Monitoring & Evaluation for Routine Immunization: Data For Action

Using information to improve routine immunization services

Presentation 2 Objectives

• Be familiar with the role of information in routine immunization

• Be able to use, modify or develop tools for monitoring or improving data quality and use at health facility / district level

• Be aware of resources available for vaccination information in routine immunization

Overview of M&E framework for RI

Inputs Outcome Impact

Short-Term Long-Term

Vaccines, services delivered, advocacy, planning, training

Increase vaccination coverage

Reduce vaccine-preventable disease (VPD) burden

Reduce infant and child morbidity and mortality

In every country:at least 90% fully immunized, with at least 80% in every district*

-Eradicate polio-Reduce VPD mortality and morbidity

Reduce child mortality by 2/3 by 2015 (from 1990 levels)**

* WHO / UNICEF Global Immunization Vision and Strategy ** Millennium Development Goal 4

Goa

ls

How monitoring works for RI

• RI staff at all levels routinely monitor system performance and use this information to drive decision-making

• Monitoring indicators include– Doses administered, coverage, dropout

• Monitoring tools include– Monitoring charts, tables, monthly summary forms

• Internal monitoring activities include– Supervision visits– Rapid community assessments

How evaluation works for RI

• Internal evaluation activities include– Annual reporting of ~40 EPI indicators to

WHO/UNICEF including doses administered and immunization coverage

– Data quality self-assessments– Lot quality assurance surveys

• External evaluation activities include– External immunization coverage surveys– Data quality audits

How Data for Action works for EPI

• RI staff are expected to monitor their system AND use this information for action

• Use of RI information to improve coverage is often the weakest part of RI

• Supervisors (& you) should observe and ask staff if they know how to both calculate and use monitoring indicators, tools and activities

Common RI Indicators• Service performance

– Defined as number of children receiving one of the later vaccines– Coverage with DTP3 (DTP = DPT = DTC) – Coverage with measles– Percentage of children never reached

• Access – Defined as availability/start of services (number of children who

received one of the earliest vaccines)– Coverage with BCG or DTP1

• Utilization – Defined as continued use of services

– “Dropout rate” e.g. the number of children who received an early vaccination (DTP1) compared to the number of children who received a later vaccination (DTP3)

How to calculate coverage

– Coverage formula

________number of doses given_______ X 100estimated number of age-eligible children in catchment area

– Sources of error for coverage• Number of doses given• Estimated number of age-eligible children in the

catchment area

How to calculate dropoutDropout definition: Child begins but does not complete

immunization schedule

Drop-out rate formula

[ ( # Beginning – # Ending ) / # Beginning ] X 100

– Usually, series begins with DTP1 or BCGand ends with DTP3 or measles

= [( DTP1 – measles ) / DTP1] X 100 = [( DTP1 – DTP3 ) / DTP1] X 100 = [( BCG – measles ) / BCG] X 100 = [( BCG – DTP3 ) / BCG] X 100

Visualization of Never-reached versus Drop-outs

District A District B0

20

40

60

80

100

50

85

4258

DTP1DTP3Pe

rcen

t

Never-reached

Drop-outs

Never-reached

Drop-outs

Practice: Calculate Coverage and Dropout

  Compile population and coverage

data from previous 12 monthsProblems analysis

Name of Health

Facilities

Target pop < 1 yr

Doses givenImmunization coverage

(%)Infants non immunised

Drop out rate (%)

Identification of problems

Category

DTP1 DTP3 Measles DTP1 DTP3 Measles DTP3 MeaslesDTP1 & DTP3

Access Utilization1, 2, 3, 4

A B C D E F G H I J K L M N

  # # # #(C/

B)x100(D/

B)x100(E/

B)x100 B - D B - E(C-D)/C x

100 See flow chart "Interpretation"

Berma 430 502 472 445                  

Dokuy 781 836 353 538                  

Dara 490 355 342 524                  

Ira 916 651 573 572                  

TOTAL                          

Tool 1: Monitoring chart

• Used at multiple levels to visually track monthly performance• Charts include:

– Number of doses administered per month– Cumulative number of doses administered in year– Coverage rate– Difference in number of doses administered between 2 vaccines

(dropout)– Monthly target and cumulative target population

• Good charts are:– Up to date– Properly filled

Completing an Immunization Monitoring Chart

• Enter monthly objectives on the y-axis (target population ÷ 12)

• Diagonal line represents regular progress over a 12 month period ending with 100% coverage

