SCHOOL-BASED IMMUNIZATION PROGRAM - coa.gov.ph · Performance Audit Report Delayed procurement of Td vaccines and low parental consent resulted in the non-immunization of 1.065 million

Performance Audit Report

Delayed procurement of Td vaccines and low parental consent resulted in the non-immunization of 1.065 million or 64% of enrolled Grade 1 students and 0.998 million or 63% of enrolled Grade 7 students in 2016

PAO-2017-04

SCHOOL-BASED IMMUNIZATION PROGRAM

Audit

Highlights

Why COA did this study

The Department of Health (DOH) launched the School-based Immunization Program (SBIP) in 2013 to ensure prevention of morbidity and mortality of school age children due to vaccine-preventable diseases. Government funds amounting to at least ₱330 million and ₱282 million were allocated for the nationwide immunization campaign in 2015 and 2016, respectively. DOH claims success at 95% immunization coverage of public school students enrolled in Grades 1 and 7. Thus, the need to determine whether DOH is making progress in achieving its goals for the program.

In order to confirm the aforementioned assumptions, COA (1) identified the program’s goals and objectives and the extent these goals can be measured; (2) determined the fund allocation, extent of utilization and whether these were enough to procure the required type and quantity of vaccines; and (3) determined the extent the program achieved its immunization goals and the extent of participation of partner agencies in achieving these goals.

COA reviewed relevant guidelines, reports and regulations to determine the program goals, objectives and implementation processes. To assess the extent of program’s success, program implementation for 2015 and 2016 was reviewed taking into consideration the principles of efficiency, economy and effectiveness. Areas that were looked into included, among others, procurement of vaccines, inventory management, participation of partner agencies, fund utilization and reporting of accomplishment.

What COA Recommends

To increase the immunization coverage and attain the herd immunity target, DOH in coordination with DepEd need to minimize students without parental consent by adopting and implementing, among others, an appropriate communication plan and strengthening coordination efforts among partner agencies. DOH needs to undertake its procurement plan as scheduled and address immediately any issue that may hinder the availability of vaccines in time for the vaccination period. There is also the need to improve procurement planning and inventory management, accomplishment reporting and financial recording to promote efficient, economical and effective program implementation and accountability of program managers.

November 2017

SCHOOL-BASED IMMUNIZATION PROGRAM

Delayed procurement of Td vaccines and low parental consent resulted in the non-immunization of 1.065 million or 64% of enrolled Grade 1 students and 0.998 million or 63% of enrolled Grade 7 students in 2016

What COA Found

The SBIP intends to provide all public school students enrolled in Grades 1 and 7 nationwide with booster doses of routine vaccines to ensure that high level of protection is maintained against measles, rubella, diphtheria and tetanus. Only students with parental consent are vaccinated. While the program aims to immunize all students in the said grade levels, achieving a 95% immunization target was already considered a success following the principle of herd immunity.

For 2015 and 2016, the SBIP failed to achieve the immunization rate target in both Measles Rubella (MR) and Tetanus Diphtheria (Td) vaccines for Grades 1 and 7. While there was an increase of 12% in MR for Grade 1 from 60% in 2015 to 72% in 2016, the rates for Grade 7 did not change at 72%. The Td vaccination rates of 73% and 72% in 2015 for Grades 1 and 7, respectively, dropped to 36% and 37% in 2016.

Figure1: Immunization Rates in 2015 and 2016

The decline in immunization rates for Td was caused by lack of Td vaccines during the campaign period in 2016. The gap of at least 20% between actual immunization rate and the target rate was mainly attributable to students not vaccinated in the absence of parental consent.

Increasing awareness on the benefits of the program particularly for the parents and guardians will lower the number of students without consent. Apparently, the absence of communication plan and lack of coordination efforts among partner agencies and appropriate information materials to ensure high coverage impacted the attainment of the target.

The timely procurement of vaccines aimed at ensuring their availability in time for the vaccination period was not achieved in 2016 for Td vaccines due to late initiation of procurement activity and failure to address the issues that caused delay in the procurement. In addition, no policy on maintenance of buffer stock was enforced to answer for delay in the procurement of vaccines.

The noted deficiencies in the reporting system for the Nationwide Accomplishment Report (NAR) particularly on completeness of submission, accuracy of data reported and consistency in reporting impacted the efficiency and accuracy of data and information needed for decision-making.

Control on the utilization of resources could not be maximized in the absence of separate inventory management and financial recording for the program. The challenges noted did not contribute to the efficient, economical and effective implementation of the SBIP.

PAO-2017-04

School-Based Immunization Program

Page i PAO-2017-04

Contents

Letter 1

Background 2

Supply of sufficient vaccines not ensured during the vaccination month 4

Target immunization coverage not attained 8

Absence of communication plan for effective coordination and information dissemination 11

No separate program budget and recording of expenditures depriving Management with relevant information on the efficient utilization of resources committed to the program and the accountability of program managers 13

Deficiencies in reporting impacting on the efficiency, accuracy and completeness of data in the Nationwide Accomplishment Report 15

Poor inventory management as manifested in lack of uniformity in computing the quantity of vaccines for procurement, deficiency in maintenance of inventory records and vaccine utilization not accounted and reported 20

Conclusions 23

Recommendations 24

Agency Comments 25

Appendix I Accomplishment Forms 26

Appendix II Computation/Comparison 29

Appendix III Department of Health Management Comments 31

Appendix IV COA Contact and Staff Acknowledgements 33

Tables Table 1 : Funds allocated and actually obligated/expended for the SBIP

Table 2 : Accomplishment Report on Td Vaccination by Region

Table 3 : Detailed Immunization Rates for 2015 and 2016

Table 4 : Percentage of Students Without Parental Consent on Vaccination at NCR for 2016

Table 5 : Schedule of 2015 Sub-Allotments and Obligations for Other Operating Expenses of DOH Regional Offices

Table 6 : Regional Office which Requested for Allotment for Other Operating Expenses of SBIP

Table 7 : List of Schools where Number of Students Vaccinated Exceeded the Number of Enrolled Students

Table 8 : List of Schools which Data were Taken-up Twice in the 2015 Nationwide Accomplishment Report

Table 9 : Comparison between the DepEd Masterlist and the Number Enrolled Students in the Nationwide Accomplishment Report

Table 10 : Analysis of 2016 and 2017 procurement of vaccines

Table 11 : Analysis of utilization of available MR vaccines for 2016

Table 12 : Computation of Excess MR Vaccines in the NCRO


Page ii PAO-2017-04

Contents

Figures Figure 1 : Immunization Rates in 2015 and 2016

Figure 2 : Actual Vaccination of School Children under DOH SBIP

Figure 3 : Actual Procurement Timeline and Issuance of Td Vaccines to DOH Regional Offices/Provincial/City Health Units

Figure 4 : Students Vaccinated with Td

Figure 5 : 95% Target vs. Actual Immunization Coverage

Figure 6 : Percentage of Total Students With and Without Consent on Vaccination at NCR for 2016

Figure 7 : Flow of Accomplishing and Submission of the Report Forms

Figure 8 : Survey Results

Figure 9 : Flow of Receipt and Distribution of Vaccines

Figure 10 : Recording Form 1: Masterlist of Grade 1 Students

Figure 11 : Recording Form 2: Masterlist of Grade 7 Students

Figure 12 : Reporting Form: Regional/Provincial/City Consolidated Accomplishment Form Report


