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Base de données d'évaluation

Evaluation report

AZE 2000/002: National Immunization Programme Evaluation (Azerbaijan, 1999)

Author: Wylie, A.; Benesh, O.

Executive summary


It has now been almost a decade since Azerbaijan has declared itself to be an independent republic. Five years have passed since the National Immunization Programme (NIP) made significant changes in its operational protocols. The NIP has thus had adequate time to adjust to the revamped social situation and the new policies that frame the environment in which the program is currently conducted. The relatively mature stage at which the NIP is currently positioned sets the stage for an effective, informative evaluation. It can be reasonably expected that the evaluation will produce results that reflect the status of a program that has passed through a change period and has reached operational equilibrium. This report describes the first major evaluation of the Azerbaijan NIP that has been conducted since Azerbaijan declared independence in 1991.

Purpose / Objective

The objectives of the evaluation were defined as follows:
1. To estimate the vaccination coverage with EPI antigens (BCG, OPV, DPT, Measles), program utilization and program continuity, regionally and nationwide
2. To describe the current status of a variety of factors related to the delivery of immunization services in selected regions of Azerbaijan, where conditions for delivery of health services are expected to be different.


Two major types of studies for the assessment of the National Immunization Program in Azerbaijan were used. The first involved obtaining precise estimates of the coverage of the EPI antigens - those that form the core package of vaccines that are recommended by the WHO - among children aged 15 to 26 months. A national immunization coverage survey was conducted using a randomized multi-stage cluster design. During this survey, 12,645 households were visited in 5 defined regions of Azerbaijan. A total number of 801 eligible children were identified, from which 43 were excluded afterwards because of doubts in terms of quality.

The second study was targeted to assessing a variety of important factors concerned with the qualitative aspects of the delivery of vaccine services. This section of the assessment consisted of an investigation of aspects of the programme such as Immunization Services delivery, Cold Chain and Logistics, and Injection Safety during visits to medical facilities, the community, and to district CHEs, selected according to criteria that reflect a variety of local and operational situations, by interview, inspection of records and observation of work. Information on these aspects of the vaccination programme was collected in a service delivery survey that gathered data from a purposive sample of facilities that were drawn from 15 rural districts and 5 cities of Azerbaijan.

Key Findings and Conclusions

One of the goals of this evaluation was to build local capacity to conduct such assessments independent of external assistance in the future. External consultants assisted NIP personnel at the beginning (design period), in the middle (sampling and training of the field personnel), and at the end (analysis and report writing) of the evaluation process. Looking back at the process used during this evaluation, it appears that while appreciable efforts were made to combine internal and external approaches, methodological problems arose from insufficient technical support to the MOH during the conduct of the survey. The experience of this evaluation suggests that technical support is necessary at all stages of the evaluation process if the product is to achieve maximum utility.

Vaccination coverage rates calculated from data extracted from children's medical records remain the most reliable measure of coverage in most countries. While patient medical documentation in Azerbaijan is not as comprehensive as in the West, it is still of reasonably high quality. After a child was identified during the household visit, surveyors went to the local health facility to find out documentation with his vaccination records.

The Immunization Card (IC) was present in 24.9% of the homes of children aged 15-26 months. The use of the IC varies considerably among regions, ranging from a low of 10.5% in rural highlands to 48.2% in assisted IDP. Children who possess the IC at home show higher rates of complete and timely immunization at 58.3% than those who did not possess an IC, at 45.9%.

The percentage of children who have a BCG scar varies significantly across regions from a low 28% in Nahichevan to a high 71% in Urban. The prevalence of the BCG scar among surveyed children does not correspond to the vaccination coverage figures as measured through guardians' report and documentation. The high discrepancy of 45% between reported by guardians' vaccination coverage rates and prevalence of BCG scar was identified in rural high lands region, while in the others, it ranges from a low 15% in urban and 22% in rural low lands to 32-33% among IDP and in Nahicevan. It is worth mentioning that the rate of 15% in urban is close with expected scare failure rate after a successful immunization. While in the other regions, the results suggest that either the vaccination coverage rates estimated in this survey are inaccurate (i.e., overestimates), or that an unacceptably high proportion of children are not efficiently vaccinated with BCG in Azerbaijan, especially in Nahicevan, among IDP and in rural high lands.

The national immunization program does provide OPV0 at birth and National Immunization Days were conducted in the country during the spring in 1997-1999. Estimated vaccination coverage with OPV0 was 73.3% for national level, but varies from 49% - assisted IDP to 82% - urban population. The proportion of children who received 2 OPV doses during an NID was 59.4% at national level, that is, much lesser than the reported figures for 1997-1998. The worst OPV NID coverage was identified among Nahicevan children - 9%. For rural population and assisted IDP, the figures vary from 46 to 57%, and only in urban children the estimated coverage was 80%.

Another attempt to assess the protection of children against polio was made by calculating the proportion of children who received at least 3 OPV doses given by routine immunization or NID.
The estimated coverage does increase in all regions, but is still less than 90% among children from Nahicevan (75%), assisted IDP and rural high lands (88%).

According to survey findings presented, the proportion of children vaccinated before the age of twelve months (fifteen months for measles) is significantly lower than crude coverage rates for all antigens except BCG. The differences between the antigen-specific crude coverage rates and timely coverage rates range from 8.1% for OPV to 13.6% for measles. Less than two out of every three children are fully immunized according to acceptable time limits established by the NIP.

Excepting BCG vaccination, national figures for valid immunization coverage by one year dropped down to 72.4% for DPT3, 66.9% for measles and 50.59% for fully immunized. Overall, every second child in the country is not fully immunized with valid doses within the required time. The situation is more dramatic in Nahicevani and among IDPs, where coverage by individual antigens is from 51 to 68%, and fully immunized with valid doses by one year are only 34-40% of the children.

The national estimate of the drop-out rate for DPT1-DPT3 is 3.9%. The lowest drop-out rate is registered among urban children and the highest (9%) in Nahicevan. It is worth mentioning that country estimates of OPV1-OPV3 drop-out rate are higher (8.4%) in spite of the fact that DPT and OPV vaccines should be administered to the child the same day. DPT1-Measles and OP1-OPV3 drop-out rates are close to 10% or more in all country regions except Urban. These findings suggest that an important proportion of children receive the first dose from the EPI schedule (i.e., DPT1) but then fail to complete the entire EPI schedule (the measles vaccine is the final in a series of vaccines recommended for administration over the first 15 months of a child's life).

Guardians who reported that their child was completely or partially unimmunized were asked to state the primary reason for their child's unimmunized status. Half of the total is from two main types of reasons: the child was said to have been ill at the time, or lack of knowledge about the needed immunization or dosage.


Taken together, these results suggest that the revision of the immunization service delivery system could significantly increase vaccination coverage through the increase of program use and reduction of drop-out rates.

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