An Evaluation of Immunization Services, Using the Reaching Every District Criteria, in Two Districts of Gujarat, India

"India's system of paper documentation for childhood vaccination that is not always available on site, coupled with unreliable electricity, reduces access to important information and increases the likelihood of missed opportunities for vaccination."

In 2002, the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and other partner agencies in Gavi, the Vaccine Alliance introduced the Reaching Every District (RED) strategy in order to improve immunisation systems in areas with low coverage. The present study used RED indicators to assess strengths and weaknesses of immunisation services in 10 primary health centres (PHCs) in Gujarat, India.

RED outlines 5 operational components that are specifically aimed at improving vaccination coverage in every district: (i) planning and management of resources; (ii) re-establishment of regular outreach services; (iii) community links with service delivery; (iv) supportive supervision: on-site training; and (v) monitoring and use of data for action. Each of the categories includes a list of indicators for evaluating and implementing optimal immunisation programmes.

In April 2013, the researchers conducted a group interview at each participating PHC in 2 districts in Gujarat: Mehsana (immunisation coverage 72%) and Dahod (immunisation coverage 32.9%). Interview participants included the PHC medical officer, auxiliary nurse midwife (also known as Female Health Worker in some areas of India), the accredited social health activist (ASHA), the person responsible for maintaining vaccine cold chain, and local health officials. They were given a questionnaire for assessing immunisation delivery with 6 sections, 1 for each of the 5 RED operational components and a sixth section based on cold chain issues.

Figure 1 in the paper illustrates the score that each PHC received (scale 0.0-1.0) for each of the 6 indices. Scores ranged from a low of 0.38 from 1 PHC in Dahod that only met 38% of the "community links with service delivery" criteria, to a high of 1.0 from 3 PHCs (1 PHC in Dahod and 2 PHCs in Mehsana) that met 100% of the "cold chain monitoring" criteria.

With regard to the former category, the researchers note that, in both Mehsana and Dahod, community leaders were involved in improving immunisation delivery, including among hard-to-reach populations. To that end, most PHCs included community leaders in their advisory committees (4 PHCs in Dahod, 4 PHCs in Mehsana). Community leaders often identified populations in need of vaccine (4 PHCs in Dahod, 3 PHCs in Mehsana), secured venues for outreach PHCs (4 PHCs in Dahod, 2 PHCs in Mehsana), identified barriers to vaccination in acommunity (4 PHCs in Dahod, 3 PHCs in Mehsana) and provided vaccine and vaccine-preventable disease (VPD)-related health education to the community (4 PHCs in Dahod, 4 PHCs in Mehsana). Fewer than half of the PHCs had educational material for community leaders (1 PHC in Dahod, 3 PHCs in Mehsana), but many held information sessions to educate community leaders about vaccination and VPDs (3 PHCs in Dahod, 3 PHCs in Mehsana). Community volunteers assisted during immunisation sessions at all sites.

The major issues that emerged from the evaluation included inconsistent availability of supplies, inconsistent electricity, inconsistent access to the current paper-based immunisation records system, difficulty in reaching migrant populations, and cold chain equipment malfunctions in some cases. To elaborate on some communication-related findings:

• Staff retention and long-term job vacancies were identified as barriers to providing consistent vaccine delivery (5 PHCs in Dahod, 3 PHCs in Mehsana).
• Most of the PHCs in this study used an electronic registry but relied heavily on hard copy patient immunisation records that were often not available during immunisation clinics, making it difficult for immunisation providers to determine which vaccines are needed. The researchers suggest that devices such as hand-held tablets with Wi-Fi hotspots and/or cellular technology could overcome some of these barriers and would allow access to a registry, thus having the most current information about needed vaccines readily available.
• Interviewees discussed the challenges associated with delivering vaccine to various populations because of socio-demographic, geographic, and cultural barriers. Staff from 1 PHC in Dahod suggested reaching out to migrant populations during the marriage season and during festivals. Perhaps there could be additional or special vaccination outreach activities during these events.
• Most supervisors offered guidance in overcoming barriers to vaccine delivery (4 PHCs in Dahod, 5 PHCs in Mehsana), and PHC informants generally viewed the guidance as helpful (4 PHCs in Dahod, 5 PHCs in Mehsana). Many PHC informant groups reported they would like to have more supervisory visits (4 PHCs in Dahod, 2 PHCs in Mehsana).

In conclusion, the researchers "expected to see serious breakdowns in the vaccine delivery system, particularly in Dahod (the low coverage district). However, while PHCs did not report optimal vaccine delivery (based on the RED criteria) they reported that overall they have very high coverage within their jurisdiction and identified very few problems. This in itself is inconsistent as immunization coverage in both districts is clearly sub-optimal....These issues must be addressed in order to improve vaccination coverage of India's children, particularly as additional vaccines are added to India's National Immunization Schedule."