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COMMUNITY HEALTH CELL
326. V Main, I Block
Korambngala
Banga:or»-560034
India
45
011 5
HEALTH AND NUTRITION
<
of the 1985-89 Plan of
1.
The Health and Nutrition chapters
priority for child
guided by
the: overriding
Operations
were
This was expressed in the primary objective of reducing
survival.
years,
infant mortality rate from 114 to 90, during the five years.
The
IMR figure for 1987 reached 95.
UNICEF role in this period has
necessarily been determined by several factors, among them, the size
and complexity of the tasks to be addressed, the policies and
priorities of the government (e.g. health policy of 1983, and the
implementing systems of the government and the pace at which they
move).
As will be seen from the following discussion, the major
advances have been in the programmes of immunization and iodine
deficiency control.
Through these two programmes,
programmes, we have seen a
major improvement in the health system to deliver, for the first
time, a universal contact service - EPI, as well as to organize
sectors outside of health to reach a national health goal - control
of IDD.
These approaches have established a successful model for
the decade ahead.
In strategic terms, variable experience has been
gained
in
the
social
communication
and
the
involvement
of
non-government organizations, both of which are major building
blocks for UNICEF cooperation in the 1990's.
*
2.
Overview 1985-89;
Looking back,
the plan of operations
appear remarkably ambitious, covering as it does, virtually every
aspect of public health relevant to the needs of children.
The
gains in EPI, detailed later in this chapter, have established new
capacities within
the health system.
The- strengths
of
this
programme lie in the comprehensive nature of the national plan and
UNICEF's willingness to raise necessary outside resources totalling
$110 million.
UNICEF collaborated closely with the Government in
all dimensions of the EPI programme.
The result has been not only
an increase in immunization, but not less important, a precedent
which gives the public health system the confidence to build other
interventions on a similar scale.
*
3.
The
phased expansion of EPI over five years
has been
accomplished on schedule.
This enormous task has been possible
because of strong government and political commitment, backed by
sound professional support.
For the immunization programme, the
was
technology
available
was
specific
and
effective;
policy
specif ic
and
available
precisely defined; clear operational guidelines were
widely disseminated; supplies needed were estimated, and ttheir
availability ensured; a plan for indigenous product development was
initiated; training materials for auxiliaries and professionals were
produced to support training programmes at national, state, district
and peripheral levels.
All these components of programme support,
J
46
essential for operationalizing any primary health care intervention.
have not been available for most PHC interventions.
4.
Interestingly,
the
other
ambitious
project
in
health,
diarrhoea management, as comprehensive in its planning approach as
immunization, has not produced commensurate results. Political will
for action has not been strong or articulate, and the absence of an
approved National Plan or policy has left bureaucrats and workers
uncertain regarding key elements of
strategy.
While we have
participated in numerous meetings
and
working
groups
to resolve
meetings and
issues, the lack of technical consensus,
often
on
small
issues
like
consensus,
ORS packet size/composition , role of home fluids, open sales of ORS,
etc. has left decision-makers paralysed.
What UNICEF could achieve
during this period was two-fold:
a nationwide study on knowledge,
attitude and practices on diarrhoea management, the largest of its
kind anywhere, which clarified the present situation of attitudes
and treatment of diarrhoea an
identified a
large number of
misconceptions upon which the original plan had been built.
Most
important,
we
identified
numerous
cultural
beliefs
and
have
practices upon which to base sound treatment advice, as well as
recognizing the critical role played by private, often non-licenced
practioners who treat over three-fourths of all diarrhoea cases. As
a result,
a clear national
policy has
finally been
framed.
Concurrently, UNICEF moved ahead on the communication and training
front.
Preparing a set of 23 video modules, illustrating clinical
case management, an illustrated field guide and video training
module for paramedics and public advocacy material for use of ORS.
The IMA (Indian Medical Association) doctor retraining seminars have
now reached over 30,000 private practioners with a standardized
video training course.
5.
UNICEF assistance in leprosy has been limited to three of the
212 districts in which the disease is endemic.
The overall impact
is, thus necessarily modest.
At the same time, UNICEF made a
substantial contribution to
the nation
wide
social
awareness
campaign.
This has been critical ;for acceptance by the patients and
the community alike that leprosy is treatable.
The preparatory work
in planning and material production has been done but the major
public information effort is still ahead of us .
6.
UNICEF
involvement
in
the
f ields
of
acute
respiratory
infection, sexually transmitted diseases, Ituberculosis, rheuma tic
fever, genetically transmitted diseases, has: been modest at best.
UNICEF is assisting the Government in redesigning new disease
specific projects such as ARI and anaemia control with much greater
emphasis on addressing the behavioural <_aspects of target groups and
building upon the delivery infrastructureJ strengthened through UIP.