Page iii PAO-2017-04

Abbreviations

AEFI Adverse Effect Following Immunization

APP Annual Procurement Plan

ARMM Autonomous Region in Muslim Mindanao

BAC Bids and Awards Committee

CAR Cordillera Autonomous Region

CARO Cordillera Autonomous Region Office

CHO/U City Health Office/Unit

COA Commission on Audit

DepEd Department of Education

DILG Department of Interior and Local Government

DM Department Memorandum

DO Department Order

DOH Department of Health

DPCB Disease Prevention and Control Bureau

EPI Expanded Program on Immunization

FHRP Family Health and Responsible Parenting

FT Fund Transfer

GVAP Global Vaccine Action Plan

HPCS Health Promotion and Communication Service

HPV Human Papillomavirus Vaccine

IEC Information, Education, and Communication

ISSAI International Standards of Supreme Audit Institutions

LCEs Local Chief Executives

LGUs Local Government Units

MCV Measles Containing Vaccine

MHU Municipal Health Unit

MOA Memorandum of Agreement

MR Measles-Rubella Vaccine

NAR Nationwide/National Accomplishment Report

NCR National Capital Region

NCRO National Capital Region Office

NTP Notice to Proceed

OIC Officer-In-Charge

PO Purchase Order

PHO Provincial Health Office

PPMP Project Procurement Management Plan

PR Purchase Request

PTA Parent-Teacher Association

RD Regional Director

RF Recording Form

RHU Rural Health Unit

RITM Research Institute for Tropical Medicine

ROs Regional Offices

SAAs Sub-Allotment Advices

SAOB Statement of Allotments, Obligations and Balances

SBIP School-Based Immunization Program

SOE Summary Of Expenses

Td Tetanus-diphtheria Vaccine


Page iv PAO-2017-04

Abbreviations

ToT Training of Trainors

TWG Technical Working Group

WMCHDD Women’s Men’s and Children’s Health Development Division

WHO World Health Organization

Page 1 PAO-2017-04

COMMISSION ON AUDIT Commonwealth Avenue Quezon City

November 23, 2017 DR. FRANCISCO T. DUQUE III SECRETARY Department of Health Tayuman, Manila

Dear Secretary Duque:

In line with its vision to become an enabling partner of government in ensuring a better life for every Filipino, the Commission on Audit (COA) conducts performance audits to help government agencies better perform their mandates and achieve program goals and objectives more economically, efficiently and effectively. Pursuant to Section 2 (2), Article IX-D of the 1987 Constitution which vests COA the exclusive authority to define the scope of its audit and examination, and establish the techniques and methods required therefor, the COA Chairperson issued Office Order No. 2016-962 dated November 9, 2016, creating audit teams to conduct performance audits on selected priority programs/projects of the government. COA has identified the Department of Health (DOH) Immunization Project for Schools as one of the priority programs to be audited. The audit aimed to: (1) identify the program’s goals and objectives and the extent these goals can be measured; (2) determine the fund allocation, extent of utilization and whether vaccines procured were sufficient for the target beneficiaries; and (3) determine the extent the program achieved its immunization goals and how the identified partner agencies participated in achieving these goals. The School-Based Immunization Program (SBIP) was allotted at least ₱330 million and ₱282 million in 2015 and 2016, respectively, for the immunization of Grades 1 and 7 students enrolled in public schools nationwide against Measles, Rubella, Tetanus and Diphtheria diseases. The audit covered the program implementation in 2015 and 2016. We reviewed the applicable laws, rules, regulations and related guidelines to SBIP implementation. We interviewed key officials and requested for clarifications to better understand the process by which DOH plans, implements and oversees the program. We also looked into the documentation related to SBIP which included, among others, procurement documents, records of receipts and issuances of vaccines, financial records and accomplishment reports. Likewise, ocular inspections were conducted to check inventory management and reporting. Lastly, survey was conducted in sample schools in the National Capital Region (NCR) to validate the program implementation and reporting.

Republic of the Philippines


Page 2 PAO-2017-04

Background

We conducted the audit from January to June 2017 in accordance with the Fundamental Principles of Performance Auditing as embodied in the International Standards of Supreme Audit Institutions (ISSAI) 300. The standard requires that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

The Expanded Programme on Immunization (EPI) of the Department of Health has focused on the provision of free vaccines for infants since 1975. However, the protection provided by some of these vaccines decline over time and booster doses of appropriate vaccines are required to ensure that high levels of protection are maintained.1

Protected from the threat of vaccine-preventable diseases, immunized children have the opportunity to thrive and a better chance of realizing their full potential. These advantages are further increased by vaccination in adolescence and adulthood. As part of a comprehensive package of interventions for disease prevention and control, vaccines and immunization are an essential investment in a country’s—indeed, in the worlds—future.2

In 2013, DOH, in collaboration with the Department of Education (DepEd) and Department of Interior and Local Government (DILG) through their various local health units, conducted the first national School-Based Adolescent Immunization in public schools of priority provinces and cities where high risk and vulnerability, based on behavior and potential for outbreak in school and community were observed.3 The National Epidemiology Center reported the increasing cases of measles, probable diphtheria in 2010-2011and suspected pertussis in 2011-2012 among adolescents, thus, Measles-Rubella (MR) and Tetanus-diphtheria (Td) vaccines were introduced as an integral immunization strategy. The program covered all 1st year to 4th year high school students (Grade 7-10) in public school of the priority provinces and cities.4 During the same year, Human Papillomavirus (HPV) vaccine was introduced as one component in the comprehensive strategy for the prevention of cervical cancer. Grade 5 female learners within the age range of 10-14 years old in selected public schools in Region VII and Cordillera Autonomous Region (CAR) and a private school in Region VII were given the vaccine under SBIP.5 The Adolescent Immunization was expanded in 2014 to cover all thirteen (13) years old in-school and out-of-school adolescents.6

The SBIP was expanded in 2015 to a nationwide and yearly immunization of all school children enrolled in Grades 1, 4 and 7 with MCV/Td, HPV and MR/Td vaccines, respectively.7 However, a department memorandum issued at a later date specified that the program shall only include

1 DOH Department Memorandum No. 2015-0146 dated May 20, 2015, p. 1 2 World Health Organization (WHO) Global Vaccine Action Plan (GVAP) 2011-2020, published 2013, p. 12 3 Supra Note 1, p. 1 4 DOH Department Memorandum No. 2013-0168 dated May 16, 2013, p. 2 5 DOH Department Memorandum No. 2013-0291 dated August 6, 2013, p. 3 6 DOH Department Memorandum No. 2014-228 dated July 22, 2014 7 Supra Note 1, p. 2


Page 3 PAO-2017-04

Tetanus-diphtheria and Measles-Rubella vaccines for all Grade 1 and Grade 7 students in public schools nationwide.8

Figure 2 : Actual vaccination of School Children under DOH SBIP

Source: Cembo Elementary School, Makati City

The SBIP’s goal is to reduce the morbidity and mortality among school children, a strategy that supports the goal on elimination of Measles and Maternal and Neonatal Tetanus.9 The performance indicator of most vaccine-preventable disease to achieve the control, elimination and eradication is to achieve at least 95% administrative coverage in any vaccine delivery point, following the principle of herd or population immunity.10

The Guidelines in the Implementation of SBIP as embodied in the DOH Department Memorandum issued for the purpose provides that:11

1. All school children enrolled in Grade 1 and Grade 7 shall be vaccinated with the appropriate vaccines as specified:

a. All eligible school children (male and female) shall be screened for their measles vaccination history at the time of school entry and vaccinated if evidences show either zero or only 1 dose to ensure that these students receive at least 2 MCV by school entry.

b. Administered with one (1) dose of Tetanus-diphtheria (Td) vaccine.

c. All male and female students enrolled in Grade 7 regardless of age shall be vaccinated with 1 dose each of Measles-Rubella and Td vaccines on the same immunization session.

