Routine Immunization
Routine Immunization
Routine Immunization
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<strong>Routine</strong> <strong>Immunization</strong><br />
The ‘Muskan’ initiative<br />
Bihar, India<br />
Aradhana Johri,<br />
Joint Secretary,<br />
Ministry of Health & Family Welfare<br />
Govt. of India
India, a changing environment<br />
National Rural health Mission, the Flagship program of<br />
GoI launched in 2005<br />
�Communization – Incentivised ASHA in each village. Village<br />
Health Committees set up. Community oversight at every level<br />
�Decentralized district planning, flexible need based funding by<br />
GOI. Funding enhanced.$150 mill to Bihar.<br />
�Infrastructure strengthening at each facility. IPHS norms made.<br />
2 ANMs at sub health centre. PHCs are 24*7 with 3 nurses.<br />
CHCs are First referral unit<br />
�Converged outreach scheme of monthly Village Health<br />
Nutrition Day launched nationally<br />
�Institutional deliveries increased exponentially due to GOI<br />
incentive scheme<br />
*ASHA Accredited Social Health Activist; ICDS Worker, **ANM= Auxiliary Nurse Midwife. IPHS= Indian Public Health Standards
<strong>Immunization</strong> Specific Initiatives in India<br />
• Decentralized planning & need based funding.<br />
• Improving service delivery through:<br />
– Alternate vaccinators<br />
– Alternate Vaccine Delivery<br />
– Increased services through Special immunization drives<br />
– Improving mobilization & tracking through community<br />
link workers* & vaccinators**<br />
• Improving supervision & monitoring<br />
• Intensified session Monitoring by partners<br />
• Ongoing training of HWs in immunization<br />
– 51% Health Workers trained in India (107,066 / 209,695)<br />
– 90.6% in Bihar (11478 / 12675)<br />
*ASHA Accredited Social Health Activist; ICDS Worker, **ANM= Auxiliary Nurse Midwife.
• State in North India,<br />
bordering Nepal<br />
• Population 93 million<br />
(9% of total population)<br />
•Poor infrastructure and<br />
annual floods add to<br />
service delievery<br />
challenge<br />
•Poor roads and power<br />
supply<br />
•Frequent polio SIAs. 15<br />
days / month<br />
Bihar: A Challenge<br />
Gujarat<br />
Jammu & Kashmir<br />
Rajasthan<br />
Himachal Pradesh<br />
Punjab Chandigarh<br />
Uttarakhand<br />
Haryana<br />
Delhi<br />
Dadra<br />
Daman<br />
& Nagar<br />
& Diu<br />
Haveli<br />
Maharashtra<br />
Goa<br />
Karnataka<br />
Uttar Pradesh<br />
Madhya Pradesh<br />
Andhra Pradesh<br />
Puducherry<br />
Lakshadw eep Tamil Nadu<br />
Kerala<br />
Chhattisgarh<br />
Orissa<br />
Sikkim<br />
Arunachal Pradesh<br />
Assam<br />
Nagaland<br />
Bihar Meghalaya<br />
Manipur<br />
Jharkhand West Bengal Tripura<br />
Mizoram<br />
Andaman & Nicobar Islands
Bihar: A Challenge ( contd..)<br />
Indicator<br />
MMR<br />
IMR<br />
Bihar<br />
371<br />
58<br />
India<br />
301<br />
55
RAJASTHAN<br />
GUJARAT<br />
JAMMU & KASHMIR<br />
HIMACHAL PRADESH<br />
PUNJAB<br />
UTTARANCHAL<br />
HARYANA<br />
MADHYA PRADESH<br />
D&N HAVELI<br />
MAHARASHTRA<br />
GOA<br />
KARNATAKA<br />
UTTAR PRADESH<br />
CHHATTISGARH<br />
ORISSA<br />
ANDHRA PRADESH<br />
PONDICHERRY<br />
TAMIL NADU<br />
LAKSHADWEEP KERALA<br />
India: 47.6%<br />
DLHS-2 (2002-04)<br />
Fully Immunized Children<br />
Evaluated Coverage<br />
BIHAR<br />
SIKKIM<br />
JHARKHAND<br />
WEST BENGAL<br />
ARUNACHAL PR.<br />
ASSAM<br />
MEGHALAYA NAGALAND<br />
MANIPUR<br />
MIZORAM<br />
A&N ISLANDS<br />
Source: http://www.mohfw.nic.in/dlhs/dlhs08_release_1.htm<br />
RAJASTHAN<br />
GUJARAT<br />
JAMMU & KASHMIR<br />
HIMACHAL PRADESH<br />
PUNJAB<br />
UTTARANCHAL<br />
HARYANA<br />
MADHYA PRADESH<br />
D&N HAVELI<br />
MAHARASHTRA<br />
GOA<br />
KARNATAKA<br />
UTTAR PRADESH<br />
CHHATTISGARH<br />
ORISSA<br />
ANDHRA PRADESH<br />