U7
7.
The chosen objective in maternal health, to reduce low birth
weight, maternal, pre-natal and neo-natal mortality, were over
ambitious in relation to the magnitudes and underlying causes of
these problems.
All the same,
UNICEF has supported a major
initiative for comprehensive MCH care in 9 districts, starting with
training and equipping
the village
mid-wife
and
establishing
effective referral services for pregnancy and delivery care.
This
is expected to expand to more districts in the Sth five year plan as
a major initiative for safe motherhood.
strengthening
in
village
health
8.
Numerous
activities
non-government organizations,
information
management
committees ,
systems, traditional health systems, referral services, central drug
supply and management and organization of health services were
envisioned in the Plan of Operations but not achieved in any
sense.
substantial sense.
These elements have been strengthened only to
the extent they were found to be part of the major programme thrusts
like EPI, MCH and leprosy control.
We have learned that UNICEF’s
ability to improve the functions of the overall health system is
necessarily linked through specific programme activities,
rather
than as an across-the-board approach to the system, As a corollary,
our effect on the system is proportionate to the "scale” of our
activities within it.
9.
Persistent attention given by UNICEF over the past five years
to a wide range of activities to address iodine deficiency disorders
(IDD) has culminated in a major achievement, with mandatory iodation
of salt, now a law in 7 states and in the whole country by 1992.
The production of iodated salt for human consumption has already
reached 50 per cent of the need and is slated to rise to 100 per
cent within another two years.
This programme reaps an optimal mix
of advocacy, planning, inter-sectoral activities, field research,
communications, collaborative efforts with government as well as
private sector and the application of appropriate technology.
10.
While efforts in anaemia and vitamin A has so far been less
successful, GOI, with UNICEF support, has documented the weaknesses
of the current programmes and has accepted in principle that these
two important areas be
integrated with the EPI programme —
providing iron folic tablets to pregnant women, pre-natal care and
vitamin A as a regular part of immunization outreach visits,
Both
these programmes require greater attention, logistics and supplies
which have plagued them todate, issue readily resolved when linked
to a successful EPI system.
48
11.
UNICEF has made many alliances to promote the infant feeding
code and wide range of activities has been supported, particularly
through NGOs .
Legislation has passed the Upper House of Parliament
but has been repeatedly delayed in the Lower House through the
successful efforts by the milkfood industry.
A swell of public
demand suggests that this law will be enacted within the next year,
Inspite of UNICEF's constant interest in appropriate weaning, there
Similarly in areas
is no clear forum through which UNICEF can act.
of maternal malnutrition, our efforts require an environment and a
system to carry these important messages and programmes to the
Possibilities in this regard will unfold as the government
people.
plans for for women and children become clearer for the 8th five
year plan.
12.
During the last five years, a national task force on growth
monitoring as convened regularly at UNICEF, resulting in continuing
dialogue and exploration of ways to implement and expand growth
promotion activities.
While this may seem a small accomplishment,
the preservation of growth monitoring activities in the ICDS system
and the continuing interest of primary health care programmes
throughout the country is to a significant extent, a result of
UNICEF advocacy.
Extensive field testing has involved designing of
improved mother-child growth card which includes primary health care
concepts like ante-natal care, maternal nutrition,
immunization,
vitamin A, iron folic and an array of health education messages
within the basic activity of monitoring and promoting growth.
Presently in use through NGOs, its acceptance by ICDS is still
problematic as nutrition and health matters are seen by many to lie
in another ministry as a prime responsibility of health workers.
13.
The Plan of Operations were over ambitious in their objectives
in that they did not quite match the present capacity in both UNICEF
and the government.
Many envisioned activities were not linked to
existing programme within the health system.
It is clear that for
any intervention to be strengthened, it has to happen in the context
of existing programmes of collaboration between Government and
UNICEF.
U9
14.
IMMUNIZATION:
Expansion:
the
Technology
leadership
of
With continued
14.1
Mission of Immunization, the last 143 districts (Phase V) were
included in the phased geographic expansion of the accelerated
All the 448 districts in India are now
immunization programme .
Over
under UIP, making UIP and EPI virtually the same - all India.
50 percent of the last 143 districts are in states which have high
infant mortality rates, and less developed health infrastructure,
Bihar, Uttar Pradesh, Rajasthan and Madhya Pradesh.
They are also
the least developed districts within these states.
Achieving the
desired immunization coverage in these districts, is a challenging
Attention is being focused in these areas by
and difficult task.
instituting state-specific
state-specif ic strategies, micro-planning at district
level and monitoring district-wise coverage of immunization services.
14.2 The policies of using one needle and one syringe for every
child who comes for immunization, opening a vial of vaccine for even
one child, discarding unused vaccines at the end of the day, are now
instituted by the Government as a necessary part of improving
Primary immunization services are now being
quality of services,
provided to infants - reducing the upper age limit to focus on the
most critical age group.