2. School-based vaccination shall be a FREE routine service to be administered by the health center catchment and the schools;

8 DOH Department Memorandum No. 2015-0222 dated July 21, 2015 9 DOH EPI (http://doh.gov.ph/expanded-program-on-immunization) 10 Letter of OIC Director III, Family Health Office-Disease Prevention and Control Bureau (DPCB), DOH dated June 1, 2017 11 DOH Department Memorandum 2015-0238 dated July 22, 2015, p. 1-2


Page 4 PAO-2017-04

3. Only students with parental/guardian consent shall be vaccinated;

4. In case of zero or 1 dose or vaccination refusal, or no immunization card presented, the student shall not be suspended, grounded, nor reprimanded.

To affirm the partnership of concerned agencies in the implementation of SBIP, a Memorandum of Agreement (MOA) was entered by the DOH, DepEd and DILG on August 3, 2015 to define therein the roles and responsibilities of each department. DepEd and DILG are tasked to issue their own memorandum to ensure their respective department’s active participation to the activity of the SBIP.12

The budget of SBIP was lumped in the DOH’s Family Health and Responsible Parenting (FHRP) – Women’s Men’s and Children’s Health Development Division (WMCHDD) in 201513 and the Expanded Program on Immunization (EPI) in 2016.14 The funds allocated for the SBIP vaccines identified in the Project Procurement Management Plan (PPMP), Annual Procurement Program (APP) and the operating expenses for the Regional Offices traced in the Sub-Allotment Advices (SAAs), Statement of Allotment, Obligations and Balance (SAOB) and respective Summary of Expenses amounted to ₱330.02 million in 2015 and ₱282.02 million in 2016. Amounts obligated reached ₱186.93 million in 2015 and ₱262.75 million in 2016.

Table 1: Funds allocated and actually obligated/expended for the SBIP

2015

(In million pesos)

2016

(In million pesos)

Vaccines and Logistics

178.82 231.00

Other Expenses 151.20 51.02

Total 330.02 282.02

Obligated 186.93 262.75

Unexpended 143.09 19.27

Supply of sufficient vaccines not ensured during the vaccination month

The MOA between DOH, DepEd and DILG as well as all the DOH Department Memoranda containing the guidelines in the implementation of SBIP explicitly state that the immunization shall be done every August of the year.15 All Grades 1 and 7 school children enrolled in public schools shall be vaccinated with Measles-Rubella and Tetanus-diphtheria vaccines.16

12 Memorandum of Agreement between DOH, DepEd and DILG entered on August 3, 2015, p. 3 13 DOH Annual Procurement Plan FY 2015 – 4th Update, p.2,4-8 14 DOH Annual Procurement Plan FY 2016 - 2nd Update, Vaccines, p.1 15 Supra Note 12, p. 1 16 Ibid., p. 1


Page 5 PAO-2017-04

Under the MOA, the DOH shall designate its Assistant Secretary from the Office of Policy and Health Systems as its national focal person and the Chairperson of the Technical Working Group (TWG) who will oversee the entire program implementation to include the timely distribution of vaccines to DOH regional offices, LGUs and schools.17

In line with the Republic Act No. 9184, the DOH prepared its Annual Procurement Plan (APP) for FY 2016 which provides for the schedule for each procurement activity18 and the public bidding as the mode of procurement for vaccines.19 Advertisement and posting of invitation to bid should start in January 2016 with the Notice of Award and contract signing in March 2016.20

Records showed that the Bids and Awards Committee (BAC) received the undated Purchase Request (PR) for Td vaccines on March 4, 2016. The bidding process lasted for 78 days or until May 30, 2016 upon posting of performance security by the supplier. The Purchase Order (PO) and Notice To Proceed (NTP), which were released by the Accounting Division on July 1, 2016 were issued to the supplier on July 25, 2016. Late initiation of procurement process and replacement of the signatory in the procurement document brought about by the new administration delayed the procurement process by about four months. These conditions which impeded the timely procurement of vaccines could have been avoided or readily addressed by key officials of the program taking into consideration that vaccines should be available in time for the vaccination period in August.

NTP was issued to the supplier on July 25, 2016 and expected delivery date of the first batch is within 60 days upon receipt of PO and NTP by the supplier or until September 23, 2016 and 120 days for the second batch or November 22, 2016. Actual deliveries were received at the Storage and Distribution Department, Research Institute for Tropical Medicine (RITM)21 from September 27, 2016 to December 20, 2016 or way beyond the scheduled immunization month of August 2016. Actual distribution of vaccines to DOH Regional Offices and Health Units started in October 3, 2016 and lasted until Year 2017.

17 Ibid., p. 2 18 Republic Act 9184, Revised Implementing Rules and Regulations, Annex “C” –Recommended Earliest Possible Time and Maximum Period Allowed for the Procurement of Goods and Services 19 Supra Note 14, p.1 20 Ibid., p.1 21 RITM Vaccine Storage Facility (http://ritm.gov.ph/about-us/our-facilities/vaccine-storage/)

Late initiation of procurement activities and delays in procurement process not addressed

http://ritm.gov.ph/about-us/our-facilities/vaccine


Page 6 PAO-2017-04

Figure 3: Actual Procurement Timeline and Issuance of Td Vaccines to DOH Regional Offices/Provincial/City

Health Units

It was noted that the Accounting Division waited for the submission by the Procurement Service of the updated Tax Clearance Certificate causing delay in the release of PO and NTP to supplier.

In anticipation that Td vaccines will not be available on time, the OIC-Undersecretary of Health, Office for Technical Services, issued the unnumbered memorandum on July 11, 2016 providing the following:

Conduct inventory of Td vaccines in all health facilities; and

Strategize administration of Td vaccine by prioritizing the public school areas where Diphtheria and neonatal tetanus cases have been reported for the past 2 years.22

These remedial measures would not result in the attainment of target coverage rate considering that no policy on maintenance of buffer stock of vaccine is enforced for the SBIP.

Due to insufficient number of vaccines during the immunization period, only health centers/facilities with Td vaccine in stock in August 2016 were able to administer the vaccine on priority public schools. Nationwide, only 36% of students enrolled in Grade 1 and 37% in Grade 7 were vaccinated with Td in 2016 leaving 64% of Grade 1 and 63% of Grade 7 not vaccinated.

22 DOH Unnumbered Memorandum dated July 11, 2016, from OIC-Usec. Bayugo

64% of Grade 1 and 63% of Grade 7 students not vaccinated with Td vaccines in 2016


Page 7 PAO-2017-04

Figure 4: Students Vaccinated with Td

It should be noted that aside from all schools in Region 2, a number of schools in different municipalities and cities of other regions were not able to give Td vaccines to their students. It was only in Region VI and CAR where rates are close to the target. The low regional immunization rates are illustrated in Table 2.

Table 2: Accomplishment Report on Td Vaccinations by Region

Region Grade 1 Grade 7

Enrolled Vaccinated % Enrolled Vaccinated %

NCR 171,926 95,622 55.62 176,103 104,240 59.19

CAR 31,174 28,237 90.58 28,969 26,381 91.07

I 88,629 58,361 65.85 90,113 58,114 64.49

II - - - - - -

III 197,234 5,317 02.70 189,254 1,429 00.76

IV-A 226,294 10,802 04.77 216,083 25,019 11.58

IV-B 72,495 57,172 78.86 62,318 35,553 57.05

V 139,249 3,574 02.57 126,242 4,407 03.49

VI 152,639 140,471 92.03 141,774 126,432 89.18

VII 15,016 1,762 11.73 89,500 20,097 22.45

VIII 63,399 4,724 07.45 66,660 5,920 08.88

IX 77,803 29,118 37.43 73,061 46,257 63.31

X 103,365 68,281 66.06 77,455 47,407 61.21

XI 100,222 12,011 11.98 90,538 24,791 27.38

XII 103,295 16,757 16.22 80,498 13,782 17.12

CARAGA 61,392 45,637 74.34 55,773 36,220 64.94

ARMM 59,141 19,677 33.27 24,095 13,540 56.19

Total 1,663,273 597,523 35.92 1,588,436 589,589 37.12

Management commented that the bidding process was done within the prescribed period but the Purchase Order and Notice to Proceed was not released until the copy of the renewed Certificate of Tax Clearance was submitted because it was then nearing expiration and the DOH Accountant did not want to certify the funds availability until the bid documents are complete.


