REVIEW AND ACTION PLAN PREPARATION FOR THE IMMUNIZATION PROGRAM

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2 REVIEW AND ACTION PLAN PREPARATION FOR THE IMMUNIZATION PROGRAM Health Managers Modules for Immunization

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4 Health Managers Foreword Modules for Immunization 3 The Universal Immunization Program, launched in 1985 for reducing deaths and disabilities due to vaccine preventable diseases in the country, has received a special impetus through the National Rural Health Mission (NRHM). The strengthening support provided by NRHM includes funds, resources, strategic guidelines and contractual manpower for program management. Since 2005, when the NRHM came into effect, there has been an increasing trend in Immunization coverage and quality. Child Health managers introduced to manage and oversee child health and immunization in select districts of low performing states, as well as other health managers from non-medical background introduced through the NRHM, was found to have an increasing role in the Immunization Program. However they often came with no prior knowledge, experience or skills related to management of the Immunization program. Their roles and therefore their requirement in the program were identified as being a mixture of technical, supervisory and managerial. This set of modules covers many of these aspects, and have been developed for self as well as collective learning by program managers and supervisors. The modules have been compiled from existing literature related to the Immunization program and health management available in India with the Ministry of Health and Family Welfare as well as with UNICEF, WHO, USAID and PATH. The materials have been adapted to meet the requirements at the primary levels of health program management in the country, particularly at the sector, block and district levels. The National Child Health Resource Center (NCHRC) at the National institute of Health and Family Welfare (NIHFW) has worked closely with national trainers in Immunization at the NIHFW and the Immunization officer of United Nations Office for Project Services, Norway India Partnership Initiative (UNOPS-NIPI) in developing these modules. The pilot testing of these modules has been conducted in Orissa, Bihar and Rajasthan involving the district, block and sub block level managers and supervisors along with select state level trainers, and their feedback has been incorporated. UNOPS-NIPI has been instrumental in identifying the need for improving program management at implementation levels as an important step to achieve enhanced program coverage and quality, and have also provided the required support for the development of these modules. We hope that this set of module will prove to be useful in enhancing the capacity of managers and supervisors at implementation levels for improving quality and coverage of lmmunization. Dr. Kaliprasad Pappu Director, UNOPS-NIPI LFA New Delhi Prof. Jayant K. Das Director, National Institute of Health and Family welfare New Delhi

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6 Table Health Managers of Modules Contents for Immunization 5 Abbreviation...7 Objectives & Contents...9 A. Introduction...10 B. Setting program processes, outputs and goals...12 C. Systematic review of the program...14 D. Annual review for next program cycle: developing the budget plan...15 E. Action plan preparation...24 Final Assessment Facilitators Guide References Answers of Module Answers of Module Answers of Module Answers of Module Answers of Module Answers of Module Answers of Module

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8 Health Abbreviation Managers Modules for Immunization 7 AEFI AMC ANM ASHA AVD AWW BCG BEE CDPO CFC CHC CMO CPCB DF DIO DPT GoI HMIS HR HW ICDS IEC ILR JE LHV MDG MOIC NCC NGO NRHM NYK OPV PHC PIP Adverse Events Following Immunization Average Monthly Consumption Auxiliary Nurse Midwife Accredited Social Health Activist Alternate Vaccine Delivery Anganwadi Worker Bacillus Calmette-Guérin Block Extension Educator Child Development Project Office/Officer Chloro Fluoro Carbons Community Health Center Chief Medical Officer Central Pollution Control Board Deep Freezers District Immunization Officers Diphtheria Pertussis Tetanus Vaccine Government of India Health Management Information System Human Resource Health worker Integrated Childhood Development Services Information, Education & Communication Ice-Lined Refrigerator Japanese Encephalitis Lady Health Visitor Millennium Development Goals Medical Officer in Charge National Cadet Corps Non Governmental Organization National Rural Health Mission Nehru Yuva Kendra Oral Polio Vaccine Primary Health Center Program Implementation Plan

9 8 Program Review and Action Plan Preparation POL Pro MIS RCH RI TT UIP UNICEF UNOPS-NIPI USAID VHND VHSC VPD VVM WHO WIC WIF Petrol/diesel/ oil/lubrication Procurement Management Information System Reproductive and Child Health Routine Immunization Tetanus Toxoid Vaccine Universal Immunization Programme United Nations Children's Fund United Nations Office for Project Services Norway India Partnership Initiative United States Agency for International Development Village Health and Nutrition Day Village Health and Sanitation Committee Vaccine Preventable Disease Vaccine Vial Monitor World Health Organization Walk-in cooler Walk-in freezer

