Report of Workshops on Expanded Program on Immunization (EPI) held at district & Eastern regional level in Nepal.
By: Nawaraj Subba, MPH, MA

General Background
His Majesty's Government, Ministry of Health has given priority to the Expanded Program on Immunization. Since it is one of the most cost-effective health interventions, it has achieved reputation of popularity in the population and interest of planner and managers in the country. One of the immediate objectives of the EPI program are to reduce Neonatal Tetanus (NNT), to reduce measles, and to eradicate Poliomyelitis by the year 2000¹. To achieve the above objective, EPI program has set targets in all 75 districts for uniform increases and sustained high levels of homogenous vaccination (at least 80% for OPV3, DPT3, BCG, and measles in children under one year of age and 80% for TT2 vaccine in pregnant women². Measles vaccination coverage in the Eastern region for the fiscal year 2056/57 (1999/2000) was 71.8% and at national level 76.9%.³ The Annual Report of DoHS (2056/57) has pointed out that strategies related to EPI are only particularly effective and coverage is still low for various vaccines. National Immunization Days (NIDs) can only be successful if generally high population immunity has already been achieved, a situation that is not possible if large numbers of children are dropping out of the routine program⁴. Report has pointed out that the strategy related to EPI are only partially effective and it requires revise and update EPI strategy to comply with current and future needs⁵. It is also empirically felt that different national campaigns are pushing regular program towards shadow in districts. The heterogeneous coverage of EPI within districts is another major problem that has been neglected for years

In accordance to Annual Report of Ministry of Health, Department of Health Services 1999/2000, coverage of Polio-3 vaccination was 80%, DPT-3 80%, Measles 77% and BCG 97%. And as we analyze the reports published by Department of Health Services over past 6 years

we find following fact and figures. Measles coverage in national level was 72% in 1994/95, 87% in 1995/96, 88% in 1996/97, 89% in 1977/98, 81% in 1998/99 and 77% in 1999/2000. Similarly coverage of DPT-3 in national level was 77% in 1994/95, 81% in 1995/96, 80% in 1996/97, 83% in 1997/98, 76% in 1998/99 and 80% in 1999/2000. EPI coverage has generally been observed as downward trends over past six years in Nepal.

The heterogenous coverage has been hidden but most considerable issue on the way of achieving the goal of EPI. Sometime the data of a district could mislead the real situation of specific pocket area (VDCs) of the district. For example, Siraha district has reported 87% district coverage but there are still health institutions having coverage of 3% in Siraha HP, 53% in Lahan⁶. Similarly another example can be taken from Saptari where there are still health institutions having below 60% coverage whereas district overall coverage is 87%⁷. So, higher achievement of a district coverage does not necessarily assure its homogenous coverage within the district.

Regional and districts Workshop on Strengthening low EPI coverage.
An attempt took place to assess the cause of low coverage in a regional level workshop held at Biratnagar on December 2001 organized by Eastern Regional Health Services Directorate. The workshop went through identification of almost all problemss and possible solutions to be taken.

Writer of this article had also coordinated the regional level EPI training workshop at Biratnagar and district level workshop on strengthening low measles coverage at district level in Sunsari and Morang district on behalf of Eastern Regional Health Services Directorate in December 2001. The article is written based on the above mentioned workshops.

Objectives:

Problems identified causing low coverage of EPI program. There are numerous problems exist in our health system.The immediate causes of low coverage have been identified by District Health Officer, District Public Health Officer, EPI Supervisor, cold-Chain Assistant, Incharges of PHC, HP and Sub Health Posts; can be categorized as follows:

1. Inactive VHW and MCHW.
2. Inadequate coordination between VHW and MCHW.
3. Inadequate counseling to mother given by VHW/MCHW to the mother.
4. Over-reporting and underreporting by VHW and MCHW.
5. Irregular attendance of VHW at post and inconsistent in time.
6. Use of needle and syringes are not properly sterilized. Abscess as complication following injection has been learned from HP/SHP.
7. VHW/ MCHW are not feeling their moral responsibility for giving vaccine in proper time and interval to their target group.
8. VHW and MCHW are failed to get support from local leaders, FCHV, TBA and others.
9. In Charge of Health Post and Sub Health Post are not aware of their target.

1. EPI posts are not located as per need of population. Immunization posts are five whether the VDC has 4000 population or a village having 20000 population. Likewise EPI posts are same whether area of a VDC has area of 100 Sq.Km or a district having 500 Sq.Km. So revision of the number of EPI posts required at micro- level.
2. Irregularity in conducting routine EPI post in the villages by VHW/MCHW has been reported. People are not confident about time, place and health worker at post. So they are still confused.
3. VDC are not aware enough to manage the EPI post in their wards.