U.3 Coverage
:
From policy to training to supplies, the system
is largely in place to deliver complete immunization to pregnant
women and infants throughout India.
Demand for these services still
falls short of the need.
This is reflected in the overall coverage
by immunization services with all vaccines.
The coverage has, all
the same, been steadily increasing as seen from the following
tables.
Preliminary results from a recent National EPI Review,
shows some variation, due to statistical and other reasons, from the
routine performance statistics generated by the Government system.
Iminunization Performance (Percentage)
Routine Statistics
(1988-89)
March-April
BCG
DPT3
OPV3
MEASLES
TT2
ft
79.87
79.97
75.46
54.80
65.04
Figures are tentative.
ft
Coverage Evaluation
Survey
52.54
64.49
63.86
34.45
65.79
■ft A
50
IMMUNIZATION PERFORMANCE (%)
100
80
60
40
20
0
BCG
OPV3
MEASLES
Routine Statistics
■ CES
DPT3
from GOI (1988-89)
TT2
’ 51
IMMUNIZATION PERFORMANCE (%)
100
90
80
70
60
50
1
40
30
J
20
10
0
Ifliiii
Mi
DPT3
OPV3
II ■
MEASLES
1981
■ 1985
r::: -1 1986
1987
H 1988
I
on^Tr
COMMUNITY health cell
3zb, V Main, I Block
Koramongala
6angalofe-560034 *'/
India
I 1989*
TT2
52
In computing the percentage performance, the denominator used
by Government for surviving infants is the estimated mid-year
population x crude birth rate x (1 - 0.7 IMR).
Y
For pregnant women,, the
’’
denominator used by Government is the
estimated mid-year population
- -ix 1.05 (5 percent adjustment for
pregnancy wastage).
The performance ratio takes into account vaccines for infants
born in the previous year, but without including them as
"eligibles" in the current
-..w year.
A*
Based on 32 coverage evaluation surveys
conducted nationwide
in May 1989 in a population of 72 million
weighted for
population and collated by Dr Jon Rohde.
14.4 The total number of
pregnant women and infants reported to
have been immunized between
April 1987 and March 1988 and between
April 1988 and March 1989 are as follows:
1987-88
TT2
14,606,024
(including booster)
16,524,000
0PV3
Measles
BCG
Infants
Infants
Infants
Infants
1988-89*
Pregnant women
16,522,442
14,367,144
9,989,485
16,221,494
18,129,000
17,107,000
12,424,000
18,107,000
14.5 The estimated disease and death reduction associated with
this
performance is shown below,
This is based on the WHO formula for
computing morbidity and case 1fatality (Reference:
"Setting Disease
Reduction Targets" WHO SEA/EPI/NEET.88/15.
Disease
Cases
Prevented
Deaths
Prevented
Neonatal Tetanus
Measles
Diphtheria
Pertussis
Poliomyelitis
(Paralytic)
Childhood
Tuberculosis
157,000
11,802,800
189,500
14,327,700
106,800
125,600
236,000
14,200
71,600
6,400
12,100
10,900
53
DROPOUT RATES FOR
25
DPT3, OPV3 AND TT2
20
15
10
5
n
OPV3
E\\\\\W) nnoq
54
14.6 During 1988, the median dropout rate for DPT3. was 18Z, for
0PV3 17% and TT2 9%.
These represent a marginal improvement from
the previous year.
Where coverage levels were low, surveys showed
that one third to half of the infants had not been reached with any
immunization service.
Reasons
for non-immunization or dropout
relate
to
lack of
services
in
20
to
30
percent
of
cases
(non—availabi1ity of vaccines,
postponement of the immunization
session and absence of health workers were also recorded as reasons
for immunization
failure
in some
surveys).
Therefore, making
immunization services available for every village is critical.
The
Government Ol India and state governments have recently decided to
ensure that immunization services will be available for every
village and urban unit on a fixed day every month, which will be
widely publicized.
14.7 Of greater concern, is the 70 to 80 percent of cases, where
lack
of
information
is
the
prime
reason
for
dropout
for
non-immunizat ion.
People are sometimes not aware of the
place, day or time of the immunization session;
need to return for more doses to complete the immunization
schedule;
optimal age for immunization;
importance of measles immunization;
need for early registration during p*"
---- ‘7” to ensure that
pregnancy
both doses of tetanus toxoid are given on time;
few contraindications to vaccination;
harmless reactions of immunization.
The mother being busy, illness of the mother or long periods of
absence of families visiting their native place, were other reasons
given.
Far greater efforts to publicize the service and to inform
parents of the need to return are required.
