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Evaluation report

2010 Iraq: External Evaluation of joint WHO/UNICEF project “Diseases Eradication, Elimination and Introducing new vaccines (D2-16)”

Executive summary


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The “Disease Eradication, elimination and Introducing New Vaccines” project was launched by WHO and UNICEF in order to assist the Ministry of Health of Iraq to revitalize the vaccination programme for infants and children and reverse the down trend of coverage of infants by essential vaccines, decentralize vaccines storage facilities and to assess the need for introducing new vaccines into the national immunization programme. The key developmental goal of the project was to contribute to the reduction of infant and child morbidity and mortality through protecting more children against vaccine preventable diseases.

The project was funded by UNDG-ITF earmarked for the UN Cluster-D: Health and Nutrition of USD 12 million, of which WHO receives USD 6,101,841 and UNICEF USD 5,798159. On top of this budget (all provided by the Japanese Government), the MoH pledged USD 25 million and each of WHO and UNICEF allotted USD 52,254 and USD 1,400,000 respectively.

The project beneficiaries were children less than 5 years of age at the national level in the 18 governorates of Iraq, with some interventions of focused on selected districts.

The original project duration was February 2007 to March 2008. However, due to unavoidable delays in implementation, the project was extended to June 2009 and the target dates for achieving the desired outcomes were also deferred.

The project major implementation partner was the Ministry of Health, all WHO and UNICEF programmes were implemented in close coordination with MoH staff with active participation of WHO and UNICEF national staff in Iraq. At central level, the Ministry of Health was involved in setting policy and strategic direction and Macro-plans and was responsible for the overall monitoring and evaluation of the project. The national Expanded Immunization Programme (EPI) manager was entrusted with the overall management of the programme. At the governorate level, a governorate EPI manager was responsible for micro-planning and implementation and monitoring of the activity in the governorate. At a Community level local community leaders including religious leaders were involved in social mobilization and were responsible for encouraging families to immunize children and facilitate mobile teams‟ movement from house to house. Other partners included 400 fields‟ monitors from IRCS and around 40 supervisors from medical schools who were involved in monitoring the campaign.
The under 5-children in Iraq as a whole and without discrimination benefited from various public health control activities of this programme through support of immunization campaigns including NIDs and social mobilization.

The evolution took also into consideration the effect of unstable security situation in Iraq during the project implementation period, and the remote nature of managing, implementing and monitoring the project activities inside Iraq from WHO – Iraq, based in Amman, Jordan. This resulted in further challenges and difficulties during project implementation.

The following outcomes resulted from project implementation as at end of 2008:

 90% of the urgently needed vaccines, syringes and measles laboratory equipment and supplies were provided, with no reported shortages.
 Only 60% of districts reported 80% or more infant coverage with DPT3 in remote/hard-to-reach areas (This was addressed by SIAs after expansion of the project duration) and regular reports on EPI coverage were received from 80% of districts.
 Two rounds of house-to-house OPV immunization campaigns were launched in September/October 2007 and October/November 2008, which reached more than 90% of under 5 children.
 Measles case-based surveillance and measles laboratory-based diagnosis was well established.
 92% of 9-59 months old children were vaccinated by measles-containing-vaccine through house-to-house national MMR campaign (April/May 2008).
 Eight hospitals had a well functioning rotavirus surveillance system, but only 50% of the selected hospitals, had a well functioning system for surveillance of bacterial meningitis.
 The three regional vaccine stores in Erbil, Babel and Basra were constructed and became functional.
The implementation phase of the project has witnessed a complex and volatile security situation. The 2005-2007 time periods was referred to as most insecure period with very high incidence of violence. The fragile situation resulted in massive turnover in the government in general and in particular the MoH staff at all levels, this situation was complicated with attacks against health professionals and migration of the skilled health professionals. Lack of MoH operational running costs, security situation on the ground not allowing for freedom of movement have also affected the implementation of this project resulting in prolonged and extended implementation period.

On top of these difficulties, delays in disbursement of funds and deficiencies in documentation, reporting, data analysis and structured supervision, non-participation of some DoH focal points in training, limited distribution of technical guidelines had all contributed to delays and to unsatisfactory performance in certain districts.

