An EPI Unit, located in the Department of State for Health, is responsible for the planning, overall supervision, implementation, monitoring and evaluation of the programme. Since its inception in May 1979, the EPI progressively increased immunization coverage within its target population until 5 years ago when coverage started to fluctuate.
Initially, the program used the mobile strategy (i.e. visiting villages, and immunizing target children and pregnant women), which was found to be expensive and not sustainable. In that regard, the Department of State for Health (DOSH) decided to use the Maternal and Child Health (MCH) teams to deliver the immunization services at all the static and outreach clinics. In 1995, the private clinics were involved in the provision of immunization services to increase immunization delivery points.
According to existing information, there has never been a comprehensive EPI review in The Gambia. However, components of the programme have been assessed over the years and those assessments identified some strengths and challenges that needed to be explored further. The current review is in response to the need for a comprehensive assessment of the programme.
Purpose / Objective
The overall objective of the assessment was to review the performance of the programme, with particular attention paid to the areas of management, coordination, funding, service delivery, the achievements and constraints of EPI in The Gambia, with a view of guiding future performance towards sustainable EPI target diseases control and maximum impact on child survival.
The review assessed all the four levels of the health care delivery system, namely: central, divisional, health facility (hospital, major and minor health centres, outreach post) and primary health care villages.
The DOSH, assisted by the local consultant, compiled and used a comprehensive list of public health facilities to be reviewed. Facilities were purposively selected, taking into account a balance in the following criteria: catchment area; performance of the division; and location vis-à-vis, peri-urban, urban and rural. With the limited number of hospitals (3) and major health centres (6), it was decided that these should be reviewed in total. Additionally, 7 (20%) minor health centres, 42 (10%) primary health care villages and three outreach sites were observed.
The WHO Immunization Service Assessment Tool was adapted and used for the review. The full review team participated in the adaptation process.
Key Findings and Conclusions
The Gambian programme has, over the years, been a success story including being a leader in EPI advances. To no surprise, the review team identified the following key achievements:
- High rate of access to Maternal and Child Health services including immunization: All health facilities provide immunization services at both static facility and a number of outreach sites. The outreach sites are permanent and the catchment population is aware of the days services are provided at the site.
- Although immunization coverage is declining, coverage is still relatively high.
- The Government has increased budgetary allocation for the purchase of routine vaccines.
- The programme organized successful National Immunization Days in 1998, 1999 and 2000.
- The country has reached a near eradication of poliomyelitis.
- There is high public awareness about EPI Vaccines.
- The country has successfully included two new vaccines into the immunization services.
Key Issues that need to be addressed--
Decline in immunization coverage:
DPT 3 coverage has declined from 97% in 1998 to 74% in 2000 and full immunization has declined from 80% to 69% over the same period.
Uncertainty of vaccine supply:
The current funding sources for Hep B and Hib vaccines (the Italian Government and Aventis, respectively) end within 4 months (December 2001). To date, there are no confirmed sources of financing for the two vaccines. The supply of these two vaccines, particularly the Hib vaccine, has been very erratic. The programme experienced Hib vaccine stock out at least 3 months each year of the last 5 years.
Aging Cold Chain equipment:
Although most of the cold chain equipment is still functioning, over 50% of them have been there for 10 years or more. At the moment, there is neither a replacement plan nor available resources for replacement.
Interruption of outreach services:
Over 50% of health facilities reported interruption of outreach activities as a result of unavailability of vaccines and/or transportation.
Absence of annual report of service delivery indicators:
The team was unable to locate annual reports for the programme or the entire DOSH.
High vaccine wastage rates:
Although vaccine wastage is not routinely monitored at any level, a vaccine utilization and wastage study conducted in 1999 reported a high wastage rate for all antigens.
Need for strong advocacy for the programme:
The EPI has been perceived as being fully funded by UNICEF and WHO, which may have been true in the 1980s and 1990s, but this is no longer the case. Hence, there is a need for strong and high level advocacy to compete for Government resources.
Weak inter-Unit collaboration:
All EPI data from the field are sent to the Epidemiology and Surveillance Unit (ESU), but there is no mechanism in place for the information to be shared with the EPI. Making this situation worse, the ESU has not been analysing any of the health data. It was only recently that the DOSH began to make an effort to have routine data analysed.
Government to ensure continuous availability of vaccines:
- Increase and maintain vaccine line-item in the annual recurrent budget (for traditional vaccines)
- Apply for Global Alliance for Vaccines and Immunizations support for both windows 1 & 2
Replace and expand cold chain equipment urgently
Government should develop a transport replacement policy:
- Consider shifting from the use of four-wheel to two-wheel vehicles for outreach services
Planning directorate should re-organize the Epidemiology and Surveillance Unit to ensure the collection and use of routine data at all levels:
- DOSH to ensure the production of annual reports
- ESU to establish a mechanism for sharing routine data with relevant units
Need to adopt the multi-dose vial policy (MDVP) and monitor vaccine wastage
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Department of the State for Health and Social Welfare