1. There are plenty of posts for MCHW are still vacant and VHW are not enough mainly in the hilly and mountainous districts.
2. There is a problem of vaccine supply especially during rainy season.
3. Transfer of health workers, deputation, leave and training.
4. Irregularity in Routine EPI program.
5. Since there is inefficacy of skill still exists in MCHW and VHW.
6. Delay or improper payment of TADA for health worker and peon.
7. Lack of monitoring, evaluation and feedback of achievement at SHP/HP/District and Regional levels.
8. IEC materials are lacking. There are still many people those are taking vaccine just by imitation but do not know for what diseases they are taking vaccine for.
9. Failure rate of vaccine is a major problem especially for measles vaccine.
10. Cold-chain maintenance especially at field is a problem during summer season.
11. There is no provision of tracing of drop out children.

1. Difficult topographical condition.
2. Transfer of health worker, deputation, leave and training.
3. Strike and Nepal Band.
4. Inadequate awareness of EPI program among people and political leaders.

Possible Solutions identified. Once the causes of low EPI coverage identified by District Health Officer, District Public Health Officer, EPI Supervisor, cold-Chain Assistant, Incharges of PHC, HP and Sub Health Posts have also discovered Possible solution as follows:

1. Refresher training for VHW and MCHW, fulfillment of vacant posts and strengthening of management can motivate towards job.
2. Inadequate logistic supply can be controlled by timely demand requisition system from needy level. Even after being supplied the needle and syringe there is still use of same old out conditioned needles have been used by VHW at the post and that can be controlled by supervision from Health Post and Sub-Health Post level.
3. Proper use of Monitoring profile, register, HMIS forms and HMIS forms can guide our poor monitoring in the right direction. Timely review of program and necessary feed back to the concerned should be implemented.
4. Incomplete and unreliable reporting from VHW can be controlled by supervision by the HP/SHP In charges, supervisors and need to be analyzed, feedback of report to the respective VHW, SHP by HP and district level.
5. Since VHW/MCHW are not carrying EPI program full time at the post mother are confused with their post operation time table. A signboard with information of time, place, date, name of responsible health workers and services provided should be mentioned and to be placed around the EPI post for public information dissemination. It may help people to take service and to do monitoring as well.
6. Routine EPI program has been fall under shadow due to different campaigns such as NIDs, MNT, NLEC, Vitamin A distribution program etc. They are only complementary means to meet our target. But health workers seem inadequately oriented to their regular EPI program. So it requires more orientation as well as their involvement in micro-planning process at health post and sub-health post level.
7. Management should be strengthened and co-ordination should be established at all levels. Feeling of responsibility and accountability should be enhanced through power delegation and transparent policy at all levels.
8. The work of a VHW demands physical fitness to carry out her/his job. So old and incapable VHWs should be replaced by golden handshake as far as possible.
9. In order to strengthen cold chain in the district the number of sub centers should be increased as per need of the district.
10. Number of EPI posts should be increased in populous and large geographical area. Tendency of carrying out 2-3 days EPI program at the HP/SHP should be ended and out reach EPI posts should be strengthened.
11. Poor cold chain condition at posts site can be minimized by making provision of frequent moment of supply.
12. Special programs are needed for marginalised people. It may be such as health education program, school health program, and provision of additional posts and involvement of the leader from local ethnic groups for certain unaccess geographical area.
13. Mother groups can be strengthened by regular involvement of VHW/MCHW in meeting where orientation could be provided to mothers. FM and Radio could be used for IEC dissemination.
14. Coordination with municipalities, NGOs, INGOs should be strengthened in terms of micro-planning, implementation and reporting within a district.
15. Since sterilization is sensitive and technical issue it can be solved by local level support. Local post management committee or ward committee or VDC could manage fuel or wood necessary for sterilization. The quality assurance of sterilization could be monitored with the help of local level e.g. SHP/SP/VDC level by checking and ensuring proper boiling time period at post.
16. Since VHW/MCHW could be careless and negligence in terms of use of proper diluent, proper and safety techniques for vaccination that can be ensured by supervision from SHP/HP and DHO level in the district.
17. Nominal registration charge can contribute for retention of cards and may assure update recording, reporting due to its provision of financial reporting. And it would also be a resource for fuel and maintenance of stove and sterilizer etc.
18. Additional operation of the vaccination post other than regular camp are needed to increase the coverage.

Conclusion.  The promising solutions for respective problems noted above were explored by the districts themselves. In accordance to the concluding speech at the workshop Regional Director as well as participants have admitted that most of our existing problems (around 80%) could be solved within district level. So district itself can change the scenario if it is activated. Since majority of the problems could be solved by district level and below; initiation should be focus to this areas. Some practical problems and issues have been raised; which need to be considered by policy level.

©2002, Nawaraj Subba.

References
¹ DoHS, 1999/2000, Annual Report, Kathmandu Nepal, p.21
² idem
³ DoHS, 1999/2000, Annual Report, Kathmandu Nepal, p.20
⁴ MOH/DoHS, WHO, UNICEF, 1998, Routine Immunization and NID survey report, p.14
⁵. DoHS, 1999/2000, Annual Report, Ministry of Health, Department of Health  Services,Kathmandu, Nepal.
⁶HMIS / ERHSD, 057/58.

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