routine immunization

Routine Immunization

The ‘Muskan’ initiative

Bihar, India

Aradhana Johri,Joint Secretary,

Ministry of Health & Family Welfare Govt. of India

India, a changing environment

National Rural health Mission, the Flagship program of GoI launched in 2005

�Communization – Incentivised ASHA in each village. Village

Health Committees set up. Community oversight at every level

�Decentralized district planning, flexible need based funding by

GOI. Funding enhanced.$150 mill to Bihar.

�Infrastructure strengthening at each facility. IPHS norms made.

2 ANMs at sub health centre. PHCs are 24*7 with 3 nurses.

CHCs are First referral unit

�Converged outreach scheme of monthly Village Health

Nutrition Day launched nationally

�Institutional deliveries increased exponentially due to GOI

incentive scheme*ASHA Accredited Social Health Activist; ICDS Worker, **ANM= Auxiliary Nurse Midwife. IPHS= Indian Public Health Standards

Immunization Specific Initiatives in India

•• Decentralized planning Decentralized planning & need based funding.

•• Improving service delivery through:Improving service delivery through:

– Alternate vaccinators

– Alternate Vaccine Delivery

– Increased services through Special immunization drives

– Improving mobilization & tracking through community

link workers* & vaccinators**

• Improving supervision & monitoring

• Intensified session Monitoring by partners

• Ongoing training of HWs in immunization

– 51% Health Workers trained in India (107,066 / 209,695)

– 90.6% in Bihar (11478 / 12675)

*ASHA Accredited Social Health Activist; ICDS Worker, **ANM= Auxiliary Nurse Midwife.

Bihar: A Challenge

Uttarakhand

Maharashtra

Karnataka

Lakshadw eep

Goa

KeralaTamil Nadu

Puducherry

Andhra Pradesh

Dadra & Nagar Haveli

Rajasthan

Gujarat

Daman & Diu

Jammu & Kashmir

Uttar Pradesh

Madhya Pradesh

Haryana

Punjab

Delhi

Himachal Pradesh

Chandigarh

Jharkhand

OrissaChhattisgarh

Andaman & Nicobar Islands

MeghalayaBiharAssam

Sikkim

ManipurTripura

Mizoram

Arunachal Pradesh

Nagaland

West Bengal

• State in North India,

bordering Nepal

• Population 93 million

(9% of total population)

•Poor infrastructure and

annual floods add to service delievery

challenge

•Poor roads and power

supply

•Frequent polio SIAs. 15

days / month

Bihar: A Challenge ( contd..)

IMR

MMR

Indicator

5558

301371

IndiaBihar

RAJASTHAN

ORISSA

GUJARAT

MAHARASHTRA

MADHYA PRADESH

BIHAR

KARNATAKA

UTTAR PRADESH

ANDHRA PRADESH

JAMMU & KASHMIR

ASSAM

TAMIL NADU

CHHATTISGARH

PUNJAB

JHARKHANDWEST BENGAL

ARUNACHAL PR.

HARYANA

KERALA

UTTARANCHAL

HIMACHAL PRADESH

MANIPUR

MIZORAM

MEGHALAYANAGALAND

SIKKIM

GOA

A&N ISLANDS

D&N HAVELI

PONDICHERRY

LAKSHADWEEP

RAJASTHAN

ORISSA

GUJARAT

MAHARASHTRA

MADHYA PRADESH

BIHAR

KARNATAKA

UTTAR PRADESH

ANDHRA PRADESH

JAMMU & KASHMIR

ASSAM

TAMIL NADU

CHHATTISGARH

PUNJAB

JHARKHANDWEST BENGAL

ARUNACHAL PR.