Recommendations for WHO, UNICEF and MoH:

a) The expanded programme on immunization is an integral part of the regular PHC activities. It is the most cost-effective intervention for reduction of infant and child morbidity and mortality from vaccine- preventable diseases. The success of this programme is dependent on maintaining above 80% vaccination coverage with vaccines that meet internationally recognized standards.
The MoH of Iraq should therefore, maintain close cooperation with WHO and UNICEF to ensure that the awareness and political commitment that was developed through this project does not diminish or be compromised as a result of possible changes in government structures.
b) The assistance of specialized UN agencies is indispensable under emergency situations. However, the MoH should develop its capacity to assume full leadership and national ownership of the EPI.
Continuous capacity development, allocation of funds for procurement of urgently needed vaccines and supplies and exercising overall supervision and oversight of immunization services are fundamental pre-requisites in this respect.
Nevertheless, the MoH should continue to call on WHO for technical assistance and capacity development, in areas were the national technical capacity and experience is limited or incomplete.
c) House-to-house national campaigns remain the most effective strategy for addressing the decline in immunization coverage under emergency situations.
The sudden drop in vaccination coverage in communities which had traditionally maintained high coverage brings about the risk of disease outbreaks because as new cohorts of unimmunized children accumulate, pockets of susceptible build-up.
The MoH should therefore, continue to launch NPNIDs and measles mopping up campaigns on regular basis, as long as measles is not eliminated and polio free status is not declared by WHO in neighboring countries, especially under a situation where there is flood of visitors to religious places in Iraq from these countries.
d) The MoH should continue to carry out periodic assessments of the trends of incidence of vaccine- preventable diseases and conduct surveys to identify pockets of un-immunized infants and children nation-wide, with special emphasis on remote and hard-to-reach areas. The ultimate objective is to ensure that at least 80% coverage of children is fully immunized for all essential EPI antigens.
e) The evaluation revealed that deficiencies were identified in documentation, detection of adverse events following vaccination, reporting and, surveillance of bacterial meningitis.
The MOH should therefore, ensure that an effective health information system is in place to ensure that surveillance of EPI diseases meets the WHO criteria of acceptability (by health workers), completeness, accuracy, timeliness, representativeness, consistency and sensitivity.
This would require further capacity development of MoH staff at all levels, through continuing education, on-the-job-training and supervision in close coordination with WHO and UNICEF technical staff.
f) The internally displaced population represents a major problem with regard to immunization because they often live under appalling conditions and their movements are difficult to track.
Identifying the needs of that population through periodic assessments, should therefore be considered as a high priority for EPI national managers who should spare no effort to reach them through mobile vaccination teams.
g) There are good reasons to believe that further efforts need to be exerted in order to strengthen AFP surveillance and measles laboratory-based diagnosis. This could be best achieved by continuous capacity development of the technical and managerial capabilities of MoH staff through on-the-job-training and supervision.
h) The current reporting channels at central level need to be unified to ensure that data is analyzed on a regular and timely manner and findings are followed up.
i) The current supervisory structure of the EPI should be decentralized to ensure affective and timely response to any declining drop in vaccination coverage or sudden onset of localized outbreaks.
j) Plans should be developed for periodic training of DoH and surveillance focal points to update their knowledge, orienting new staff and develop capacity to conduct training of trainers‟ sessions at district level.
k) The technical guidelines and operation manuals on EPI diseases and laboratory surveillance should be widely distributed to all PHCU use and staff adequately oriented on their contents.
l) The facilities for bacterial meningitis and rotavirus laboratory surveillance have been established in the selected 8 hospitals, but the facilities are not fully functional. The MoH should follow up to ensure that all facilities are functioning to their full capacity.
m) The decision on introducing new vaccines in the EPI is still pending. Should a decision be made in this respect, the MOH should ensure that the necessary funds are secured for procurement of the new vaccines.
n) The potency of vaccines procured through the international market, the continuous supply of vaccines and the safety of vaccination procedures, are pre-requisites for the success of EPI.
The MoH should therefore, maintain effective system for quality assurance of vaccines from the point of collection to the point of service delivery.
o) The MoH should follow up to ensure that used syringes, needles and empty vaccine vials are disposed of according to the recommended safe methods at the service delivery level and not dumped with other solid waste.
This requires undertaking undeclared supervisory visits to PHC facilities and vaccination teams to ensure compliance.

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