14.8 Fewer than one third of all children had an immunization card,
the most basic communication tool, any many who have them cannot
tell if the child is fully immunized.
A new card carefully tested
to assure understanding even by illiterates, is under print and will
be used by end 1989.
55
is.
Improving Measles Coverage
:
Measles vaccine was introduced
in 1985,
ratner late
in
the programme.
Though there
is a
programme.
significant increase, the coverage levels remain far less than
desired.
There are several reasons.
reasons.
Measles is not considered to
be a serious disease by health personnel and even doctors; people
feel it is part of every life — and some even think it is a
visitation of a "goddess”.
Adverse
reactions,
after
measles
vaccination, which has been publicised in the press, has led to
restrictive directive from the Government,
(such as
"Measles”
vaccine will be administered in the presence of ’’doctors only”).
Now, a major comprehensive strategy is being formulated, to improve
coverage.
Information on the seriousness of measles will be made
available to professionals, health personnel
personne1 and people.
Some
states
have
decided
to designate specific
specif ic
days when measles
vaccination will be available.
The Indian Medical Association is
designating 1990 as the year of measles, when their members will
promote the importance of both the disease and the vaccination.
Most importantly, the communication strategy that emphasizes full
immunization (completion of all the boxes in the immunization card)
is expected to give a boost to measles coverage.
Tetanus Toxoid:
16.
leidllUS 10X0 IQ? Coverage levels with tetanus toxoid are one
highes t in
Tn India in developing countries - 65%.
of the highest
The recent
coverage
evaluation
surveys
confirm
this.
This
vaccine
was
introduced in the MCH programme in the late 1960’s.
Tetanus Toxoid
has been used for injury by rural and urban population - therefore,
there is no resistance from either the people or professionals for
this vaccine.
The high coverage of tetanus toxoid points to
relatively high levels of at least one antenatal contact of the
mother with health services,
This has obvious implications for
improving antenatal care which still requires major strengthening,
judging from the basis of inacceptably high levels of maternal
mortality.
17.
Urban
Immunization:
urpan imniuiiizaiion
:
Special efforts are r being
made
to
provide immunization services in the 3,500 urban units in India.
Norms for cold chain equipment for urban areas were developed and
equipment supplied.
The emphasis is on immunization in urban
slums. A workshop resulted in the development of specific plans for
12
metropolitan
cities,
results
in special
initiatives.
For
instance, the Mayor of Patna, Bihar, along with the State Branch of
the
Indian
Medical
Association,
intensified
immunization
activities.
663 immunization service centers were set-up, through
effective networking of local private practitioners, people and
NGO's, covering 1.2 million population, half of whom were slum
dwellers.
The efforts are being sustained through 40 permanent
centers, catering to 55 slum pockets.
Through a series of meetings,
urban plans were developed for around 500 urban units. More than the
11
56
plans themselves, the planning process for immunization services in
urban areas brought
1
together various agencies and departments for
coordination and collaboration.
18.
The infrastructure is inadequate for providing primary health
care, MCH,> and
and immunization services in urban slums.
Now that
immunization has been placed high on the health agenda of urban
services, critical issues for urban primary health care are being
raised.
It is not advisable to build an infras ructure based on PHC
and sub-centres on the basis of population similar to rural areas,
There are resources — these resources are not yet harnessed for
priority activities in health
particularly, not for preventive
and promotive aspects.
Coordinating mechanisms, joint planning,
area-specific iresponsibility and accountability, remain the major
ways for achieving immunization goals.
19.
Private practitioners have contributed in varying degrees to
immunization.
For example in the city of Bombay, the coverage
evaluation survey revealed a far greater proportion immunized (81Z
with 0PV3) than routine government statistics (less than 50Z for
OPV3), since the contribution of private practitioners is not being
included by government data.
The Indian Medical Association and
Indian Academy of Paediatrics have been playing an important role
for promotion of immunization.
Workshops have been held to define
immunization policy, practices and quality services by professional
groups.
20.
’Suraksha’, a iregistered society in Hyderabad, brings together
the government departments of_ health
----- 1 and urban development, NGOs,
medical colleges, Rotarians
Rotarians for a
a common goal of immunization,
Based on their success, this experience is now being replicated in
other urban areas.
The Urban Basic Services (UBS) strategy, has
been an important instrument not only for convergence of services,
but also for boosting immunization coverage significantly.
Similar
improvements have been observed in some <_areas where the ICDS scheme
is implemented although it is not consistent, Urban immunization is
an opportunity for partnership.
To exemplify, a series of meetings
are scheduled between the 1,400 Rotary clubs with 50,000 members,
and the 1,100 state/local branches of T
the Indian Medical Association
with 70,000 members to conduct joint efforts
--- ; for urban immunization.
