Author: Department of Health
Expanded Programme on Immunization aims to reduce morbidity and mortality of six EPI diseases: Poliomyelitis, Diphtheria, Pertusis, Tuberculosis, Tetanus and Measles. The coverage was above 90% in the 80s but there was a dip in the mid-90s due to the shortage of logistics, resulting in the re-emergence of EPI diseases. To clear this backlog, a crash programme was launched in 1999. A Third Party Evaluation (TPE) of EPI coverage was conducted during June 2000 under UNICEF assistance. The results showed that 70% of children were found fully immunized. Keeping in view the target of above 95% coverage set for the crash programme, these results were quite disappointing. The Department of Health, on probing, found that the availability of staff and cold chain equipment were the major differences among the poor and good performing districts besides geographical differences.
Purpose / Objective
The aim of the study is to improve and strengthen EPI Punjab for better service delivery, with the objective of preparing an inventory of EPI logistics in Punjab to find the condition of Cold Chain Equipment and other EPI logistics available at the various levels.
Two forms were designed for collection of data: one, according to the record of District Stores, and the other part to be filled in at the facility level. Data was collected from the district, tehsil, and sub-stores at RHC / BHU and EPI Centers.
Key Findings and Conclusions
The results conclude that majority of the cold chain equipment was procured during the 80s and early 90s, hence needs replenishment at the earliest. Repair and maintenance require proper allocation and timely attention to compensate the shortage in the field. Electrification of BHUs is a major barrier to establishing Static EPI Centers besides deficient cold chain. Measures should be taken to ensure that all the health facilities are electrified and all the resources / donors should be tapped to replenish cold chain.
Deep freezers and refrigerators are the most commonly used equipment at vaccine points. In urban areas, all the health facilities are well equipped except for a few run by local bodies, while in rural areas, 2.4% RHCs and 61.2% BHUs are without cold chain equipment. In most of the districts, more than 50% of BHUs are without any cold chain equipment. Despite electrification 36 (12%) RHCs and 307 (35%) BHUs are not working as static EPI Centers. Despite the shortage of cold chain equipment in the field, a bulk of equipment is lying dormant in the district EPI stores.
62% of the existing cold chain equipment, although working, has completed their life as they were supplied during the early stages of the programme i.e. late 80s and early 90s. A substantial quantity of equipment: 175 small refrigerators, 121 ILRs, 34 TCWs and 87 Deep Freezers are out of order for want of minor repairs. The District Health Officers are reluctant to get them repaired due to fear of audit objections. Similarly, a large number of unserviceable equipment is dumped in stores for auction, which include 586 small refrigerators, 266 ILRs, 157 deep freezers, 25 TCWs, 1556 stabilizers, etc.
Vehicles and bicycles for the transportation of field and supervisory staff are again inadequate. Moreover, an adequate quantity of POL is not provided for the vehicles and motorcycles.
Government allocates extremely insufficient budget for the maintenance and repair of cold chain equipment. Moreover, the allocated budget is not according to the actual needs of the districts. It may be reasonable in some districts, while in others it is ridiculously low. Almost all the major donors have withdrawn their support of cold chain equipment. Only UNICEF continued to supply equipment. UNICEF supplied ILR to EPI during the recent years. These have been immediately distributed down to the district and are used in EPI static centers and at sub-stores for out-reach teams. It is worth mentioning that this equipment does not actually cater to the needs of the immunization programme. It works only as a refrigerator and there is no freezing compartment to freeze ice packs, which are essential to be used during outreach vaccination sessions.
Practically, there is no monitoring system to assess the actual operational status of the equipment. Moreover, no appropriate system exists for their repair. Most of the District Health Officers are reluctant to get their out-of-order equipment repaired due to fear of audit objections. The financial power of District Health Officers is limited. If he repairs equipment in installments, there is audit objection. If he gets approval from higher quarters, it usually delays the case to an undesirable period so that after sanction, the situation has changed and the cost may have increased.
The cold chain technicians deployed at the divisions are sitting idle and are under utilized. They have neither established workshops at the divisional level for repairing the equipment nor do they visit the districts falling in their jurisdiction. The staff involved in the cold chain maintenance has not been trained in a long time.
Due to insufficient cold chain equipment, out-reach teams in the rural area have to travel long distances for taking vaccine before they reach the community. Sometimes, the vaccinator takes the vaccines required for the next few days from the sub-store and keeps them in a domestic refrigerator either at his own residence or in the community. This practice severely endangers the vaccine and it is possible that by the time vaccine reaches the child, it may have lost its potency due to the interruption of cold chain.
Stabilizers are insufficient for all the working cold chain equipment. Non-availability of stabilizers makes the equipment more vulnerable to damages due to electric fluctuations.
Table thermoses are far less than those required for the ongoing immunization programme. It has been observed that above 90% of vaccination sessions have been conducted without the proper use of table thermoses. In such a situation, the credibility of the vaccine cannot be certified.
Presently, cold chain equipment is far less than what is required. The EPI Directorate has chalked out the minimum requirement criteria at each level of health facility. The EPI Directorate is tapping many potential sources for the provision of cold chain equipment. It has been planned to get complete cold chain in two steps. In the first step, keeping in mind the present working status of cold chain equipment, all the health facilities in the rural areas will be supplied with cold chain equipment. In the second step, all the cold chain equipment supplied before 1990 will be replaced.
All the outlived equipment should be replaced. At least 10% additional equipment should be made available at the district level as buffer stock, to be used in case of emergency replenishment.
For the safety of equipment in the prevailing condition of power fluctuations, it is mandatory that all equipment be protected with stabilizers. Similarly, all the EPI stores should be equipped with generators as back-up apparatus in case of power failure, with adequate allocation of fuel. Solar / kerosene oil refrigerators should be arranged for non-electrified health facilities to establish EPI center.
Maintenance and regular update of temperature record of every cold chain equipment are the only tools for monitoring cold chain integrity. All the cold chain equipment must have a thermometer. All efforts should be made to get the health facilities electrified.
The cold chain technicians at the divisional level should be made responsible for the maintenance of the cold chain equipment in the entire division. Regular training of staff involved in the maintenance of cold chain equipment should be top priority.
Government should be approached for earmarking of budget for the repair and maintenance of cold chain equipment.
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