Reaching Every Child for Primary Immunization: An Experience from Parsa District, Nepal

This document describes activities and an approach used in the Parsa District of Nepal to involve community leaders and local health workers, volunteers, and organisations in tracking children who had dropped out or not started their basic immunisations, and motivating their caregivers. This strategy included training and ongoing communication within the community, as well as the implementation of a 'drop-out slip' system, that served to remind parents to continue with immunisation programmes.

To link health facilities with the communities they serve, a one-day orientation was organised for Village Development Committees (VDC) which included
elected VDC members, VDC secretaries, health workers, Female Community Health Volunteers (FCHVs), traditional healers, school teachers, social workers, and local non-governmental organisations (NGOs). During the orientation, representatives of different organisations from the community identified the causes of low coverage and high drop-out in their community. Information on the drop-out rate and various other aspects of immunisation is shared by health workers with community leaders, as well as community volunteers, NGOs, schools, social workers and donors. Community health workers and village facilitators (VFs) were trained to monitor children who were never reached (“left out”) and children who had dropped out before receiving all the needed vaccinations. Whenever they see that a child is left out or dropped out, they are instructed to use the drop-out slip, to call that child for vaccination with the help of the FCHV and community mobilisers (CM). In a two-day training session, health workers were introduced to monitoring their own work by using a wall chart that displays the facility’s cumulative monthly drop-out rate.

Bi-monthly review meetings were held with health workers and the members of the community where participants identified strong and weak VDCs and made action plans to reduce the drop-out rate. Messages on immunisation were communicated through local radio, mosques/temples and schools. Six months after the programme began, a district-level workshop meeting reviewed the progress and developed action plans for sustaining the effort.

The document outlines the following as the key achievements and strategies.

• Improved linkage between the community and health system for immunisation - critical linkages between various community organisations and the health facilities were identified and established at VDC and ward level. The improved linkages between the health system and community leaders led to better co-ordination and collaboration reflected in the regular monthly meetings of the village health management committees that discussed the barriers faced by the immunisation programme and how to overcome them.
• Community support for routine immunisation - support was mobilised to strengthen cold chain operations and to support volunteers. Teachers now inform their students about date and place of immunisation sessions in their respective VDCs, while religious leaders announce vaccination sessions from their temples (mosques/mandir) using mikes.
• Improved monitoring and quality of routine data - health facilities monitor their immunisation data using a wall chart. All peripheral level workers know how to calculate drop-out rates. Introduction of several tools improved their understanding of left-out and drop-out, calculation of drop-out and coverage, and identification of weak VDCs. One important tool was the introduction of the EPI register where each infant’s immunisation status is recorded by ward. Drop-out slips are given by FCHVs to parents of children who have dropped out. The drop-out slip is used by the FCHV as an appointment slip to inform the mothers at the household level on the day of immunisation in the area. The organisers reported that during July-September, 2003, 89 % of the drop-out children were informed using drop-out slips, and 42% of them came back and were vaccinated after they had received the drop-out slip. A small booklet containing the date and place of all immunisation sessions was made available to the community and health workers.

According to the report, during the initial phase in four VDCs, drop-out was reduced from 40% to 10%. Subsequently, the approach was introduced in the entire district and a gradual number of VDCs with drop-out rates less than 10% reduced from 45 to 6.