Page 8 PAO-2017-04

Clarification if there is any existing policy on safety measures to ensure that sufficient quantity of required vaccines is available when needed by the program revealed that Management just make sure that vaccines for SBIP are procured in time for the campaign in August. For vaccine in routine program, a buffer stock is maintained all year round. In times of stock outs of vaccines due to failure of bidding, the buffer stocks are used.

With vaccine as its basic component, no amount of preparation such as orientation of vaccinators, availability of logistics, obtaining parental consent and the like would ever make an immunization program successful without it. Considering that Td vaccines were not procured and delivered in time for the 2016 vaccinations, this situation may still occur in the future resulting anew in lack of vaccines during vaccination period. In the absence of policy requiring a buffer stock of vaccines for SBIP, Management must ensure that vaccines are procured and distributed before August by strengthening its monitoring on the actual procurement and distribution of vaccines. Any delay and deviation from the procurement schedule that may impact on timely distribution of vaccines must be readily addressed.

Insufficient quantity of vaccines during vaccination period creates a massive impact in the program implementation leaving significant number of students susceptible to vaccine-preventable diseases until the next immunization period while others are totally deprived of the health benefits from immunization.

Target immunization coverage not attained

Guidelines in the Implementation of School-Based Immunization under DOH Department Memorandum No. 2015-0238 dated July 22, 2015 provides that all eligible students enrolled in Grades 1 and 7 shall be administered with appropriate vaccines.23 DOH claimed that performance indicator of most of the vaccine-preventable disease to achieve the control, elimination and eradication is to attain at least 95% administrative coverage. It was added that this is an evidence based goal to attain herd immunity.

Herd immunity occurs when a significant proportion of the population (or the herd) have been vaccinated, and this provides protection for unprotected individuals. The larger the number of people who are vaccinated in a population, the lower the likelihood that a susceptible (unvaccinated) person will come into contact with the infection. It is more difficult for diseases to spread between individuals if large numbers are already immune, and the chain of infection is broken.24

The Nationwide Accomplishment Reports (NAR) for the 2015-2016 revealed that the SBIP failed to achieve the 95% target immunization rate. For 2015, the immunization rates for MR and Td ranged from 60% to 73%

23 Supra Note 11, p. 1 24 Segen’s Medical Dictionary, 2012 Farlex, Inc. (http://medical-dictionary.thefreedictionary.com./herd+immunity)

Actual immunization coverage at least 22% below the 95% target herd immunity primarily due to absence of parental consent and lack of Td vaccines in 2016


Page 9 PAO-2017-04

or 22% to 35% below the target. There was an increase of 12% in the immunization rate for MR in Grade 1 students while the rate for Grade 7 did not change at 72%. The Td vaccination rates fell from 73% in 2015 to 36% in 2016 for Grade 1 and from 72% to 37% for Grade 7. In effect, Grade 1 students who were not vaccinated are susceptible to vaccine-preventable diseases until they reach the next immunization in Grade 7 while the Grade 7 who missed the chance are deprived of the health benefits of immunization.

Table 3: Detailed Immunization Rates for 2015 and 2016

2015 Grade 1 Grade 7

MR Td MR Td

Vaccinated 1,302,171 1,576,044 1,234,985 1,236,812

Not vaccinated 853,798 579,925 484,939 483,112

Total per masterlist 2,155,969 2,155,969 1,719,924 1,719,924

Immunization Rate 60% 73% 72% 72%

2016 Grade 1 Grade 7

MR Td MR Td

Vaccinated 1,197,182 597,523 1,146,504 589,589

Not vaccinated 466,091 1,065,750 441,932 998,847

Total per masterlist 1,663,273 1,663,273 1,588,436 1,588,436

Immunization Rate 72% 36% 72% 37%

sa

Figure 5: 95% Target vs Actual Immunization Coverage

Source: DOH

The low immunization rates were attributable mainly to the policy of “No parent/guardian consent, no immunization”. In 2016, the lack of TD vaccines contributed significantly to low immunization rates.


Page 10 PAO-2017-04

The program implementation of nationwide coverage necessitated the collaboration of DOH, DILG and DepEd. Funds allocated and obligated for the procurement of vaccines and logistics, expenses related to vaccinators such as training/orientation, honoraria and cost of transporting them to and from their assigned schools, supplies and materials for information dissemination and other program-related expenditures, when summed up is material in amount that had to be paid out before and/or on the day of immunization. All the preparation effort and expended funds go to waste when vaccines, the main component of the program, are not available. The vaccine administration, storage and transport, immunization safety as well as the steps of addressing adverse events following immunization are discussed in detail in the guideline but there was not a single section pertaining to ways to increase parent/guardian awareness and/or consent nor remedial courses of action in case of any event that may lead to low immunization rate.

Management admitted that the approved consent for vaccination from the students’ parent/guardian, a policy imposed by the DepEd, hinders achieving the desired coverage. Other reasons such as absentees, illness, hesitancy of mothers for fear of side effects or adverse events following immunization (AEFI) contributed to low coverage.

Management further commented that they have no intention to vaccinate anyone of the students who missed the Td vaccines because it will be too costly on their part and will disrupt classes and school activities being conducted. Besides, the vaccines are mere booster doses because the children had been vaccinated when they were younger. The Management also stated that they will wait for the disease to happen before they do the catch up immunization.

Clarification on the 5% rate of students that could not be vaccinated given the 95% target revealed that it is attributed to the drop-outs mainly because of absenteeism and contra-indication of vaccination. For students who were absent during the vaccination period, they could be vaccinated at the nearest health centers to prevent disruption in schools.

It is apparent that DOH is not anticipating higher percentage of students without parental consent to achieve the herd immunity at 95%. Considering that the highest immunization rate achieved in 2015 and 2016 was only 73%, the percentage of children without consent nationwide could be readily estimated to at least 20%. At the NCR, the percentage of children without consent stood at 35% for both Grades 1 and 7 in 2016.

Table 4: Percentage of Students Without Parental Consent on Vaccination at NCR for 2016

Grade 1 Grade 7 TOTAL

Enrolled 171,926 176,103 348,029

With Consent 113,845 112,995 226,840

Percentage of Students with Consent to Enrolled

66% 64% 65%

Percentage w/o consent to enrolled 34% 36% 35% Source:


Page 11 PAO-2017-04

Figure 6: Percentage of Total Students With and Without Parental Consent on Vaccination at NCR for 2016

Absence of communication plan for effective coordination and information dissemination

The tripartite MOA entered into by the DOH, DepEd and DILG on August 3, 2015 provides the rationale for the institution of an immunization program, the immunization period and the roles of the participating agencies. The MOA states that DOH, as the overall lead agency, shall develop communications plan including risk communications in coordination with DepEd and DILG, among others.25

A Communication Plan is a document that guides organizations and project workers in managing and implementing communication efforts to reach desired goals. It is like a road map that provides a common direction for people working on a project so that limited resources are maximized and communication interventions are managed well.26

DOH DM No. 2015-0238 was issued on July 22, 2015 to provide guidelines in the implementation of the School-Based Immunization Program. While the memorandum was addressed to DOH officials it includes the roles and functions of other agencies and partners such as the DepEd, DILG, Local Government Units (LGUs), Parents-Teachers Association and Private Sector/ Professional Organizations.27