21.
bysiem
System buppori
Support::
The
central and state governments,
and
c one e rned district d fficials continued to give importance to the
delivery of immunization services,
Along with family planning.
immunization is now considered a priority,
Maintenance of the cold
chain and the logistics system, provision of necessary vaccines,
insistence of sterilization through auto-claves, reducing the number
of contraindications to immunization, are actively promoted.
u
57
22.
Training for planning and management of
the immunization
programme continued to be an important input,
Six national and ten
state level ma n a g e me n t courses were held for senior and mid-level
managers.
Over 140 district level workshops were conducted to
improve
1the
planning
and
management
skills
of
block
level
pe rsonne1.
Newe r areas in the immunization programme are being
inc 1uded , such as surveillance, training technologies.
Recognizing
that one training; exposure may not culminate in acquiring t he
necessary skills, supervisory visits are being used to follow up
training programmes,
Guidelines for this have been developed and
widely disseminated,
During the initial
initial three
years of UIP, me
medical
officer
was
trained inin each
block.
Subsequently,
eligibility norms for training have been changed to include all
medical officers at block level,
Training plans are being developed
to ensure that all medical and paramedical personnel have been
trained in all districts.
23.
The National EPI Review showed that the levels of knowledge of
workers
increased
significantly
after
training,
but
was
not
necessarily followed by improved skills or compliance to standard
procedures and techniques.
The next phase of
the immunization
programme has to make major efforts in improving quality of services
through continued refresher training, supportive supervision and
guidance.
The monthly review meetings at each level will be used as
a forum for training and updating knowledge.
Materials are being
developed for twelve annual sessions.
24.
With consistent efforts to develop training capacity, several
states
have
developed the ability
to
undertake
training
for
immunization through a core group of trainers.
Additionally, this
core group iiss exposed to newer programme initiatives.
In Tamil
Nadu, a group of trainers are now developing training strategies to
every
extend
opportunity
provided
by
UIP'
linking
to
UIP ' for
interventions for elimination of neonatal tetanus,
tetanus, safer motherhood
and young child survival.
25.
Self sufficiency for the immunization programme is a goal of
the National Technology Mission on Immunization.
India is the only
developing
country
which produces
BCG
vaccine.
The
quality,
production
capac i ty
and
technologies
used
were
reviewed
and
add i t iona1 equipment is being procured to step up production.
58
Similarly, DPT vaccine production in the country was reviewed by a
consultancy team and steps initiated for qualitative improvement and
increased production capacity.
A policy decision has been made by
Government of India to produce OPV in the country.
A joint
UNICEF/WHO consultancy is reviewing the production plans and designs.
26.
Indigenous production of cold chain equipment is a priority.
The cold boxes and vaccine carriers produced in India were tested in
a WHO
laboratory and were
found
to meet the international
standards.
These efforts will contribute significantly towards
sustaining immunization services in the next decade.
27.
Making essential supplies available for the immunization
programme (instead of cash equivalence) has proved to be a critical
factor in operationalizing UIP.
The large volume of equipment and
supplies needed, their replacement, maintenance and information on
status of
functioning, are important for sustained programme
delivery. A computerized materials management information system is
being developed at the National Industrial Development Corporation.
The system is linked with districts (based on information from
primary health centers), and all levels of storage for both vaccines
and equipment. Some key features of this initiative are
forecasting replacement;
estimating additional needs due to infrastructural expansion;
linking
maintenance
through
an
information
system
of
"down-time” for equipment;
forecasting vaccine needs based on production capacity;
distribution of vaccines and supplies.
28.
Performance Review:
un d e r t aken Tn 1989.
for data collection
Government of India.
29.
The first National
EPI
Review was
The study design, objectives and instruments
were developed jointly by WHO, UNICEF and
The objectives of this study were to
review the programme inputs like policies, plans, resources;
study details of
processes of
implementation,
including
operational
strategies, management of various
resources,
training, supervision, information systems and
monitoring, training,
logistics;
study programme output, in terms of actual performance and
extent of coverage of beneficiary population.
study the
occurrence
diseases.
impact of the
with reference
programme in terms
to specific vaccine
of disease
preventable
59
30.
Twentynine expert teams, with faculty from medical colleges
and public health experts from various organizations, studied 18
major and seven small states, as well as four metropolitan areas Delhi, Bombay, Calcutta and Madras,
In depth analysis of systems,
and
state-specific
reviews
are
unique
features.
Action
for
immunization depends largely on state initiative and implementation;
therefore, state-specific reports are more meaningful.
The national
report of the study is being finalized.
31.
All states and most medical colleges now have the capacity to
undertake the coverage evaluation surveys.
They are an integral
part of
every training activity.
Information is collected on
reasons
for dropout
and non-immunization,
which
is
used
for
unders tanding
communication needs.
Coverage
Evaluation Surveys
(CES) have become a critical part of programme management.
