2000 CBD: Immunisation Services Assessment Report: Cambodia National Immunization Program
The rationale for conducting an assessment at this time has many parts. The last comprehensive review of immunization services was conducted in 1992. As current immunization services management and delivery systems were substantially defined and implemented in the period 1992-1996, prior to the recent implementation of health sector reforms, an immunization services review is timely in this transitional period. Within the framework of the Immunization Coordination Sub-Committee (ICSC), the National Immunization Programme is developing in 2000 a multi-year national action plan for the period 2001-2005. An assessment will provide an adequate framework for the review of programme priorities, strategies, and components; and also provide recommendations to be included in the five-year plan. Cambodia has applied to GAVI for support from the newly established Global Fund for Children's Vaccination (GFCV).
Purpose / Objective
The purpose of this report is to provide the Ministry of Health and partner agencies with a comprehensive description of both the assessment findings and the logic underlying the assessment team's recommendations. The information on which this report is based will be used in updating the NIP National Five Year Plan and to inform the preparation of a series of funding proposals to the Global Alliance for Vaccines and Immunization (GAVI).
The assessment was designed to:
- Review current performance and financing of the national immunization programme (NIP)
- Assess current management and delivery of immunization services
- Provide recommendations on how to achieve maximum programme effectiveness within the overall principles and operational framework of health sector reforms
A central level assessment was conducted consisting of document review, interview of main stakeholders in the MOH for different NIP functional areas, and final adaptation of questionnaires.
Field assessment at provincial, operational district and health center level, based on an adapted version of the GAVI draft tools for the assessment of immunization services, was done. The 15 operational districts were selected based on the geographic and demographic situation.
A financial assessment used an adapted version of the draft CVP/Abt immunization financing tool. A section containing finance-related questions was included in the field assessment.
Key Findings and Conclusions
The principal strategies outlined in the EPI National Five Year Plan 1998-2002 remain a suitable basis for the development of the updated National Immunization Programme Five Year Strategic Plan. An observable outcome of the implementation of strategies for increasing immunization coverage, articulated in the previous five year plan, was an arresting of the decline in coverage rates for BCG, OPV3, DPT3, Measles and TT2. This decline, observed between 1995-1998, followed three years of reported substantial increases in the coverage rates of all antigens (UNICEF, 1999).
In addition, further development of disease surveillance systems, notably for AFP as a marker for poliovirus infection, has indicated that there is no evidence of circulating wild poliovirus. Strategies for strengthening measles surveillance activities, as well as supplemental measles immunization programs, resulted in the implementation of pilot programs in 6 provinces in 1999 and surveillance activities in all provinces in 2000. Neonatal tetanus surveillance had been commenced at National-level facilities and, in 1998 and 1999, community-based NNT surveillance activities were piloted in two ODs. In summary, the principal strategies articulated in the existing plan appeared to be producing measurable outcomes and there was no indication of need for fundamental change in strategic direction.
The management capacity at OD and HC levels requires strengthening to achieve the efficient organization and delivery of integrated outreach, as proposed in the current draft of the 'Guidelines for Outreach Services' by the MOH Health Sector Reform group. In many of the Health Centers visited, staff reported difficulties with the availability of funding for ice and fuel for transportation, resulting in the cancellation or deferment of scheduled immunization outreach activities. At the village level, this was reported to result in low confidence in the predictability of visits by health center outreach teams, with negative impacts on numbers presenting for immunization when teams actually arrived.
Feedback systems to Province, OD and HC levels within the NIP require additional development. There was little evidence of effective information feedback, from higher to lower levels of the health service provision structure. This included both NIP reporting and HIS mechanisms. The need for effective feedback to inform quality management decision-making was universally recognized by the Assessment teams.
In many of the locations visited, especially at province and operational district level, cold chain function appeared to be satisfactory. However, at all levels, including the central level, significant problems requiring priority attention with vaccine forecasting and ordering, cold chain equipment use, and programmed maintenance and repair were identified.
In some of the locations visited, there was evidence of the dissemination and implementation of the 1996 Injection Safety policy and the related 1998 Guidelines. However, in a number of operational districts and health centers, the policy appeared to be poorly understood and inadequately monitored.
In many of the locations visited, there was evidence, in the form of cases recorded and reports completed, that disease surveillance was being undertaken. However, there was little evidence that the information collected through disease surveillance activities was being used to inform programme decision-making. In addition, there was no evidence of feed-back of the use of disease surveillance data from operational districts to the service delivery and community levels.
In general, technical understanding of the reasons for the calculation of key statistics including target population, coverage rate, drop-out rate and wastage rates was low at OD and HC levels. No attempts were apparent to use these indicators of service performance to improve the quality of immunization service delivery. Very few respondents at these levels were aware of all of these statistics or of the formulae for their derivation.
Funding for the immunization program has been very donor-dependent. While the MOH contributes two key operating costs -- staffing and ice for the cold chain, its contribution represents a small portion of the overall program costs. There are many planning and budgeting issues that are beyond the scope of the NIP. In 1999, all the districts and provinces undertook an annual planning exercise. However, the health budgets then allocated to each district and province were calculated based on national formulas, and not in accordance with the workplans created. Almost no integrated budget and activity planning and monitoring are done at the facility level. As a result, the NIP often does its own activity planning and secures its own funding. This mode of operation ensures funding for immunization, but does not promote integration of immunization into overall health services or into the national budget planning process. As the planning and budgeting processes improve as part of the health sector reforms, and if the national budget funding can cover operational costs of outreach, the NIP should seek to work within the district and provincial planning mechanisms.
While there is strong technical focus and support of immunization activities and programming, it is somewhat disengaged from the financing issues. Staff at all levels were not very focused on managing funds for immunization activities. Often, the EPI Officer would have little information on program funding, referring questions to Finance Officers. Working in collaboration with the planning and finance departments, the NIP should work to improve planning and financial management capacity at all levels.
The Assessment recommended that the restructure process be completely implemented as soon as possible and that the national budget fully fund the cost of outreach activities. At the service delivery level, the Assessment recommended strategic reviews of cold chain management and the implementation of plans for more efficient deployment, management and maintenance of cold chain equipment and resources. Similar strategic reviews were recommended for injection safety and improvement to immunization service delivery.
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