Consequently, the DepEd attached the said DM to its own memorandum issued on July 31, 2015 to all concerned Directors and Heads of Units enjoining them to provide full support in the conduct of the activity.28 There was no indication, however, that a copy of the said DM was disseminated to other agencies/sectors. In August 2015, the

25 Supra Note 12, p. 2 26 Asian Institute of Journalism and Communication-A Guide on Communication Planning, March 2012, Chapter 3, p. 14 27 Supra Note 11, p. 5-6 28 DepEd Memorandum No. 82, s. 2015 dated July 31, 2015 & DepEd Memorandum No. 128, s. 2016 dated August 16, 2016

Partner agencies not able to participate as expected due to lack of coordination efforts on their roles particularly on communications and information dissemination involving stakeholders of the program


Page 12 PAO-2017-04

immunization activity was delayed in the city and province of Iloilo due to non-receipt of the DepEd memorandum.29

On the other hand, verification from DILG revealed that it did not issue any memorandum/circular/similar documents to carry out the department’s role in the implementation of the SBIP of MR-Td vaccines. As a result, DILG was not able to perform its tasks, which included, among others the following:

a. To issue a memorandum to all the local chief executives (LCEs) for their active participation to the activity including the organization of the vaccination team for deployment to school and completion of the activity and ensure high immunization coverage per grade level.30 At the NCR, the DOH Regional Office constituted the vaccination teams.

b. Enjoin LGUs to prepare and submit reports to DOH.31 In 2016 campaign, no reports were received from 7,140 out of 38,803 schools involving 310,856 Grade 1 students and 1,020 out of 8,282 schools or 156,000 Grade 7 students. The absence of reports impacts on the completeness and accuracy of data used for the computation of immunization rates for which the performance of the program is assessed.

Likewise, the DOH DM and the tripartite MOA did not specify which party shall conduct the orientation of the vaccination teams and of beneficiaries’ parents/guardians. This activity should be part of communication efforts to provide common direction to vaccination teams to facilitate the conduct of vaccination including the reporting requirements. At the National Capital Region, it was the DOH Regional Director that initiated the conduct of orientation. It coordinated and invited representatives from the DepEd and DILG through the Schools Division Superintendent and LCEs, respectively. The DepEd and DILG mobilized parents of eligible students for orientation on the disease, program and immunization activities32 while school authorities had made the orientation as part of the agenda in the PTA meeting held before the vaccination day.

Streamers, standees, pamphlets and advisory sheets prepared for information dissemination purposes were in English, thus, may not be understood or appreciated by some parents/guardians. Naturally, parents/guardians will not allow their children to be vaccinated if the benefits that can be derived therefrom are not properly explained and understood.

Management commented that the information dissemination materials are translated to the local vernacular but no copies of any related materials were presented to the audit team.

DOH commented that the EPI and the Health Promotion and Coordination Service (HPCS) call for orientation meeting/workshop to reorient stakeholders on the activity and provide any update. The HPCS with their

29 SunStar Iloilo, August 10, 2015 by Lydia C. Pendon 30 Supra Note 11, p. 6 31 Supra Note 12, p. 4 32 Ibid., p. 3-4

Need to provide readily understandable information materials


Page 13 PAO-2017-04

original counterparts and DepEd has consultation workshop, develops video presentation and prototype Information, Education, and Communication (IEC) materials for reproduction at the regional levels. The information and materials are disseminated to the regional/provincial/city counterparts for distribution to the schools. Further, the school/classroom clinic teachers disseminate the information for the immunization activity to secure the consent of parents or guardians of the students prior the vaccination.

The audit team took note of the efforts to disseminate information on the immunization program. As the absence of parental consent is the main cause for not attaining the immunization target rate, there is a felt need to enhance the existing approach to address the issue.

The absence of communication plan was manifested in the deficiencies noted. The plan would detail the active participation of partners and stakeholders and effective information campaign to achieve the desired goals. Considering that immunization coverage is below the target herd immunity, effective communication plan is necessary for the SBIP to address the causes hindering the attainment of the target.

No separate program budget and recording of expenditures depriving Management with relevant information on the efficient utilization of resources committed to the program and the accountability of program managers

The SBIP as a program should be provided with a budget necessary to attain its objective. Management did not provide the audit team with the program budget for 2015 and 2016.

The team noted that SBIP was a sub-program of Family Health and Responsible Parenting (FHRP)-WMCHDD in 2015. Its appropriation/budget was lumped in the FHRP budget and could not be separately identified. Since the Annual Procurement Program was also presented by major program, the allocation for vaccines and logistics (syringes and collector boxes) for SBIP/Adolescent Health was traced to the Project Procurement Management Plan (PPMP). However, there was one supplemental PPMP wherein charges for the SBIP could not be derived. Budget for other related operating expenses were traced to the Sub-Allotment Advises (SAAs)/Fund Transfer (FT) released to the regional offices. Summary of Expenses (SOE) or Statement of Allotments,

No separate program budget for SBIP


Page 14 PAO-2017-04

Obligations and Balances (SAOB) were submitted by the Regional Offices but some without details or object of expenditures.

Table 5: Schedule of 2015 Sub-allotments and Obligations for Other Operating Expenses of DOH Regional Offices

Region Amount

Received Amount

Obligated Balance

NCRO ₱10,000,000.00 ₱9,536,470.39 ₱463,529.61

CARO 5,200,000.00 5,125,500.00 74,500.00

RO I 5,200,000.00 5,199,932.97 67.03

RO II 5,500,000.00 5,235,990.00 264,010.00

RO III 6,500,000.00 6,500,000.00 0.00

RO IV-A 6,800,000.00 6,800,000.00 0.00

RO IV-B 5,200,000.00 5,200,000.00 0.00

RO V 7,900,000.00 7,000,000.00 900,000.00

RO VI 8,300,000.00 8,300,000.00 0.00

RO VII 12,000,000.00 11,932,734.19 67,265.81

RO VIII 7,500,000.00 4,455,390.45 3,044,609.55

RO IX 6,100,000.00 6,100,000.00 0.00

RO X 6,000,000.00 5,990,362.00 9,638.00

RO XI 9,900,000.00 9,900,000.00 0.00

RO XII 6,700,000.00 6,693,271.00 6,729.00

RO XIII 5,500,000.00 5,340,602.28 159,397.72

ARMM 5,700,000.00 5,700,000.00 0.00

doh

The SBIP was transferred to the EPI per DOH DM No. 2015-0226 dated July 22, 2015.33 The items in the 2016 PPMP, however, were not categorized per sub-program. The allocation for the SBIP was identified using the type of vaccines used by the program namely Measles-Rubella (MR) and Tetanus-diphtheria (Td) vaccines. The allocation for SBIP logistics (syringes) could not be derived from the total allocation for EPI. For the regional offices, except for the regions which requested for sub-allotments under DOH DOs 2016-0196 dated July 25, 2016 and 2016-0221 dated August 30, 2016, others regions used their regular appropriations to defray the operating expenses for the SBIP.

Table 6: Regional Office which Requested for Allotment for Other Operating Expenses of SBIP

Region Amount

Received Amount

Obligated Balance

CARO ₱3,887,072.00 ₱3,493,072.00 ₱394,000.00

RO IV-B 3,351,000.00 1,587,421.72 1,763,578.28

RO VII 3,000,000.00 0.00 3,000,000.00

Source: DOH

Details of expenses identifiable with SBIP were requested from the DOH Regional Accountants, however, eight out of seventeen (17) regional offices did not submit summary of expenses for 2015 and 2016. In the absence of information regarding the budget allocated to the SBIP coupled with the absence of separate recording for program expenditures, monitoring, control and accountability over the resources committed for the program cannot be enforced.

33 DOH Department Memorandum 2015-0226 dated July 13, 2015

No separate accounting of expenditures of the program


Page 15 PAO-2017-04

Management commented that they have maintained subsidiary records for expenditures under the SBIP but nothing had been presented and submitted to the audit team up to the writing of this report.