PONDICHERRY<br />
TAMIL NADU<br />
LAKSHADWEEP KERALA<br />
DLHS-3 (2007-08)<br />
BIHAR<br />
SIKKIM<br />
JHARKHAND<br />
WEST BENGAL<br />
DLHS-2<br />
Data not available<br />
14 to 40<br />
40 to 55<br />
55 to 75<br />
75 - 85<br />
85 - 93.4<br />
India<br />
Bihar: 24.4 % Bihar: 41.4 %<br />
ARUNACHAL PR.<br />
ASSAM<br />
MEGHALAYA NAGALAND<br />
MANIPUR<br />
MIZORAM<br />
A&N ISLANDS
Muskan (In English…Smile)<br />
English Smile)<br />
An Innovative Initiative in Bihar<br />
• Target children 0-23 months: ~ 4.7 million<br />
• Augmentation of immunization efforts started in 2005<br />
through special immunization drives<br />
• Later formalized as ‘Muskan Muskan’ in Oct-2007<br />
• Partners in Implementation :<br />
– State Health Society, Bihar<br />
– UNICEF<br />
– NPSP/WHO<br />
• Enhanced Political commitment
Enhanced Political Commitment<br />
�Oversight by the<br />
Chief Minister of Bihar<br />
�Regular Review by<br />
the Executive Director<br />
�State Task force<br />
meetings to review the<br />
programme & take<br />
corrective actions
Involvement<br />
of village<br />
level Mahila<br />
Mandal *<br />
Performance<br />
based<br />
incentives for<br />
service<br />
providers<br />
* Local women’s group<br />
Muskan Strategy<br />
Inter- Inter<br />
Sectoral<br />
Coordination<br />
Muskan<br />
Strategy<br />
Identification<br />
&<br />
Tracking of<br />
beneficiaries<br />
Review of<br />
Microplan
How ‘Muskan Muskan’ Works<br />
• Muskan Register & Survey<br />
– Enlisting of all beneficiaries through h-to-h survey by<br />
community link workers (ICDS* & ASHA**)<br />
– Regular updating of muskan registration data<br />
Recording & Registering ( Jan-Nov’08)<br />
(>60% Muskan Registers Updated )<br />
Data not available<br />
Less than 50 %<br />
50 to 79 %<br />
80% & above<br />
* ICDS: Integrated Child Development Scheme<br />
** ASHA: Accredited Social Health Activist Picture><br />
Source: WHO/NPSP & UNICEF RI Monitoring<br />
KAMUR<br />
CHAMPARAN WEST<br />
BUXAR<br />
ROHTAS<br />
CHAMPARAN EAST SITAMARHI<br />
SHEOHAR<br />
GOPALGANJ<br />
SIWAN<br />
BHOJPUR<br />
AURANGAABAD<br />
SARAN<br />
GAYA<br />
MUZAFFARPUR<br />
PATNA<br />
NAWADA<br />
MADHUBANI<br />
DARBHANGA<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
JEHANABAD<br />
LAKHISARAI<br />
SHEIKHPURA<br />
n : 36,980<br />
JAMUI<br />
SUPAUL<br />
MADHEPURA<br />
VAISHALI<br />
SAMASTIPUR SAHARSA<br />
KHAGARIA<br />
BEGUSARAI<br />
BANKA<br />
ARARIA<br />
BHAGALPUR<br />
PURNIA<br />
KATIHAR<br />
KISHANGANJ
…How How ‘Muskan Muskan’ Works<br />
• Weekly Muskan sessions<br />
– Microplans revised and 6700 additional ANMs hired<br />
– Increasing outreach sessions by adding an additional day for<br />
immunization<br />
(8-10 outreach sessions per each sub-center area per month)<br />
– Integrated efforts of ICDS and health department at all levels esp.<br />
at imm session<br />
Re-establishing Outreach services (Jan-Nov’08)<br />
(>90% Sessions Held)<br />
Data not available<br />
Less than 50 %<br />
50 to 79 %<br />
80% & above<br />
KAMUR<br />
Picture><br />
CHAMPARAN WEST<br />
BUXAR<br />
ROHTAS<br />
CHAMPARAN EAST<br />
SITAMARHI<br />
SHEOHAR<br />
GOPALGANJ<br />
SIWAN<br />
BHOJPUR<br />
AURANGAABAD<br />
SARAN<br />
GAYA<br />
MUZAFFARPUR<br />
PATNA<br />
NAWADA<br />
MADHUBANI<br />
DARBHANGA<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
JEHANABAD<br />
LAKHISARAI<br />
SHEIKHPURA<br />
JAMUI<br />
n : 36,980<br />
SUPAUL<br />
MADHEPURA<br />
SAMASTIPUR VAISHALI<br />
SAHARSA<br />
BEGUSARAI<br />
KHAGARIA<br />
BANKA<br />
ARARIA<br />
BHAGALPUR<br />
Source: WHO/NPSP & Unicef RI Monitoring<br />
PURNIA<br />
KATIHAR<br />
KISHANGANJ
Improved Micro Planning using GIS<br />
• Urban RI initiated in 23 towns and cities of Bihar<br />
• Micro-planning and monitoring using GIS technology
