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Indian Pediatr 2012;49:
187-188 |
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Intrapartum Perinatal Mortality
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*Robert L Goldenberg, #Elizabeth M Mcclure, and
†Beena D Kamath
*Drexel University, Philadelphia, USA, # Research
Triangle Institute, North Carolina, USA, and
†Cincinnati
Children’s Hospital Medical Center, Ohio, USA.
Correspondence to: Robert
L Goldenberg;
Email: [email protected]
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It is estimated that more than
10 million children in India do not receive BCG, 3 doses of OPV and DTP,
and measles vaccine during their first year of life and more than 3
million of these do not receive any immunizations[1]. The complexity and
diversity of India means that the distribution of unvaccinated and
partially vaccinated children is not equal either between or within
states. How immunization performance gaps are bridged is of interest to
all stakeholders – Union and State governments and immunization
partners. Bihar, India’s second more populous state historically
competed for the inauspicious distinction of having the lowest
immunization coverage rates in the country. To be certain, times have
changed and Bihar’s progress to improve vaccination coverage over the
past several years has been considerable. For these reasons, the
assessment by Goel and colleagues of Bihar’s Muskaan Ek Abhiyan
campaign [2] is timely and welcome.
The article presents the experience of Bihar’s
Muskaan Ek Abhiyan and compares survey data from other Empowered
Action Group (EAG) states to assess immunization coverage improvement.
The conclusions of the authors, namely that there was marked improvement
in immunization coverage and there are replicable lessons to learn from
Bihar’s experience, are incontrovertible. Coinciding with a change of
government and the design and implementation of Muskaan in 2005,
vaccination coverage rates have climbed steadily, demonstrating that
improving India’s Universal Immunization Program (UIP) is possible in
the most intractable areas.
Unfortunately, this assessment falls short of what is
needed, namely a comprehensive in-depth analysis of the effectiveness of
Muskaan. Instead, the report relies on a normative description of
its interventions and state-wide comparison of survey assessed
vaccination coverage to make its point. The authors correctly point out
that it "is difficult to extract the effect of individual interventions
of Muskaan." Such an assessment is difficult; but it is not
impossible. It is precisely this disaggregation of individual components
of Muskaan that is needed to provide useful insight to the
relative merits of interventions and the mechanisms that affect
vaccination coverage [3,4]. Rather than the fault of the authors, this
situation illustrates the need to advocate for the use of appropriate
methodologies when evaluating large scale programs, as well as – and
above all – the need for valid and reliable data from multiple sources
in order to do so.
India’s Universal Immunization Program (UIP) targets
an estimated annual live-birth cohort of 26 million children and faces
multiple challenges that include high drop outs rates, a dearth of
trained human resources at all levels, periodic vaccine stock-outs,
infrequent supervision, unsafe waste disposal practices of injection
material and inconsistent communication promoting immunization [5]. In
addition, India’s UIP also suffers from a lack of reliable, well
organized program data to permit robust monitoring and evaluation to
guide UIP strategic planning and policy formulation. There is a
desperate need to improve the accuracy, completeness, timeliness and
feedback of UIP-related data at all levels. The state-of-the-art Health
Management Information System (HMIS), designed to collect service
statistics and program related information for numerous programs at the
district level, generates data that often bears little resemblance to
reality and is of little use to program managers. The ultimate impact of
immunization efforts is reduced morbidity and mortality due to vaccine
preventable diseases. Yet for the exception of acute flaccid paralysis
surveillance for poliomyelitis, effective and appropriate national
surveillance does not exist to provide accurate burden of disease
information and trends for the target diseases of current UIP antigens.
Moreover, plans have not materialized to establish sentinel surveillance
sites to capture disease-specific data related to new and important
vaccines such as Haemophilus influenzae type b, pneumococcal and
rotavirus vaccines. Monitoring of immunization session-sites and
community coverage, where it’s been implemented, provides real-time
assessment of the quality and reach of immunization services. Bihar has
implemented vaccination session-site and community monitoring and
together with partners provided feedback on 39,051 immunizations
sessions monitored and the vaccination status of 310,843 children 0-23
months of age [6]. In a more robust assessment of Muskaan, this
information would be crucial to better understand the intermediate
pathways associated with the uptake of immunization services.
Unfortunately, Bihar is just one of a handful of states that has
implemented this system of monitoring. Lastly, strategies and intensity
of activities required to increase coverage from 30 to 50 percent will
not be the same when attempting to raise coverage to 90 percent and
above. For this reason, it is also necessary to link budget and
expenditure data to aid decisions related to the cost-effectiveness of
different interventions.
Over the last several years, Bihar has more than
doubled its proportion of fully immunized children while aggressively
pursuing polio eradication at a level of intensity rivaled only in Uttar
Pradesh. Untangling the mixed effects in National Rural Health Mission
(NRHM), Muskaan, polio eradication efforts and the role of
Government strength and ownership is a complex endeavor that requires
robust prospective program evaluation informed by multiple data sources.
As well known evaluators have aptly stated, "Evaluations of complex
population-level interventions are likely to have complex answers, but
are necessary to improve future programs."[7]
Funding: None;
Competing interests: The views expressed in this paper are those of
the author alone and should not be attributed to the World Health
Organization.
References
1. UNICEF Coverage Evaluation Survey. All India
Report. New Delhi: UNICEF; 2009.
2. Goel S, Dogra V, Gupta SK, Lakshmi PVM, Varkey S,
Pradhan N, et al. Effectiveness of Muskaan Ek Abhiyan (The Smile
Campaign) for Strengthening Routine Immunization in Bihar, India. Indian
Pediatr 2012; 49: 103-8.
3. Ng M, Gakidou E, Levin-Rector A, Khera A, Murray
CJ, Dandona L. Assessment of population-level effect of Avahan, an
HIV-prevention initiative in India. Lancet.2011;378:1643-52.
4. Victora CG, Black RE, Boerma T, Bryce J. Measuring
impact in the Millennium Development Goal era and beyond: a new approach
to large-scale effectiveness evaluations. The Lancet. 2011;377:85-95.
5. Sagar KS. Improving UIP Coverage in India, concept
note. New Delhi: Maternal and Child Health Integrated Program (MCHIP);
2011.
6. National Polio Surveillance Project. Routine
Immunization Monitoring database. New Delhi: NPSP, WHO: 2010-2011.
7. Boerma T, d Zoysa I. Beyond accountability: learning from
large-scale evaluations. The Lancet. 2011;378:1610-1.
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