Deficiencies in reporting impacting on the efficiency, accuracy and completeness of data in the Nationwide Accomplishment Report

DOH DM No. 2015-0238 dated July 22, 2015 provides specific guidelines for the recording and reporting of accomplishment reports. It prescribes appropriate recording and reporting forms which shall be completed and submitted from the service delivery point to the next higher administrative level until the report reaches the DOH Central Office.34

Figure 7: Flow of Accomplishing and Submission of Report Forms

Source: DOH

Review of the reporting process and the Report Forms used revealed deficiencies impacting on the efficiency of reporting and accuracy of reported data.

a) Not all data required in the consolidated report can be readily obtained in the Report Forms and completion of these data involves extra time and effort

34 Supra Note 11, p. 3

Deficiency in the Report Forms


Page 16 PAO-2017-04

The consolidated report requires the number of deferred students per type of vaccine for Grade 1 but this is not found in the Recording Form 1.(See Appendix I)

The consolidated report for Grade 1 and 7 requires the number of refusal per type of vaccine which is not captured separately in Recording Forms 1 and 2.(See Appendix I)

b) No process to ensure accuracy of data reported by accounting for the number of students in the masterlist against the students given consent and those without parental consent. Similarly, the number of students with consent was not tallied against students vaccinated, deferred and refused. As a result, significant differences were not investigated or corrected. These could be attributed to different interpretation of data to be reported.(See Appendix II-A)

c) On the submission of report, responsible officer in each level of implementation (School/RHU/PHO/CHO) is required to submit the report weekly to the next level while the DOH Regional Health Office is required to submit to the DOH Central Office after two weeks.35 The absence of a definite period or fixed date within which reports should be submitted by the Regional Office caused the delay in the consolidation of data for the nationwide accomplishment report.

The DOH NCR conducted a Training of Trainors (TOT): Orientation of Vaccination Teams on Adolescent Immunization with DepEd Schools Division and LGU health staff January 21-22, 2015.36 The orientation aims to discuss the guidelines and plans for the scale up and implementation of the School-Based Adolescent Immunization Activity in NCR. On reporting of accomplishments, it was agreed during the training that DepEd Division shall provide school accomplishments to DepEd Regional Division and City Health Office, DepEd Regional Office to consolidate and furnish copy to DOH-NCRO.

The agreed reporting arrangement was, however, different from the manner of reporting provided in the DOH DM where school nurse shall submit accomplished Recording Form 1 or 2 to municipal/city health unit to provincial/regional health office to DOH Central Office.37

Such difference in understanding among reporting units as to where the reports are to be submitted for consolidation impacts on the timely consolidation of data for the nationwide accomplishment report.

Management commented that submission of the accomplishment reports has been agreed during consultation workshops. Schools that conducted the immunization are requested to submit the report to the next administrative level and constantly be followed-up if delays exist. All LGUs shall also submit their report to the next administrative level.

35 Ibid. 36 DOH NCRO Personnel Order No. 2014-0978 and 2014-978A dated November 17, 2014 and January 6, 2015, respectively. 37 Supra Note 11, p. 3


Page 17 PAO-2017-04

Analysis of the Nationwide Accomplishment Reports for years 2015 and 2016 and the Accomplishment Reports prepared and submitted by the NCRO disclosed not only incomplete submission of reports but also included errors and inconsistencies in the reports that impact on the accuracy of actual immunization coverage:

a) The Nationwide Accomplishment Report as of June 16, 2017 for immunization year 2016 had undergone several revisions to include reports submitted late. As of cut-off date, reports from 7,140 out of 38,803 or 18.40% of schools for Grade 1 and 1,020 out of 8,282 or 12.32% of schools for Grade 7 remain unsubmitted and therefore not included in the analysis of accomplishment. Similarly, schools which lacked data on enrolment and vaccinated students were not included in the computation of the overall immunization rate.

b) The errors and/or inconsistencies in the reports were noted in the following instances:

The reported accomplishment (number of students vaccinated) is greater than the total enrolled students in a number of schools.

Table 7: List of Schools where Number of Students Vaccinated Exceeded the Number of Enrolled Students

Region Name of School Enrolled Vaccinated Difference

MR/MCV Td MR/MCV Td

2015, Grade 1

NCR A. Fernando ES 210 373 373 (163) (163)

NCR A. Mariano ES 179 264 264 (85) (85)

NCR Antonio Serapio ES 71 190 190 (119) (119)

NCR Gen. T. 1 ES 358 460 460 (102) (102)

NCR Malinta ES 164 572 572 (408) (408)

NCR Paltok ES 122 130 130 (8) (8)

NCR Paso de Blas ES 91 118 118 (27) (27)

NCR Punturin ES 163 164 164 (1) (1)

NCR Silvestre Lazaro ES 378 390 390 (12) (12)

III not provided 17,666 21,117 18,110 (3,451) (444)

III not provided 6,640 7,060

(420)

2016, Grade 1

NCR MUZON ES 91

94

(3)

VIII not provided 4,029 4,378

(349)

2016, Grade 7

VIII no data 5,869 6,001 0 (132)

VIII no data 6,964 26 (6,964) (26)

TOTAL

36,031 48,181 20,891 (12,241) (1,398)

doh

Incomplete, late submission of reports and errors/ inconsistencies of data in the reports


Page 18 PAO-2017-04

Double Reporting in the 2015 Nationwide Accomplishment Report

Table 8: List of Schools which Data were Taken-up Twice in the 2015 Nationwide Accomplishment Report

City Name of school Grade Level

Enrolled Vaccinated

MR TD

Caloocan Llano High School 7 510 340 336

Caloocan Bagumbong HS 7 1,017 523 523

Caloocan Caloocan National Science and Technical High School 7 136 109 109

Caloocan Kalayaan High School 7 1,447 1,121 1,115

Taguig Bagumbayan National High School 7 1,028 444 443

ource: DOH

The number of enrolled students in the DOH Nationwide Accomplishment Report vary from the number of students per masterlist of DepEd.

Table 9: Comparison between the DepEd Masterlist and the Number of Enrolled Students in the Nationwide Accomplishment Report

Grade Level

2 0 1 5

Per DepEd Per DOH Net Difference

1 2,110,567 2,155,969 (45,402)

7 1,713,333 1,719,924 (6,591)

Grade Level

2 0 1 6

Per DepEd Per DOH Net Difference

1 1,964,338 1,663,273 301,065

7 1,782,780 1,588,436 194,344

Source: DOH

Schools listed in the DOH Accomplishment Report not in the DepEd Masterlist and vice-versa.(Appendix II-B)

Errors in total enrolment and vaccinated students upon recomputation of accomplishment reports in the NCR.

The accomplishment reports in the NCR contain relevant information such as number of students ‘with and without parental consent which were not required in the prescribed format. These information were included in the consolidation but served no purpose because other reporting units were not required to provide these information.

Analysis of the results of survey conducted with the Division Superintendents, School Nurses/Clinic Teachers, LGU/City Health Officers and Health Workers in the National Capital Region also revealed different practices in the reporting of accomplishment reports. The DM provides that deferred students willing to be vaccinated shall be referred


Page 19 PAO-2017-04

to the health center for vaccination and reported in the health center accomplishment report.38 Contrary to the prescribed reporting process, 59% of 41 Grade 1 school nurse respondents and 35% of 20 Grade 7 school nurse respondents claimed that they included the deferred students vaccinated in the health centers in their report. In addition, 55% of the 38 health center nurses did not include in their report the deferred students vaccinated in the health centers. These deviations impact on the completeness and accuracy of the consolidated report and the data for the computation of the overall immunization rates.

