Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGAMUZAFFARPUR
SAMASTIPUR SAHARSA
GOPALGANJ
BEGUSARAI
MUNGER
KHAGARIA
MADHEPURA
KISHANGANJ
ARWALLAKHISARAIJEHANABAD
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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGA
MUZAFFARPUR
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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGA
MUZAFFARPUR
SAMASTIPUR SAHARSA
GOPALGANJ
BEGUSARAI
MUNGER
KHAGARIA
MADHEPURA
KISHANGANJ
ARWALLAKHISARAIJEHANABAD
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
……How How ‘‘MuskanMuskan’’ WorksWorks
•• 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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGA
MUZAFFARPUR
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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGA
MUZAFFARPUR
SAMASTIPUR SAHARSA
GOPALGANJ
BEGUSARAI
MUNGER
KHAGARIA
MADHEPURA
KISHANGANJ
ARWALLAKHISARAIJEHANABAD
SHEIKHPURA
SHEOHAR
Tracking of Beneficiaries (Jan-Nov’08)
(>65% Due List Registers Used)
Source: WHO/NPSP & Unicef RI Monitoring
n : 36,980
Data not available
Less than 50 %
50 to 79 %
80% & above
……How How ‘‘MuskanMuskan’’ WorksWorks
•• 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
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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGAMUZAFFARPUR
SAMASTIPUR SAHARSA
GOPALGANJ
BEGUSARAI
MUNGER
KHAGARIA
MADHEPURA
KISHANGANJ
ARWALLAKHISARAIJEHANABAD
SHEIKHPURA
SHEOHAR
Source: WHO/NPSP & Unicef RI Monitoring
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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGA
MUZAFFARPUR
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
SITAMARHICHAMPARAN EAST
AURANGAABAD
VAISHALI
BHAGALPUR
DARBHANGA
MUZAFFARPUR
SAMASTIPUR SAHARSA
GOPALGANJ
BEGUSARAI
MUNGER
KHAGARIA
MADHEPURA
KISHANGANJ
ARWALLAKHISARAIJEHANABAD
SHEIKHPURA
SHEOHAR
Data not available
Less than 50 %
50 to 79 %
80% & above
……How How ‘‘MuskanMuskan’’ WorksWorks
•• 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
ARWALLAKHISARAIJEHANABAD
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