinators] oversaw our village’s immunization session, and gave us a lot of helpful feedback. They asked us not to use terms like ‘DPT’ and to instead explain what the vaccination is for in our local language while speaking to the parents so that they understand better.” PATH staff also showed the women how to make “due lists.” Says Ms. Reena, “Earlier, the ANM would vaccinate all the babies who showed up on the day of the session and we would think that was 100% immunization. Now, our ANM pulls out her record and makes a list of all the children who are due to be vaccinated a few days before the session. Then we, the ASHAs and the Anganwadi workers, circulate the list among ourselves and remind all the due kids’ parents a day before the session. This way, we can get a more accurate idea of what percentage of the children are being immunized on time and can track who is missing sessions. It also saves us a lot of time—instead of going to every house the day before the session, we only go to the relevant families.” The Field Coordinator also observed the Village and Health Sanitation Committee meetings and gave suggestions about how to make them better. For example, he told the committee that the village head must be present at the meetings so that important decisions can be taken then and there, without delay.
Apart from supervising vaccination sessions and village meetings, the SCLTI project is also building the capacity of government health workers at various levels through training and orientation, thereby enhancing immunization service delivery. Till date, 56% of ASHAs, 87% of ANMs, and 86% of supervisors in project areas have been oriented on practical aspects of immunization.
Keeping fragile, temperature-sensitive vaccines safe
Perhaps most importantly, it is the ANMs who are being given crucial feedback about conducting immunization sessions and maintaining the efficacy of fragile, temperature-sensitive vaccines. Ms. Vimla, the ANM for Manhar village, describes how PATH staff taught her to read the vaccine vial monitor (VVM) correctly and identify and dispose of spoiled vaccines.
The SCLTI project doesn’t just confine its cold-chain improvement activities to ANMs. Till date, the initiative has monitored all cold chain points in intervention areas as per the government-prescribed format for assessing the cold chain situation. After the first round of visits, PATH staff suggested various corrective measures. When a second assessment was conducted after a few weeks in these cold chain points, significant improvement was seen. In addition, all cold chain handlers of intervention districts have been given on-the-job training on vaccine and logistics management, equipment maintenance, and trouble shooting and emergency planning. These efforts have gone a long way toward ensuring that vaccines are being stored, transported, and administered in the correct conditions.
Small miracles, big results
Perhaps it is Naya Bazar, a tiny marginalized settlement in Gwalior city, that best illustrates the changes in recent months. As you walk through its narrow winding lanes, past open drains and wafting strains of Bollywood music, you can almost sense the quiet but determined spirit of the everyday heroes who are bringing about a silent health revolution. Meet Ms. Geeta, a bright and talkative young woman who is an Urban Social Health Activist in her community. An expert singer and dholak (Indian drum) player, she sings songs during women’s meetings to motivate moms to get their babies immunized. Ms. Geeta recently attended a training session held by PATH and talks about its benefits. For instance, she explains how the health workers were educated to tell pregnant women that the tetanus toxoid vaccine administered during pregnancy affects the unborn child as well and is thus imperative. “With this training and support, people listen to us more now. We also feel enlightened and inspired. After all, if we ourselves are not educated, how can we educate other people?” says Ms. Geeta, whose dream is to become an ANM someday.
The Block Medical Officer also feels that PATH has provided much needed support. He explains that if for some reason a vaccination session doesn’t take place, PATH alerts the government and helps them organize another session some days later. “They have really helped us by coordinating between what’s happening at the ground level and us. The workshops have also yielded results and supportive supervision has been excellent,” he says.
To transform a struggling immunization delivery system into a truly efficient one, it is of paramount importance to get a number of things right: creating microplans, implementing alternate vaccine delivery, maintaining the cold chain, identifying and disposing of spoiled vaccines, recording important data, and giving communities the right information. By supporting the government in its efforts to provide routine immunization to its population and paying attention to these crucial details, the SCLTI initiative is helping thousands of children gain the most fundamental right of all—the right to life.