Strengths in local systems | Opportunities for improvement in local systems | |
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Local service planning and delivery Data sources: interview and audit | • Recent innovations recognised by most (14/18) staff: new vaccines or planning, with one mention of new quarterly outreach increasing efficiency • Recent in-service training in SIREP reported by many (11/18) staff • Static services available 5 days per week • All clinics tallied vaccinations to report into national health information system • 82% of clinics conducted as planned (annual total of 109 implemented of 133 planned) | • Outreach was limited - minority (2/9) static facilities used outreach with overnight stays for remote areas • Outreach planning process not able to be described by half the staff, less than a quarter planned on population basis, no clinics used population data to estimate outreach supply quantities • Many clinics with few patients: mean 17/clinic, IQR 3–26, maximum = 62 • Estimation of coverage impossible for more than half (10/18) staff due to lack of catchment data, only one clinic displayed coverage • No clinics with lists of children overdue for vaccination, one third of clinics used child registers • Local reasons for clinic cancellation were adverse weather, lack of transport or slow disbursement of funds |
Infrastructure and supplies Data sources: interview, audit and observation | • Most clinics had road access, with two outreach clinics on walking trails • Water supply in nine (of 12) clinics and electricity in eight (of 9) static sites • Functional injection equipment, safety boxes and weight scales in all clinics • 10 (of 12) clinics with appropriate, functioning cold chain equipment • Supplies of all relevant vaccines (including IPV and PCV) and injection equipment present • No expired or discontinued vaccines found | • Eight (of 12) clinic sites needed renovation (by local standards), 9 (of 12) did not have usable toilets • No clinics with kits for managing severe acute adverse events • Cold storage monitoring inconsistent, no clinics with written temperature records • Half the clinics had clear records of vaccine stock usage, not well reconciled with tallies of patients vaccinated, none able to match supply to population • Recording forms did not clearly account for three new vaccines: IPV, PCV, MR • Lack of important guidance documents: one (of 12) had an immunization manual, and four had child health standard treatment guidelines |
Staff knowledge and staff practice during immunization sessions Data sources: interview and observation | • More than half of staff could correctly cite recently introduced vaccines (11/18) and handling of lyophilised multi-dose vials (15/18) • Twenty staff (nurses and CHWs) across 12 clinics, vaccinating mean of 17 children per clinic falls below WHO maximums (30 per staff member [15]); • Core interactions (weight, screening and vaccination) done for 14 of 15 observed patients • Observation against WHO session checklist (Fig. 1) shows key elements of safe injection in over 80% sessions | • Less than half of staff could correctly cite immunization schedule (8/18), one national program target (3/18), storage temperature (6/18), interpret vaccine vial monitor display (3/18), or handling of liquid multi-dose vials (2/18) • Some important functions omitted in patient flow observations: educational interactions observed for just two of 15 patients, preventive care for mother and AEFI monitoring observed in none • Waiting times in 15 patient flow observations were significant: mean 51 min arrival to final interaction (IQR 13–90, maximum 210) • Observation against WHO session checklist sessions shows gaps in preparatory checking of vaccines, client communication and AEFI observation, and (for less than 20%) in safe injection |
Missed opportunities for vaccination Data sources: interview, audit and observation | • Most staff (13/18) stated they would open a multi-dose vial for just one patient | • Due vaccinations had been missed in 3 of 10 Child Health Record books • Reasons for missing vaccination included vaccine out of stock, clinic visit not for purpose of vaccination, or (for birth doses) childbirth in community • Two (of 15) observed patients asked to return another day for vaccination • Thirteen (of 17 respondents) staff stated they would usually ask a sick child to return at another time for vaccination |
Integration of other services Data source: interview and observation | • All staff noted a policy of integrating other care and vaccination • Nine (of 18) staff cited at least one other care (usually childhood illness) regularly integrated • Child illness care available in nine (of 12) clinics • Child illness care accompanied vaccination in seven (of 15) observed patients • Weight measured in all observed patients | • Four (of 18) staff mentioned maternal health service as integration option • Three clinics (of 12) lacked supplies, or service organization, to integrate childhood illness care with vaccination • No observation of catch-up vaccination with children presenting for illness • Three (of 15) patients observed to receive feeding counselling, two to receive vitamin A, 1 to receive albendazole • No observations of maternal preventive care or counselling • Staff reported insufficient numbers as main constraint on integrated care |
Community engagement and family viewpoints Data sources: interview, observation and focus group discussion | • Three (of 12) clinics provided verbal group health education alongside vaccination sessions • Three (of 18) staff reported support (for example food) provided by local communities • No fees for vaccines reported or observed and families did not report fees as barrier to vaccination | • No reported use of community-based trained lay health workers to help with organization, mobilization or education. • Six (of 12) clinics charged small administrative fees • Many families (6/10 groups) cited travel time, and transport costs, as significant constraints on timely attendance for vaccination • Many families (6/10 groups) sought more mobile clinics, more “on-demand” vaccination, and more reliable clinic timing • Some families (4/10 groups) sought more respectful staff-client interactions • No male family members were observed in attendance, staff cited embarrassment as a constraint on male involvement |