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
74<br />
% Monitored Sessions with Mobilizer Present<br />
(Pre & Post Muskan)<br />
51 49<br />
65<br />
AWW Presence ASHA Presence Any Mobilizer Presence<br />
Pre Muskan (n=17910) Post Muskan (n=37134)<br />
Pre Muskan : Nov-06 to Oct-07, Post Muskan: Nov-07 to Oct-08 Source: WHO/NPSP & UNICEF RI Monitoring<br />
78<br />
88
…How How ‘Muskan Muskan’ Works<br />
• Coverage based Incentive<br />
– Tracking new borns through due list<br />
– Performance based monetary incentive to workers for<br />
ensuring vaccination of over 80% due for the month<br />
Tracking of Beneficiaries (Jan-Nov’08)<br />
(>65% Due List Registers Used)<br />
Data not available<br />
Less than 50 %<br />
50 to 79 %<br />
80% & above<br />
KAMUR<br />
Picture><br />
CHAMPARAN WEST<br />
BUXAR<br />
ROHTAS<br />
CHAMPARAN EAST SITAMARHI<br />
SHEOHAR<br />
GOPALGANJ<br />
SIWAN<br />
BHOJPUR<br />
AURANGAABAD<br />
SARAN<br />
GAYA<br />
MUZAFFARPUR<br />
PATNA<br />
NAWADA<br />
MADHUBANI<br />
DARBHANGA<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
JEHANABAD<br />
LAKHISARAI<br />
SHEIKHPURA<br />
JAMUI<br />
SUPAUL<br />
MADHEPURA<br />
VAISHALI<br />
SAMASTIPUR SAHARSA<br />
BEGUSARAI<br />
KHAGARIA<br />
n : 36,980<br />
BANKA<br />
Source: WHO/NPSP & Unicef RI Monitoring<br />
BHAGALPUR<br />
ARARIA<br />
PURNIA<br />
KATIHAR<br />
KISHANGANJ
…How How ‘Muskan Muskan’ Works<br />
• Local women’s women s group* meeting<br />
– Conducting twice a month meetings<br />
– Create awareness on issues related to Health, Nutrition and<br />
<strong>Immunization</strong>.<br />
• Supportive Supervision<br />
– Integrated approach to supervision by MO & ICDS official<br />
– Random verification and cross checking of immunized<br />
beneficiaries from muskan registers.<br />
– This forms the basis for release of monetary incentive to<br />
the link workers.<br />
*Care givers with vaccinator & community link workers
ure><br />
KAMUR<br />
Inter Sectoral Coordination<br />
(>75% ICDS Presence)<br />
CHAMPARAN WEST<br />
BUXAR<br />
ROHTAS<br />
CHAMPARAN EAST<br />
SITAMARHI<br />
SHEOHAR<br />
GOPALGANJ<br />
SIWAN<br />
BHOJPUR<br />
AURANGAABAD<br />
SARAN<br />
Process Monitoring (Jan 08 to Nov 08)<br />
GAYA<br />
MUZAFFARPUR<br />
PATNA<br />
NAWADA<br />
MADHUBANI<br />
DARBHANGA<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
JEHANABAD<br />
LAKHISARAI<br />
SHEIKHPURA<br />
JAMUI<br />
SUPAUL<br />
MADHEPURA<br />
VAISHALI<br />
SAMASTIPUR SAHARSA<br />
KHAGARIA<br />
BEGUSARAI<br />
BANKA<br />
BHAGALPUR<br />
ARARIA<br />
PURNIA<br />
Data not available<br />
Less than 50 %<br />
50 to 79 %<br />
80% & above<br />
KATIHAR<br />
KISHANGANJ<br />
Community participation<br />
(>65% Local women’s group meetings held)<br />
KAMUR<br />
Picture><br />
CHAMPARAN WEST<br />
BUXAR<br />
ROHTAS<br />
CHAMPARAN EAST SITAMARHI<br />
SHEOHAR<br />
GOPALGANJ<br />
SIWAN<br />
BHOJPUR<br />
AURANGAABAD<br />
SARAN<br />
GAYA<br />
MUZAFFARPUR<br />
PATNA<br />
NAWADA<br />
MADHUBANI<br />
DARBHANGA<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
JEHANABAD<br />
LAKHISARAI<br />
SHEIKHPURA<br />
JAMUI<br />
Source: WHO/NPSP & Unicef RI Monitoring<br />
SUPAUL<br />
MADHEPURA<br />
VAISHALI<br />
SAMASTIPUR SAHARSA<br />
KHAGARIA<br />
BEGUSARAI<br />
BANKA<br />
ARARIA<br />
BHAGALPUR<br />
PURNIA<br />
KATIHAR<br />
KISHANGANJ
…How How ‘Muskan Muskan’ Works<br />
• Budgetary support<br />
– Funding support from Government of India under<br />
the National Rural Health Mission (NRHM)<br />
– Expenditure in <strong>Routine</strong> <strong>Immunization</strong> has increased<br />
more than two times in last two years<br />
• Regular Review<br />
– Reviews conducted at all levels<br />
– Monitoring by the state and partners holds the key<br />
to bridge gaps.