• Every month – Enter the antigen total for the month– Calculate the cumulative total for the antigen– Mark the cumulative total on the chart with a dot– Calculate the cumulative number of drop outs– Calculate the cumulative drop out rate

Practice: How to fill in a monitoring chart

• Zorgho, 2003• Target population < 1 =

12,897

DTP1 DTP3

Jan 836 525

Feb 909 631

Mar 818 539

Apr 1027 729

May 909 728

Jun 660 529

Jul 1001 650

Aug 860 562

1075

7523

6449

5374

4299

3224

2150

8598

9673

10748

11822

12897

1075Zorgho 2003 12897

0

836

525

836

525

909 1745

631 1156

818

539

2563

1695

1075

7523

6449

5374

4299

3224

2150

8598

9673

10748

11822

12897

1075Zorgho 2003 12897

0

836

525

836

525

909 1745

631 1156

818

539

2563

1695

311

37

589

34

868

34

1075

7523

6449

5374

4299

3224

2150

8598

9673

10748

11822

12897

DTP1

DTP30

Zorgho 2003

Tool: Immunization summary form

• Facility summary form• Summary of doses administered at facility• Data summarized from session tally sheets

• District summary form• Summary of doses administered across all facilities in

district• Data summarized from facility summary sheets

• Sent monthly by each level• Used nationally as source of information on

number of doses administered

Illustrative flow of immunization summary information

Health CenterHealth postsOutreach sites

Tally sheetsPatient registersCase reports

Health Centerconsolidates

Monthly reportsCase reportsWeekly reports

DistrictConsolidated monthlySurveillance reportWeekly reports

Consolidated monthly reports, vaccinationCase reports

National Department of Epidemiology

EPI program

Liberia Immunization Summary Form

Tool: Defaulter Tracking System

• Method to identify children who did not return for vaccination (drop outs)

• Multiple tools used as “tracking system”– Ledger of children’s names who dropped out– Tickler box or blanket

• Copy of vaccination card is kept with the month when child is expected to return

• At end of month, remaining cards used to identify and then find children who did not return

Defaulter ledger example

Source: Increasing immunization coverage at the health facility level, WHO 2001

What proportion of the children have ACCESS to immunization services? (what is DTP1 coverage?)

Tool: Prioritize your locations by severity of problems (I)

What proportion of children COMPLETE the immunization schedule (what are the DTP1 - DTP3 drop-out rates?)

Categorize the problem

HIGH coverage with DTP1 (>80%) Low coverage with DTP1 (<80%)

Drop-out rate <10%

Drop-out rate >10%

Drop-out rate <10%

Drop-out rate >10%

• Dropout rates are low = good utilization

• Coverage is high = good access

• Category 1 (no problem)

• Dropout rates are high= poor utilization

• Coverage is high = good access

• Problem Category 2

• Dropout rates are low = good utilization

• Coverage is low= good access

• Problem Category 3

• Dropout rates are high = poor utilization

• Coverage is low= poor access

• Problem Category 4

  Compile population and coverage

data from previous 12 months 

Problems analysis  

Name of Health

Facilities

Target pop < 1 yr

Doses givenImmunization coverage

(%)Infants non immunised

Drop out rate

(%)

Identification of problems

Category

Priority

DTP1 DTP3 Measles DTP1 DTP3 Measles DTP3 MeaslesDTP1 & DTP3

Access Utilization1, 2, 3, 4

1, 2, 3, 4

A B C D E F G H I J K L M N O

  # # # # (C/B)x100 (D/B)x100 (E/B)x100 B - D B - E (C-D)/C x 100 See flow chart "Interpretation"  

Berma 430 502 472 445 117% 110% 103% 30 -15 6%     1  3

Dokuy 781 836 353 538 107% 45% 69% 483 243 58%   X 2  1

Dara 490 355 342 524 72% 70% 107% 13 -34 3.7% X   3  2

Ira 916 651 573 572 71% 62% 62% 78 344 12% X X 4  4

Tool: Prioritize your locations by severity of problems (II)

Tool: Rapid community assessment• Monitoring tool used by supervisors to rapidly understand whether

vaccination services are reaching the community and identify barriers to vaccination

• Not a survey and does not generate coverage rates

• Useful to use in places where administrative vaccination coverage is reportedly high– A rapid assessment should not find many unvaccinated children

• General method– Select ~20 households and assess vaccination status and reasons for no vaccination– Should be conducted in parts of a catchment area where low coverage is expected

Thanks

Questions?