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editorial

Indian Pediatr 2012;49: 187-188

Intrapartum Perinatal Mortality


*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]


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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