HARYANA

KERALA

UTTARANCHAL

HIMACHAL PRADESH

MANIPUR

MIZORAM

MEGHALAYANAGALAND

SIKKIM

GOA

A&N ISLANDS

D&N HAVELI

PONDICHERRY

LAKSHADWEEP

Fully Immunized Children Evaluated Coverage

DLHS-2 (2002-04) DLHS-3 (2007-08)

Bihar: 24.4 % Bihar: 41.4 %

Source: http://www.mohfw.nic.in/dlhs/dlhs08_release_1.htm

India

DLHS-2Data not available14 to 4040 to 5555 to 7575 - 8585 - 93.4

India: 47.6%

Muskan Muskan (In English(In English……Smile)Smile)

An Innovative Initiative in Bihar

• Target children 0-23 months: ~ 4.7 million

• Augmentation of immunization efforts started in 2005 through special immunization drives

• Later formalized as ‘‘MuskanMuskan’’ in Oct-2007

• Partners in Implementation :

– State Health Society, Bihar

– UNICEF

– NPSP/WHO

• Enhanced Political commitment

Enhanced Political Commitment

�Oversight by the Chief Minister of Bihar

�Regular Review by the Executive Director

�State Task force meetings to review the programme & take corrective actions

InterInter--

SectoralSectoral

CoordinationCoordination

IdentificationIdentification

&&

Tracking of Tracking of

beneficiariesbeneficiaries

Review of Review of

MicroplanMicroplan

Performance Performance

based based

incentives for incentives for

service service

providersproviders

Involvement Involvement

of village of village

level Mahila level Mahila

Mandal Mandal **

Muskan Muskan

StrategyStrategy

* Local women’s group

Muskan Strategy

How How ‘‘MuskanMuskan’’ WorksWorks

•• Muskan Register & SurveyMuskan Register & Survey

– Enlisting of all beneficiaries through h-to-h survey by community link workers (ICDS* & ASHA**)

– Regular updating of muskan registration data

* ICDS: Integrated Child Development Scheme

** ASHA: Accredited Social Health Activist Picture> Picture>

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA

SITAMARHICHAMPARAN EAST

AURANGAABAD

VAISHALI

BHAGALPUR

DARBHANGAMUZAFFARPUR

SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ

ARWALLAKHISARAIJEHANABAD

SHEIKHPURA

SHEOHAR

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR


SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHARRecording & Registering ( Jan-Nov’08)

(>60% Muskan Registers Updated )

n : 36,980

Source: WHO/NPSP & UNICEF RI Monitoring

Data not available

Less than 50 %

50 to 79 %

80% & above

•• Weekly Muskan sessionsWeekly Muskan sessions

– Microplans revised and 6700 additional ANMs hired

– Increasing outreach sessions by adding an additional day for immunization

(8-10 outreach sessions per each sub-center area per month)

– Integrated efforts of ICDS and health department at all levels esp. at imm session

……How How ‘‘MuskanMuskan’’ WorksWorks

Picture>Picture>

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR

DARBHANGA

MUZAFFARPUR

SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR

DARBHANGA

MUZAFFARPUR

SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

Source: WHO/NPSP & Unicef RI Monitoring

Re-establishing Outreach services (Jan-Nov’08)

(>90% Sessions Held)

n : 36,980

Data not available

Less than 50 %

50 to 79 %

80% & above

Improved Micro Planning using GIS

• Urban RI initiated in 23 towns and cities of Bihar

• Micro-planning and monitoring using GIS technology

% Monitored Sessions with Mobilizer Present% Monitored Sessions with Mobilizer Present

(Pre & Post Muskan)(Pre & Post Muskan)

51 49

7874

65

88

0

10

20

30

40

50

60

70

80

90

100

AWW Presence ASHA Presence Any Mobilizer Presence

Pre Muskan (n=17910) Post Muskan (n=37134)

Pre Muskan : Nov-06 to Oct-07, Post Muskan: Nov-07 to Oct-08 Source: WHO/NPSP & UNICEF RI Monitoring


•• Coverage based IncentiveCoverage based Incentive

– Tracking new borns through due list

– Performance based monetary incentive to workers for

ensuring vaccination of over 80% due for the month

Picture>Picture>

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR

DARBHANGA

MUZAFFARPUR

SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR

DARBHANGA

MUZAFFARPUR

SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

Tracking of Beneficiaries (Jan-Nov’08)

(>65% Due List Registers Used)


n : 36,980

Data not available

Less than 50 %

50 to 79 %

80% & above


•• Local womenLocal women’’s group* meetings group* meeting

– Conducting twice a month meetings

– Create awareness on issues related to Health, Nutrition and

Immunization.

•• Supportive SupervisionSupportive Supervision

– Integrated approach to supervision by MO & ICDS official

– Random verification and cross checking of immunized

beneficiaries from muskan registers.