About
250 were performed in 1988 alone.
The findings of the Coverage
Evaluation Surveys show relatively lower performance levels compared
to routine statistics generated by public health system.
Partly
this is on account of the reference period for the CES exercise
which is earlier by 18
lb months or so.
Recognizing that there are
statistical valid reasons for the difference between routine data
and Coverage Evaluation findings, a continuing performance uptrend
is apparent in both the sets n f reports.
Mobilization:
32.
I’lUU ill 6(1 UlUli:
The
last few
tew years
have seen significant
change Tn general awareness of people and organizations regarding
immunization.
Large
organizations,,
with
organizations
networks
around
the
country,
have come
forward
promote
to
immunization.
Special
attention is being given in involving these organizations in the
states with least coverage (UP, Bihar, MP, Rajasthan) which has 40
population.
percent of
India’s population.
Plans are being developed and
implemented for these organizations to work with the government in a
defined geographic area, taking responsibility for networking and
demand generation.
In these areas, they would help to identify all
pregnant women and infants; ensure they have an immunization card;
support immunization sessions and workers;
inform and organize
people for the immunization session; track those who do not come and
bring them; be an information resource for immunization; and may be,
even provide immunization service.
Within states, strategies for
district mobilization and communication are being developed, whe rc
networking for demand generation with area-specific responsibilities
are identified.
Documents have been prepared to focus
f ocus action
”What
is
your
Social
Mobilization
Score?”,
"UCI
by
1990 A
Mobilization Strategy for Next
500
Days”
and ””101
101 Ways
of
Participating in UIP”.
33.
A number of voluntary organizations have been mobilized and
were assisted in preparing group specific communication materials
and training programmes, such as The Catholic Hospital Association;
Voluntary Health Association of India.
60
34.
The
recent
initiative
to
mobilize
"panchayats”
(local
self-government in rural areas) by the government, provides a unique
and vast opportunity for involving people in their own health - more
so, because one third of panchayat members will be women.
Steps
have been initiated to involve them for immunization throughout the
country, and specifically in Madhya Pradesh, Bihar, Uttar Pradesh
and Rajasthan.
35.
Rotary
clubs
all
over
the
country,
have
supported
immunization.
But is not the Saturday campaigns or occasional
house-to-house canvassing that is important.
It is their sustained
concern, collaboration with health service, pressure on
interest and concern,
leaders, bureaucrats and health systems throughout the
political leaders,
country (specifically in urban areas) that will make a sustained
immunization
activity.
They are not
simply an extension of
government but are expanding their activities in the field of social
mobi1izat ion.
People's Participation in Universal Immunization Programme
People's participation in Universal Immunization Programme
comes in many-hues and shapes in India.
In the Southern-most districts of Tamil Nadu and Kerala, it
is the mothers groups of the Health for One Million Programme
that ensures that every infant and expectant mother is immunized!
through peer group pressure and counsel.
In the Ernakulam
!
district of central Kerala, it is the District Collector who has!
taken a personal commitment to see his entire district 100X
!
immunized and 100% literate by the end of the year.
!
Tamil Nadu, one of the first states to announce fixed days
for immunization in its health facilities has ensured that
religious leaders with mass following speak up for
immunization. One such revered leader, Shankaracharya of Kanchi
declared that immunization is as sacred an obligation as the
sacred rites and ceremonies of the childhood.
The Mandya district of Karnataka has responded with an
intensive communication campaigns involving every form of
media, representatives of villages and district councils.
Volunteers of the Adult Literacy Mission, with the help of
specially prepared readers for neo-1iterates have reached out
with immunization messages to 15-20 neo-literate families each.
(more)
61
!
I
f
f
I
In Maharashtra, Impact India has taken on the responsibility!
of immunizing all the children of Dharavi, the largest slum in
Asia. Meanwhile, the villages of the states are following an
immunization calendar where every infant to be immunized is
identified and followed up with the help of calendar itself.
I
I
♦
»
In Gujarat, a local university has taken on the
responsibility of fully protecting the infants and expectant
mothers of 162 villages.
I
»
»
f
I
In Madhya Pradesh, it is the trade union of the large public
sector coal mines who have come forward not only to protect the
family members of the union, but also families in the
neighbourhood.
f
I
i
Rotarians who are in the process of creating a 10,000
medical corps and 50,000 strong volunteer force have turned
their attention to Bihar, where through the streets of Patna,
school students marched for immunization.
In Uttar Pradesh, where seven ministers have already made
!
public appeals for inter-sectoral cooperation for achieving UCI,I
the Lions Club have come forward to reorient and motivate
!
Panchayat leaders. The All India Women's Conference branch too,!
is involved in mobilising women for the achievement of UCI.
!