M<br />
U<br />
S<br />
K<br />
A<br />
N<br />
How ‘Muskan Muskan’ Works<br />
Muskan Register & Survey<br />
Muskan Sessions<br />
Coverage Based Incentive<br />
Women group meeting<br />
Supportive Supervision<br />
Budgetary support<br />
Regular Review<br />
Summary
Percent Fully Immunized<br />
RI Strengthening efforts and Survey Results<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
22.4<br />
Source: http://www.mohfw.nic.in<br />
24.4<br />
Launching RI<br />
augmentation Drive<br />
(Aug 05)<br />
Muskan<br />
Launched<br />
(Oct 07)<br />
41.4<br />
DLHS-1(1998-00) DLHS-2 (2002-04) DLHS-3 (2007-08)
% Coverage<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Evaluated <strong>Immunization</strong> Coverage : Bihar<br />
40.8<br />
46.8<br />
Source: http://www.mohfw.nic.in<br />
81.5<br />
Challenge is to reduce<br />
drop out & left out children<br />
25.6<br />
28.2<br />
54.2<br />
22.4<br />
24.4<br />
41.4<br />
BCG Measles Fully Immunized<br />
DLHS-1(1998-00) DLHS-2 (2002-04) DLHS-3 (2007-08)
Conclusions<br />
• Bihar has shown considerable<br />
improvement in immunization<br />
coverage over last two years<br />
•Improved Micro Planning, Enhanced political commitment,<br />
performance based incentives and inter-sectoral coordination<br />
are key to these achievements<br />
•Efforts are on to fill gaps in infrastructure and skilled human<br />
resources.<br />
•Improvement in data quality on GOI’s centralized web based<br />
HMIS launched in Sept.2008
Reaching the unreached…<br />
Immunizing…<br />
Muskan – Where there<br />
is a will there’s a way<br />
Muskan Session<br />
Tracking…
g{tÇ~ g{tÇ~ çÉâ<br />
çÉâ
Fully immunized – DLHS-3<br />
KAIMUR<br />
CHAMPARAN WEST<br />
BUXAR<br />
ROHTAS<br />
CHAMPARAN EAST SITAMARHI<br />
SHEOHAR<br />
GOPALGANJ<br />
SIWAN<br />
BHOJPUR<br />
AURANGAABAD<br />
SARAN<br />
GAYA<br />
MUZAFFARPUR<br />
VAISHALI<br />
PATNA<br />
NAWADA<br />
MADHUBANI<br />
DARBHANGA<br />
SAMASTIPUR<br />
BEGUSARAI<br />
NALANDA<br />
MUNGER<br />
ARWAL<br />
JEHANABAD<br />
LAKHISARAI<br />
SHEIKHPURA<br />
JAMUI<br />
SUPAUL<br />
MADHEPURA<br />
SAHARSA<br />
KHAGARIA<br />
BANKA<br />
BHAGALPUR<br />
ARARIA<br />
PURNIA<br />
KATIHAR<br />
KISHANGANJ
Percentage<br />
Monthwise % of Muskan Incentive distribution to ICDS Workers & ASHAs<br />
for Mobilization of Beneficiaries to the Session sites<br />
(Jan’08 – Sep’08)<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
7<br />
21<br />
AWW ASHA<br />
14<br />
17<br />
13 9<br />
12<br />
20<br />
24<br />
20 19<br />
19<br />
17 15 17<br />
Jan'08<br />
5<br />
Feb'08 Mar'08 Apr'08 May'08 June'08 Jul'08 Aug'08 Sep'08 Oct '08 Nov '08<br />
Months<br />
15<br />
12<br />
12<br />
13
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