Figure 8: Survey Results

School Nurse - Grade 1 (41 respondents)

School Nurse - Grade 7 (20 respondents)

Say deferred students recorded in Nurse Report

Say recorded in RHU Report, Say recorded in both

Local Health Worker

(38 respondents)

Say that they include name of students vaccinated in the

center in Health Center Report

Source: DOH

During the exit conference, Management commented that they will review the reporting forms for possible amendment. Accomplishment Reports will likewise be reviewed to ensure the reliability of data captured. It was explained that the mismatch of the list and the accomplishment reports can be attributed to the under reporting in the service delivery points because of the set deadline for submission of reports to the next higher administrative level.

38 Supra Note 11, p. 2


Page 20 PAO-2017-04

Poor inventory management as manifested in lack of uniformity in computing the quantity of vaccines for procurement, deficiency in maintenance of inventory records and vaccine utilization not accounted and reported

The procured vaccines are delivered by the suppliers to the DOH Central Office Warehouse at the RITM before these vaccines are distributed to the Regional and City Health Offices where Vaccinators Teams will withdraw the stocks needed by the program.

Figure 9: Flow of Receipt and Distribution of Vaccines

s

The standing policy in determining the quantity of vaccines to be procured is to compute for the total number of enrolled Grades 1 and 7 students of the preceding school year based on the accomplishment reports of regional offices, plus 10% buffer. The data on enrolment, however, may impact on the computation since it is being based on the National Accomplishment Report from the preceding school year which may not be reliable unless 100% submission of report by all regions is ensured. Existing balances at the RITM were not considered in the estimation of vaccines to be procured. The lack of uniformity in the process of estimation of quantity of vaccines to be procured was noted in the procurement for 2016 and 2017. The number of Td doses expected to be

Lack of consistency in the computation of vaccines to be procured


Page 21 PAO-2017-04

available in 2017 was already more than double the requirement for students in Grades 1 and 7.

Table 10: Analysis of 2016 and 2017 procurement of vaccines

Particulars MR Td Total

Grade 1 Grade 7 Grade 1 Grade 7 MR Td

2016

Enrolled per 2015 Accomplishment Report

2,155,969 1,719,924 2,155,969 1,719,924

10% Allowance 215,597 171,992 215,597 171,992

Total 2,371,566 1,891,916 2,371,566 1,891,916 4,263,482 4,263,482

No of doses to be procured

per 2016 PPMP 4,000,000 5,000,000

Available doses for use in 2016 from existing stocks in RITM

(stocks in vial x 10 doses)

0 898,940

No. of doses expected to be available for use in 2016

4,000,000 5,898,940

Percentage of stocks at RITM to total requirement as buffer stock

0% 21%

2017

Enrolled per 2016 Accomplishment Report

1,663,273 1,588,436 1,663,273 1,588,436

10% Allowance 166,327 158,844 166,327 158,844

Total 1,829,600 1,747,280 1,829,600 1,747,280 3,576,880 3,576,880

No of doses to be procured

per 2017 PPMP 5,000,000 7,000,000

Available doses for use in 2017from existing stocks in RITM

299,400 3,576,382*

No. of doses expected to be available for use in 2017

5,299,400 10,576,382

Percentage of stocks at RITM to total requirement as buffer stock

8% 100%

*Remaining Stocks as of December 31, 2016 plus undelivered units of vaccines

The team accepted the Management comment that it is not possible for them to base the quantity to be procured on the actual number of enrolled during the year because the procurement takes some time. APP showed that procurement process is scheduled as early as January and it is known that school enrollment is being done from April to May that masterlist can only be finalized by June or July.

The team conducted ocular inspection of the vaccines at the DOH Central Warehouse at the Research Institute of Tropical Medicine (RITM) last March 17, 2017 and noted that the MR and Td vaccines for the program are in good condition and the expiration dates have not elapsed. It was noted that stock cards maintained for each type of vaccine do not indicate to which programs they pertain to. For issuances, the requisitioning unit or the receiving office was recorded in the stock card without specifying the purpose or specific program for which the vaccines were issued/shipped.

Analysis of utilization of available MR vaccines for 2016 based on the reported number of students vaccinated with 25% allowance for wastage revealed that about 875,000 doses or 22% of the procured MR vaccines was not utilized.

Stock cards for vaccines not properly maintained


Page 22 PAO-2017-04

Table 11: Analysis of utilization of available MR vaccines for 2016

No. of doses of MR vaccines available for 2016 vaccination period

4,000,000

Administered No. of doses

( No. of students vaccinated divided by 0.75) or 2,343,686/0.75

3,124,915

Excess doses of MR vaccines 875,085

Percent of excess to No. of doses available for 2016

21.88 %

Source: DOH

The balance of MR vaccines will further increase if the existing stocks from 2015 balances at the Regional Offices and Health Centers are added. As noted in the DOH NCR stock cards, there are 11,793 vials of MR at the beginning of 2016 in addition to the receipt of 34,000 vials before the vaccination campaign in August 2016. Out of the total balance of 45,793 vials, 45,753 vials were issued to the City Health Offices for the year’s vaccination requirement. Analysis showed that about 67,753 doses or 14.81% of the total doses issued could be considered excess based on the number of students vaccinated in 2016.

Table 12: Computation of Excess MR Vaccines in the NCRO

Total doses distributed to NCR City Health Offices (1 vial = 10 doses)

457,530

Estimated number of students that can be vaccinated (75% on multi-vial vaccines)

343,148

Students vaccinated

Grade 1 98,858

Grade 7 107,688

Total 206,546

Administered No. of doses

(No. of students vaccinated divided by 0.75) or 206,546/0.75

275,395

Excess doses of MR vaccines 67,753

Percent of excess to No. of doses available for 2016

14.81%

Source: DOH

If catchment vaccination will be undertaken by the health centers on the identified deferred and refused students totaling 22,568 at NCR, at least 45,000 doses of MR vaccines for the program are still unutilized at the health centers.

Ocular inspection and verification of stock cards and other related documents at the City Health Offices of Makati City disclosed the following:

a. One stock card is maintained for each type of vaccine intended for different programs, thus, whether there are vaccines for SBIP cannot be verified;

b. Entries in the stock cards are erroneous or incomplete. Not all Receipts are recorded, only issues or reductions, and there are no running balances to reconcile with the actual stock on hand.

c. Not all receipts and issuances are documented. No formal request and approval is required for issuances. In one LGU, recipients are

Vaccine utilization not accounted and reported


Page 23 PAO-2017-04

simply required to sign opposite the quantity deducted in the stock card.

d. The Health Nurses in charge of the vaccine inventory was not able to provide the accounting/report for the utilization of vaccines under the SBIP due to lack of guidelines.

Taking into consideration that excess doses of vaccines at the Health Offices/Units and stocks the Regional Health Offices exist, the SBIP need to monitor and account for these vaccines to effectively manage the procurement and inventory needed during the vaccination campaign. The current system of inventory management and reporting does not promote accountability of DOH officials over program resources and effective procurement planning.

The school-based immunization program was launched to provide booster vaccines to school-age children to ensure that high levels of protection are maintained because the protection provided by some of the vaccines given to infants decline over time.39 The SBIP aimed at 95% immunization coverage following the principle of herd immunity that at this level of immune individuals in a population, a disease may no longer persist.

The timely procurement of vaccines aimed at ensuring their availability in time for the scheduled vaccination month was not achieved in 2016 for Td vaccines. In addition to late initiation of procurement activity, delay in the procurement process was not readily addressed resulting in late deliveries and distribution of vaccines to DOH regional offices and health centers. Consistency in the methodology used in estimating the procurement of vaccines was not observed. There was also no policy requiring the maintenance of buffer stock to answer for the absence or delay in the procurement and distribution of vaccines. The lack of Td vaccines had resulted in the low immunization rates of 36% for Grade 1 and 37% for Grade 7 in 2016 or about 50% decline from 73% for Grade 1 and 72% for Grade 7 in 2015.