»
i
»
i
Meanwhile, India’s largest network of non-governmental
hospitals have launched a nation-wide campaign for the rights of!
the child, wherein protection rights of infants receive a lot of I
attention.
»
i
i
In Karnal (Haryana), it is the health workers, Integrated
!
Child Development Scheme workers and the Traditional Birth
!
Attendants who form the local child survival task force to
!
ensure that every child is immunized before his or her first
!
birthday, and that every expectant mother get two TT injections.!
u
62
Communication:
36.
A comprehensive communication strategy which
will include a mFdia plan, inputs for training and motivation of
health personnel at every level is being finalized with focus on:
(a)
(b)
(c)
(d)
reaching the unreached
heightening societal awareness and conviction
empowering functionaries
energising community support
37.
In
the
absence
of
a
comprehensive
strategy,
various
communications have been undertaken in an ad hoc manner,
For
example, to improve intra-organizattonal communication in this vast
health system, a compilation of
important Government of India
circulars 017 UIP policy and guidelines were disseminated. Bimonthly
UIP newsletters are sent to all health personnel.
m^t ivat i on for functionaries, Government of
38.
As motivation
India has
decided
to) reward
the
immunization work
five outstanding
work of
of
functionaries from each district.
A certificate
cert if icate and «a medal has
been designed.
This is the first time field level functionaries are
being publicly recognized for their work in health (other than
family planning) by Government of India.
39.
For the purpose of awareness-raising, audio-visual aids were
prepared for use by health workers, the public and some, on specific
issues.
To respond to the question regarding the mono-focality of
the immunization programme, a sound-slide presentation titled "UIP
in 1990" was prepared for the Central Council of Health Ministers to
demonstrate how UIP is a strategy for strengthening the health
system, and may be used to graft selected interventions for safer
motherhood and young child
survival.
A film "Health
through
Technology" was produced to focus on indigenisation and product
development in the programme.
Private practitioners have been
increasingly
involved
in
providing
immunization
services
and
workshops and guidelines have been prepared for them.
The Indian
Academy of Paediatrics invited questions from doctors all over India
and compiled these for wide circulation.
A guide for general
practitioners is being published.
Health Action, India's premier
health journal has devoted a special issue to peoples participation
in UIP and is in the process of forming health action groups in
support of child survival through its readers.
40.
Children
are
our
crusaders.
’’Immunization
Songs"
were
composed by one of India’s most popular music directors and sung by
an equally popular playback singer from India's Hollywood - Bombay.
The lyrics were composed by a senior paediatrician. Six story books
on DIP aimed at school going children have been released.
A small
leaflet carries the schedule, and answers common questions on the
immunization programme.
H
63
41.
A
set of materials have been designed
for health and
development functionaries, To list a few - schedule, chart, poster,
village
calendars
to
keep
track
of
infants born and
their
immunization status,
school
calendars
for
children
to
record
immunization of siblings and infants in their neighbourhood, a 25
questions booklet on UIP.
42.
Government of India has also stepped up the use of mass media
for UIP.
All India Radio devotes at least two hours of air time
every day (from all its radio stations) on immunization alone.
Next
to family planning, UIP receives priority for air time,
Government
of India’s TV network - Doordarshan beams spots and films on
immunization every alternate day for atleast one minute, if not
more, from all its stations.
This TV time is equivalent to atleast
US $ 500,000 annually, for immunization elone.
43.
The Indian Railways has agreed to support immunizat ion on a
massive scale, through 100 hospitals and 571 health units.
Two
training programmes were organized for the Railways.
They also
support information dissemination,
Close circuit TVs at railway'
stations are being used to promote immunization and child survival
issues.
44.
However, these IEC activities are not part of an overall
communication strategy.
There is great urgency for an integrated
and synchronized communication and training strategies which is
consistent and mutually reinforcing, to ensure sustained demand for
services.
45.
Perspectives
Sustainability
45.1
:
The goal of reaching universal immunization
at national level needs to become the goal for each state,
state, and
within each state for every district. Coverage levels of 80 percent
and above are being increasingly recorded in districts.
High
coverage levels need to be sustained in the next decade, or
large-scale outbreaks may result.
Remaining pockets of low coverage
scale-up.
need to scale-up.
Continued financial, managerial and technical
support will be required for supply of essential items (vaccines,
syringes and needles,
training materials,
immunization cards),
communication,
training,
communication,
cold
chain
maintenance,
surveillance,
vaccine testing, indigenous production, mobility, involvement of
medical colleges.
u
64
Disease Reduction:
46.
UlMdM ReUUCllUIl:
During the next decade, the control of
vaccine preventable diseases and documentation of ’’zero" levels of
neonatal tetanus, measles and poliomyelitis need to be instituted in
districts by phases.
The elimination of neonatal tetanus, combines
immunization with interventions for safer motherhood.
