Author: Ajmal, W.; Jamal, A.
Although gains have been made in establishing a functional regional EPI management system, EPI in Afghanistan still remains far from attaining the desired coverage and consistency of routine service delivery. The existing low routine immunization coverage (31% 1999 reports and 47% survey for OPV3); a caseload of 405 cases of AFP of which 229 are confirmed wild poliovirus (from 86 sentinel sites in only 46 out of 330 districts), clearly indicates that the situation is still precarious and far from the ideal of achieving zero polio by the end of year 2000. With only eight to nine months remaining in the deadline to interrupt wild virus circulation in Afghanistan, the existing situation indicates an urgent need for identifying gaps in the current strategies. In June 1999, it was agreed by the stakeholders that following the four rounds of NIDs planned for the year, a joint assessment would be carried out to double check the effectiveness of the intervention strategies and identify remaining gaps to be filled.
Purpose / Objective
- To assess the effectiveness of the current strategy on Polio Eradication in Afghanistan, especially the routine immunization component
- To reach a consensus amongst all stakeholders on the appropriate way forward to achieve zero polio by the end of 2000
- To outline the steps needed to develop a composite EPI and PEI plan of action for the next 3 years, 2000-2002
- To conduct a desk review of existing information on polio eradication activities and routine EPI (routine reports, NID reports, previous reviews, surveys etc.) in order to synthesize information into a single data base
- To identify lessons learnt and determinants of successful implementation of NIDs, routine EPI and AFP surveillance to inform planning activities of spring NIDs and EPI plan of action 2000-2002
- To assess the effectiveness of the communication strategies for social mobilization and advocacy for polio eradication, routine EPI and surveillance.
The Rapid Assessment Procedure (RAP) was applied to carry out the exercise. This involved a combination of quantitative and qualitative assessments through the review of documents, observations, interviews with key informants and focus group discussions.
A desk review of the existing information on EPI and PEI was carried out. This involved the review of routine reports, NID reports, surveys, previous reviews and evaluations. The synthesized information was used to assess the accuracy, regional coverage, yearly trends, and a comparison of reported and survey coverage. Regional reports were prepared and provided to the teams, for use in the field.
Extensive consultations, interviews and focus group discussions were held with a cross section of regional, provincial and district authorities, concerned agencies and the civil society.
Key Findings and Conclusions
Better organization, availability of adequate resources and increased emphasis have resulted in better achievements for the NIDs. Comparatively, much less has been achieved in routine EPI. To eradicate polio as soon as possible, emphasis will have to continue and progress maintained on NIDs, more emphasis will be required on routine EPI, AFP surveillance and mopping up procedures to restore the balance required for polio eradication.
To reach the objective of eradicating polio, routine EPI and AFP surveillance will need improvements in a short period, which is beyond the capacity of the country's feeble institutional framework (MOPH) at this stage. While efforts to improve the capacity and the involvement of MOPH continue, supporting agencies UNICEF/WHO will have to take the driving seat and treat EPI and PEI on emergency lines.
Policy endorsements and additional resources will be required to achieve the goal. This will not be possible without political sanctions by the government and the will of the supporting agencies to commit additional resources. Besides, better coordination at all levels, involving all agencies and sectors, will be required to tap potential resources.
Considering the existing situation with extremely weak institutional framework of the country, precarious security, low EPI coverage and significant endemicity of the poliovirus in Afghanistan, breaking the transmission by the end of year 2000 seems ambitious but not impossible. However, with intensive efforts, it is quite possible to achieve eradication by the end of year 2001.
While the pace of progress in NIDs should be maintained and further improvements made in the planning, training and supervision aspects of the NIDs, efforts should focus more on areas like the routine EPI, where the achievements fall much short of those required for polio eradication. Geographical coverage of the AFP sites should be increased to meet the planned targets as soon as possible. Community surveillance, reporting by the vaccinators and peripheral health staff involved in outreach should be injected into the surveillance system. Such policy emphasis should be translated into allocation of the required resources for better field implementation of EPI, AFP surveillance and mopping up activities.
Considering its emergency nature, PEI should be made a regular part of the agenda at all the coordination forums including the heads of the agencies' meeting and the TCC at national level, the regional coordination bodies, and the technical working groups/health coordination committees at the regional levels. This will improve the required intrasectoral and intersectoral collaboration and ensure potential inputs of all agencies and sectors are tapped to achieve the PEI objectives. Senior WHO and UNICEF staff (national and regional level) should ensure their regular attendance and participation in the TCC to restore its national and decision making character.
Roles of UNICEF and WHO should be clearly defined and communicated to the field as part of improvements in coordination. Regular joint visits by senior WHO/UNICEF staff to the lower levels should be undertaken to promote teamwork and complimentarity between the staff of the two agencies at the field level. The latter aspect should also be emphasized in the various coordination meetings as well.
Monitoring and supervision should be intensified, and progress review should be held at every level including the district, at regular monthly intervals. Developed monitoring tools like the EPI monitoring charts should be used at every level in all regions. REMT members should visit each PEMT twice a month and, as part of such supervision, visit two to three fixed centers supervised by the PEMTs. PEMT members should visit each fixed center at least once a month.
The community should be involved in the planning and management of health activities in general and EPI/PEI activities in particular. At the district-level community, services should be integrated into the health facilities/fixed centers through district health committees, a couple of paid community workers who would supervise a number of unpaid community volunteers to cover the population in the entire catchment area.
Efforts should continue to reduce the dependency of MOPH and make it more effective. To improve the ownership of the program by the MOPH and, therefore, its integration and sustainability, a phased hand over of management and financial responsibilities should be planned and implemented. This will obviously have to coincide with the improving capacity of the MOPH, for which it will need to be assisted.
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