Immunization: Reaching excluded children
UB, Serbia - Paljuvi seems to be an ordinary village, a little bit remote, with a very bad, winding, dirt road leading through forests and fields to the next town, only some 70 kilometres away from the country's capital.
A number of grand, deserted houses greeted us when we arrived one rainy early morning. But barefooted children run through the mud from other, smaller, rundown hovels to greet us.
Nothing really unusual for a Serbian village except that some of those children - barefoot in all weathers - officially do not exist at all; their births have not even been registered.
"I don't know when they were born. That was in Belgrade. But these are my son's children and I take care of them and I know they've never been vaccinated," Dragana, a grandmother of five told a doctor when asked for any identification papers for the children.
Her daughter-in-law left the family and her son found a job in a town 30 kilometres away. Dragana is taking care of two grandchildren. Altogether 11 people - six adults and five children - live in a small two-room house, with no bathroom and no running water.
After some hesitation the medical team was admitted into a small cold hall between two rooms with a dirt floor and low uneven ceiling, a stove and a bucket of water in one corner. Slowly the people started to arrive and some of the older kids brought in a bench, wet from the rain, for the children to sit on while being vaccinated.
"I'm not afraid. I want to have a shot," five-year-old Dragan said proudly. Other children, some of them just making their first steps, push forward to see what's happening.
Not minding the conditions, three members of the UNICEF-supported immunisation team - a doctor, nurse and medical technician - started preparing for their job and comforting the parents.
The health workers said the children found it all very amusing. "It’s all very interesting for them. They follow us around all the time through the village, from one house to another. Mothers, not children, are those who complain sometimes," the doctor said.
The immunisation of children and women was announced at a different house across the street, but the well-off owner was in the fields digging potatoes and the house was locked.
"Last week we announced a vaccination session in another Roma settlement on the outskirts of the town of Ub. But nobody came to the house we'd chosen as offering the best conditions, because it turned out that everybody in the village was on bad terms with the owner. It often happens, they promise they'll come and they don't. So we have to go from door to door, convince one family after another, but we manage to finish our job," says paediatrician Dr. Anica Milosevic Popovic.
"Since they are poor, it's important for them that our visits are free-of-charge," says medical technician, Mr. Prvoslav Rankovic.
Although the official statistics say 108,000 Roma live in Serbia, the actual figure is higher. Some of them have not been registered and many assume the nationality of the majority population in the area where they live. On the other hand, one Roma nongovernmental organisation gives a ten-fold, exaggerated number of a million.
A great number of Roma children have never been enrolled in school. According to the Roma Information Centre, 75 percent of children do not finish the obligatory eight-year elementary education. The majority of them live in very bad hygiene conditions, sometimes three, four generations in a room of a few square metres.
Health workers explain that sometimes misinformation is spread, mainly by rich neighbours, that the vaccines are dangerous and poisoned. "They put their children in their BMWs and vaccinate them, and then come when we arrive to vaccinate other children on the spot, because their parents have no money to bring them to the health centre, and tell them these are bad vaccines," says project coordinator in the Ub municipality, Dr. Biljana Rajkovic.
"Do you think we can get a flue vaccine for our children as well?" a concerned father of 15-month old Danijela asked, knowing the majority of the children there suffer from chronic bronchitis. She is Milan's only child, although he is "older than 30", very unusual for this community.
For his wife, Mirjana, this is the second marriage. She has another two daughters, seven and 12 years old, but she left them behind with her first husband's family and has had no contact with them since. However, when asked by a doctor whether Danijela is her only child, she said yes. "I don't have any other children," she says.
Since the summer, UNICEF, the Serbian Health Ministry and the Public Health Institute have been sending out mobile teams to different parts of Serbia first to identify and register the unregistered children, and then to immunise them against major child killer diseases -- tuberculosis, diphtheria, tetanus, whooping cough, measles, and polio.
The team has registered 122 children under 15, and 100 women of child-bearing age in Ub since August. "Since 1 October, we've been in the field every day, we’ve visited hundreds of houses," Dr. Rajkovic says. Ub is a municipality with 33 villages and has a population of 36,900, of which about 6,500 are children.
Rajkovic has spent the last seven years in the field, visiting remote villages, identifying and curing diseases, educating parents and advising. "A few days ago we drove 200 kilometres through the area, from one village to another to sign in all the children. After such a long time in the field, I cannot even imagine how it would be to work in an office," she says.
Official statistics show a high coverage of as many as 90 percent of Serbian children with immunisation. But the figures refer only to children included in the health system, with birth certificates and medical records. A UNICEF-supported survey showed that the percentage of un-immunised children is higher in reality. Some of them have not even been registered - the highest number is among Roma, refugees and displaced persons.
According to the latest UNHCR figures, 276,281 refugees and 206,789 displaced people live in Serbia. Unlike refugee children, those belonging to the large group of the displaced population, mainly from the Kosovo province, have not been included in the regular health system in Serbia. Those children still live on the margins of society.
“The immunisation system in the country constantly covers 90 percent of children, despite the decade of crisis. It is a success, but the system has never been designed to reach marginalised groups of children. Since 1992, UNICEF has assisted to sustain the 90% of immunisation coverage, but also to reach the unreachable with vaccines, through joint efforts with the Serbian Ministry of Health,” says Dr. Oliver Petrovic of UNICEF.
He explains that besides inclusion of those children and women in the regular health system, the aim was also to include those families in the social welfare, child care and education systems - to link all those services.
About 18,000 children in five out of 23 regions in Serbia have benefited from this project, and an additional seven regions are to be covered by the year's end. In 2002, the Serbian Public Health Institute and UNICEF registered 10,446 children under 14 years of age, who belong to marginalised groups, the majority of Roma nationality. Only 33.2% of those children was previously registered in health centres and immunised. Within the programme, 65.2% of children have been completely immunised.
In addition to eight epidemiology and public health experts, 191 health workers, and 77 members of non-governmental organisations and community leaders have taken part in the implementation of the project. Inclusion of community leaders was of great significance for good response from families and the success of the immunisation.
The methodology for identification and registration of hard-to-reach and excluded children, developed with UNICEF support, has been included in the country's health legislation.
"To reach excluded children and women we need new innovative ways of working. We have to identify the barriers - economical, social, cultural or geographical - that impede some people to access services."
“To reach excluded children and women we need new innovative ways of working. We have to identify the barriers - economical, social, cultural or geographical - that impede some people to access services. This outreach initiative helps to establish the contact with excluded children when they are immunised. The official national figures on immunisation hide disparities and population groups that are not even registered and are completely missed out. These are usually the most excluded children who do not have access to most other services, such as Roma. Through this project we found that approximately 10% of non-vaccinated children were not registered at birth and many of them were not enrolled in school or in other social services.
To address this issue, UNICEF will include all relevant stakeholders at the local level to investigate why children are not registered and to design locals plans of action for the inclusion of children into the social services and birth registration. A particular focus will be placed on empowering the parents and primary caregivers to identify together how services can be improved so that all children will benefit from them”, UNICEF Area Representative said.
By Ljiljana Cvekic