At the WHO
inter-country regional meeting of EPI managers in June 1989, the
Government of India committed support for activities to eradicate
poliomyelitis by 2000 AD and eliminate neonatal tetanus by 1995.
47.
The surveillance systems would document "zero” status of the
diseases in districts,
Active surveillance will be started and even
a single reported case would be treated as an outbreak.
This
surveillance system for vaccine
preventable diseases could be
extended to include other diseases in mothers
mothers and
and children,
children.
A
district based
based,, computerized management information system (which
includes analysis of routine data, coverage evaluation survey, and
materials management) is being developed. linked to NICNET (National
Information and Communication Network),
This could be extended to
include specific information related to MCH.
FrOm EPI tO MCH:
The contacts for immunization will be used
The contacts
administer Vitamin A, promote ORT, treat pneumonia, weigh babies
and empower mothers with knowledge for improved feeding practices.
The package of services for safer motherhood may include, tetanus
toxoid immunization; antenatal care; treatment and prophylaxis for
anaemia control; birthing care; birth spacing as a health measure
and knowledge for improved care of both mother and baby.
49.
There is a need to extend a communication strategy
« ‘
‘ _
*beyond
immunization to include specific interventions for mother and child
health.
As a communication strategy for immunization draws people
for immunization services to sub-centers, primary health center and
other health facilities, these health facilities will be developed
as communication centers to the public for a complementary set of
strategies for safer motherhood and young child survival.
50.
The logist’cs, distribution and supply system developed for
UI.P can be expanded
to support minimum services at village,
sub-center and referral levels of health care.
Support is needed
for developing indigenous products, defining product standards and
specifications, testing facilities.
51.
This marks the beginning of a new phase in the programme, for
which considerable resources, in technical, managerial and financial
terms will be required.
It is expected that the massive scaling-up
of activities for child survival and development, will require
continued support of the various bilateral as well as multilateral
agencies.
65
Partners: UNICEF worked in close collaboration with WHO for
52.
the immunization programme.
Joint
consultancies were held
to
enhance country capacity for vaccine production (BCG, DPT and OPV).
Product development,
(particularly cold chain equipment) though
primarily initiated by UNICEF, has
I
been supported by WHO.
A joint
WHO/UNICEF team from the headquarters; and regional offices helped to
define testing needs and specifications for OPV vaccines, which
resulted in s reamlining the process.
Joint EPI reviews have been
conducted in several countries supported fcy WHO/UNI-GEF - in China,
Maldives, Bhutan,
UNICEF has been a technical
Bhutan, India, Bangladesh.
resource to workshops conducted by Rotary International.
Monthly
informal meetings with WHO and other bilateral
agencies
are
coordinated by UNICEF.
These forums help in information exchange
UNICEF,
and programme update.
In addition to those agencies directly
update.
involved in giving supplementary funds for immunization (CIDA, SIDA,
NORAD, ROTARY, JAPAN, USAID) other agencies such as WHO, World Bank,
Ford Foundation, DANIDA, CARE, UNDP, British Council are also
invitees.
The shared concern for achieving UCI goals, sustaining
immunization services beyond 1990 and linking immunization with
essential MCH interventions, has generated enthusiasm and commitment
for further support.
53.
MATERNAL AM) CHILD HEALTH
53.1 Since independence, and in particular in the last 20 years,
there has been considerable expansion in the physical infrastructure
in rural area through the establishment of sub—centers, primary
-.1
health
centers
and
community
health centers.
Simultaneously,
multipurpose health workers and assistants have been trained for
providing health care to rural populations.
The challenge is to
support the sub-centers, primary health centers and community health
centers to provide effective and minimal health care services,
including:
developing
problems;
an
ef fective
funct ional
referral
system
for
key
providing training in these key areas to personnel, along with
supported supervision;
defining the exact level of services
facility which is graded and linked;
make sure that essential supplies,
logistics system, is available.
to be provided at
each
backed with an effective
J
66
56.
Birth care:
oirui
A proje'ct has been initiated in 11 districts in
cove ring a total population of around 20 million.
six states covering
These
states/districts have high level of infant mortality. The objective
is to improve maternal and infant survival through improved skills
of the traditional birth attendants.
A package of services are
being given for improve ante-natal care, safer birthing practices,
total immunization coverage, use of ORT, control of anaemia.
The
traditional birth attendant (TBA) is the central figure.
55.
Three state and eight district level workshops have been held
to orient senior policy makers and mid-level programme managers, and
developed district action plans.
A core group of 15 trainers in
each project district have been trained, so that they may support
block level training. A set of training materials have been
developed
for
each level,
complemented
with
guides
for
Around 60,000 TBAs will be trained in over 18,000
facilitators.
vi 1 Lages.
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