– This forms the basis for release of monetary incentive to

the link workers.

*Care givers with vaccinator & community link workers

Inter Sectoral Coordination(>75% ICDS Presence)

ure>ure>

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR


SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR


SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR


Process Monitoring (Jan 08 to Nov 08)

Community participation(>65% Local women’s group meetings held)

Picture>Picture>

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR

DARBHANGA

MUZAFFARPUR

SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

GAYA

PATNA

JAMUI

KAMUR

ROHTAS

BANKA

PURNIA

SARAN

ARARIASIWAN

KATIHAR

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA


AURANGAABAD

VAISHALI

BHAGALPUR

DARBHANGA

MUZAFFARPUR

SAMASTIPUR SAHARSA

GOPALGANJ

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

Data not available

Less than 50 %

50 to 79 %

80% & above


•• Budgetary supportBudgetary support

– Funding support from Government of India under

the National Rural Health Mission (NRHM)

– Expenditure in Routine Immunization has increased

more than two times in last two years

•• Regular ReviewRegular Review

– Reviews conducted at all levels

– Monitoring by the state and partners holds the key

to bridge gaps.

Muskan Register & Survey

Muskan Sessions

Coverage Based Incentive

Women group meeting

Supportive Supervision

Budgetary support

Regular Review

M

U

S

K

A

N

HowHow ‘‘MuskanMuskan’’ WorksWorks

SummarySummary

RI Strengthening efforts and Survey Results RI Strengthening efforts and Survey Results

22.4 24.4

41.4

0

10

20

30

40

50

60

70

80

90

100

DLHS-1(1998-00) DLHS-2 (2002-04) DLHS-3 (2007-08)

Pe

rce

nt

Fu

lly

Im

mu

niz

ed

Launching RI augmentation Drive

(Aug 05)

Muskan Launched (Oct 07)

Source: http://www.mohfw.nic.in

Evaluated Immunization Coverage : BiharEvaluated Immunization Coverage : Bihar

40.8

25.622.4

46.8

28.224.4

81.5

54.2

41.4

0

10

20

30

40

50

60

70

80

90

100

BCG Measles Fully Immunized

DLHS-1(1998-00) DLHS-2 (2002-04) DLHS-3 (2007-08)

Source: http://www.mohfw.nic.in

Challenge is to reduce

drop out & left out children

% Coverage

ConclusionsConclusions

• Bihar has shown considerable

improvement in immunization

coverage over last two years

•Improved Micro Planning, Enhanced political commitment,

performance based incentives and inter-sectoral coordination

are key to these achievements

•Efforts are on to fill gaps in infrastructure and skilled human

resources.

•Improvement in data quality on GOI’s centralized web based

HMIS launched in Sept.2008

Muskan Session

Muskan – Where there

is a will there’s a way

Reaching the unreached…

Immunizing…Tracking…

g{tÇ~ çÉâg{tÇ~ çÉâg{tÇ~ çÉâg{tÇ~ çÉâ

Fully immunized – DLHS-3

GAYA

PATNA

JAMUI

KAIMUR

BANKA

ROHTAS

PURNIA

SARAN

ARARIA

KATIHAR

SIWAN

MADHUBANI

SUPAUL

NAWADA

CHAMPARAN WEST

BHOJPURBUXAR

NALANDA

SITAMARHI

AURANGAABAD

CHAMPARAN EAST

BHAGALPUR

VAISHALI

DARBHANGA

MUZAFFARPUR

SAMASTIPUR

GOPALGANJ

SAHARSA

BEGUSARAI

MUNGER

KHAGARIA

MADHEPURA

KISHANGANJ


SHEIKHPURA

SHEOHAR

Monthwise % of Muskan Incentive distribution to ICDS Workers & ASHAs

for Mobilization of Beneficiaries to the Session sites

(Jan’08 – Sep’08)

7

21

1417

2024

19 17 15 17

5

13 12

20 1915

12 13129

0

10

20

30

40

50

60

70

80

90

100

Jan'08 Feb'08 Mar'08 Apr'08 May'08 June'08 Jul'08 Aug'08 Sep'08 Oct '08 Nov '08

Months

Pe

rce

nta

ge

AWW ASHA

routine immunization

Documents