The immunization rates for MR had increased from 60% in 2015 to 72% in 2016 for Grade 1 while the rates remained at around 72% in the same period for Grade 7. As these rates are way below the target immunization coverage of 95%, Grade 1 students not vaccinated are left vulnerable to vaccine-preventable diseases while waiting for the next immunization in Grade 7 while those not vaccinated in Grade 7 are totally deprived of the immunization benefits from the program.

Contributing mainly to low immunization coverage was the policy of “No parent/guardian consent, no immunization.” Apparently, information dissemination efforts and materials were not adequate and appropriate in the absence of communication plan. Increasing awareness on the benefits of the program particularly for the parents and guardians will lower the percentage of children without consent. This percentage must be reduced to 5% or less for the program to achieve the desired herd immunity at 95%. There was lack of coordination among partner agencies in the program. One of the partner agencies was not able to issue memorandum to local chief executives for their active participation in the vaccination activity, including the organization of the vaccination team,

39Supra Note 11, p. 1

Conclusions


Page 24 PAO-2017-04

ensuring high immunization coverage per grade level and enjoining LGUs to prepare and submit reports to DOH.

The noted deficiencies in the current reporting system for the nationwide accomplishment report impact on the accuracy and completeness of data and information where the immunization coverage is derived. Inventory management and reporting of vaccines utilization for the SBIP was not segregated from other immunization programs of DOH. Issuances of vaccines were not validated against Vaccines Utilization Report and as such, excess issuances may not be accounted as utilized for the intended beneficiaries of the program nor considered in procurement planning.

Finally, it was noted that the SBIP budget was lumped with the budget of the major programs of the DOH and expenditures were not recorded separately depriving Management with relevant information on the efficiency and economical utilization of resources and the accountability of program managers.

The challenges noted in the implementation impact on the efficient, economic and effective implementation of the SBIP. The gaps between the actual immunization coverage and the herd immunity of 95% signified that the program has yet to achieve the desired objective of the program.

In view of the opportunities for improvement noted in the review of SBIP, it is recommended that DOH through the EPI addresses the implementation gaps that prevent the attainment of the immunization coverage target.

To ensure that sufficient quantity of required vaccines is available during the once a year immunization activity, DOH needs to undertake its procurement plan as scheduled and address immediately any issue that may affect the timely delivery and distribution of procured vaccines to health centers. Consider maintaining a buffer stock to answer for unavoidable delays in procurement and adopt a consistent methodology in determining the quantity of vaccines to be procured.

To increase the immunization coverage and attain the herd immunity target, DOH in coordination with DepEd need to minimize the students without parental consent by adopting and implementing an appropriate communication plan and strengthening coordination efforts among partner agencies particularly aimed at ensuring high immunization coverage.

The accomplishment reporting system need to be enhanced to capture relevant, complete and accurate nationwide accomplishment report from which immunization rate is derived and enrolment data for use in the estimation of vaccines to be procured are obtained. Inventory management also need improvement particularly in the maintenance of accurate and separate information and reporting of vaccine utilization for the SBIP to aid Management in procurement planning and decision-making.

Lastly, DOH should provide a separate budget for the requirement of the SBIP from which program expenditures must be accounted for to gauge the efficient and economical utilization of resources and establish accountability of program managers.

Recommendations


Page 26 PAO-2017-04

Appendix I: Accomplishment Forms40

Figure 10: Recording Form 1: Masterlist of Grade 1 Students

s

40 Supra Note 11, Annexes


Page 27 PAO-2017-04

Figure 11: Recording Form 2: Masterlist of Grade 7 Students

s


Page 28 PAO-2017-04

Figure 12: Reporting Form: Regional/Provincial/City Consolidated Accomplishment Form Report


Page 29 PAO-2017-04

Appendix II: Computation/ Comparison

A. Analysis of Related Data Reported in the Accomplishment Report in Sample Cities at NCR

NCR Accomplishment Report 2015 – Measles Rubella

Grade 1 Makati City Manila Quezon City

Students Enrolled 7,324 29,136 40,353 a

With Consent 7,030 22,085 26,744 b

Without Consent 0 7,059 10,442 c Total 7,030 29,144 37,186 d

Difference 294 -8 3,167 (a-d)

Vaccinated MR 7,030 22,033 26,628 Deferred 23 41 359 Refusal 271 4 13,721 Total 7,324 22,078 40,708 e

Difference -294 7 -13,964 (b-e)

NCR Accomplishment Report 2016 – Tetanus Diphtheria

Grade 7 Manila Taguig Caloocan City

Students Enrolled 24,294 11,220 22,977 a

With Consent 23,200 6,376 14,447 b

Disapproved Consent 1,015 0 5,288 c Total 24,215 6,376 19,735 d

Difference 79 4,844 3,242 (a-d)

Vaccinated Td 22,640 6,368 14,425 Deferred 584 1 2,797 Refusal 0 0 472 Total 23,224 6,369 17,694 e

Difference -24 7 -3,247 (b-e)

Comparison of data revealed the following:

i. Total number of students enrolled not reconciled/tallied with the number of students with and without parental consent.

ii. Total number of students with consent not tallied/reconciled with the number of students vaccinated, deferred and refused.

Significant differences not investigated or corrected. These could be attributed to different interpretation of data to be reported.


Page 30 PAO-2017-04

B. Analysis of Reported Schools in the DOH Accomplishment Report and DepEd Masterlist in Sample Cities at NCR

Comparison of gathered data showed that there are schools listed in the DOH Accomplishment Report that were not in the DepEd Masterlist and vice-versa.

Year Grade Level

City/ Municipality

Name of School Per DepEd Masterlist

Per DOH NAR

2015 1 Caloocan City Tala Elementary School 427 None

2015 1 Taguig Taguig Integrated School 715 None

2015 7 Pasig City Santolan HS 677 None

2015 7 Marikina Marikina Heights NHS 341 None

2016 1 Valenzuela City

Luis Francisco ES 289 None

2016 1 Taguig Paulina Manalo ES 138 None

2016 7 Pasig City Sta. Lucia HS 1,280 None

2016 7 Paranaque La Huerta National High School 1,028 None

TOTAL 4,895

2015 1 Caloocan City Malaria ES None 426

2015 1 Paranaque FEES - Marcelo Green None 442

2015 7 Paranaque PHNS- San Antonio None 1,184

2015 7 Las Pinas Las Pinas NHS Almanza None 837

2016 1 Manila Benigno Aquino None 623

2016 1 Valenzuela City

Antonio Serapio ES None 424

2016 7 Manila Earist None 700

2016 7 Muntinlupa MNHS Annex None 734

TOTAL 5,370


Page 31 PAO-2017-04

Appendix III: DOH Management Comments


Page 32 PAO-2017-04

s


Page 33 PAO-2017-04

Appendix IV: COA Contact and Staff Acknowledgments

Assistant Commissioner Alexander B. Juliano, (02) 952-5700 local 2022 or [email protected]

In addition to the contact named above, Emelita R. Quirante (Director IV), Michael L. Racelis (Director III), Cecilia G. Rañeses (Team Supervisor), supervised the audit and the development of the report. Eleanor B. Pilapil (Team Leader), Cherrie Lou C. Arguilla, Leonardo A. Bautista, Czyrhinne R. Castillo and Krisshia D. Genio (All Team Members) made key contributions to this report with the assistance of Priscilla DG. Rivera.

COA Contact

Staff Acknowledgments

Documents

SCHOOL-BASED IMMUNIZATION PROGRAM - coa.gov.ph · Performance Audit Report Delayed procurement of Td vaccines and low parental consent resulted in the non-immunization of 1.065 million