10 Health Managers Modules for Immunization 9 Review and Action plan preparation for the Immunization Program Objectives: The objective of this module is to enable managers to: Periodically review the immunization program and initiate corrective measures Coordinate a comprehensive annual review of the program Develop a realistic work plan for the next annual cycle Prepare a program budget for the next annual cycle Contents: A. Introduction B. Setting program processes, outputs and goals C. Reviewing the program periodically to track progress D. Annual review for next program cycle: developing budget plan E. Action plan preparation

11 A. Introduction 10 Program Review and Action Plan Preparation A program manager is like a captain of a ship. The captain determines where he would like to go in the beginning of a journey, keeps track of the course of his ship during the long journey and finally brings the ship to land in the port of destination. Likewise, a program manger needs to have clear processes and outcomes in mind at the very outset of program implementation. During the course of the implementation period, he needs to periodically review his program to see whether it is on track. Finally, at the end of the program period, he should determine whether the outputs and outcomes have been achieved. As you have seen, all health programs depend on several processes to have successful outcomes. Have you thought what are the possible processes, outputs and outcomes of the immunization program? What are the processes that you have identified to achieve your results? What mechanisms do you have in place to measure the processes and the results? We have discussed about activities, indicators, dashboards and monitoring mechanisms in earlier modules: now how would you put all of them together as you chart out the course of the program and the progress onwards to your destination? You may well understand, that all programs go through certain cycles involving different phases of planning, implementation, review and evaluation and back to planning and budgeting again. Often many programs do not improve over several years. The program teams keep making similar plans and keep following similar practices of previous years without making much effort to understand the areas of weaknesses and improving upon them. Unless the teams learn from a careful review and evaluation of the program and take concrete steps to improve them, this cycle of result-less futility will continue

12 Health Managers Modules for Immunization 11 EXERCISE: From the following list of indicators determine which ones are for processes, outputs and outcomes and identify the mechanisms you have to measure them. Percent health workers trained in Immunization Percent sessions held of planned Percent ILR points with no stock outs Sickness rates of cold chain equipment Percent of institutionally delivered Infants administered BCG at birth Percent measles coverage for first dose within one year Percent fully immunized children Number of Polio cases detected in your area Number of measles outbreaks in your area Think about the gaps you have identified in the immunization program implementation of the previous year and list out the steps and the measures you will undertake to improve them.

13 B. Setting program processes, 12 Program Review and Action Plan Preparation outputs and goals All programs are initiated with a final goal in mind. However, for goals to be achieved, careful planning and implementation are needed. It is important, therefore both to understand what the final goal (outcome to be achieved is) and the steps through which to achieve it. One simple way for a program manager to chart his course is to look at the different components that would take to make a program successful. He could further look at various critical tasks and activities within these components that are weak and need strengthening. For measuring the resultant goal as well as the progressive trends and achievements, systems need to be in place to measure and monitor. These could either be a continuous monitoring and surveillance systems or periodic assessments and evaluations. Planning Implementation Outputs and outcomes Systems for Measurement of progress and final achievement For the immunization program in your area, you need to be able to define the outputs and outcomes, the program components with critical task and activities and the systems for measurement that all need planning and budgeting for. Goal Outcome Output Reduction in under-five childhood mortality through reduction of deaths related to vaccine preventable diseases. Reduction in incidence of vaccine preventable diseases Full and timely vaccination of all children under five years with vaccines as per Universal Immunization Program schedule.

14 Health Managers Modules for Immunization 13 As an effective program manager, you must be able to have a firm grip on the processes to keep them on track. You should be able to identify the critical processes needed to reach your program goal and know how to ensure that they are comfortably progressing. You are much like the charioteer on a race track and the program processes are your horses! Do you think you can win the race if one of the horses gets out of your control? What are the program processes in your hand to make the immunization program successful? What are the resources at your disposal to make the changes necessary? What are the guidelines you need to follow so that you can ensure quality (and are not disqualified from the race)? From the modules that you have been reading you may be able to categorize the processes. Along with that you would also have to define indicators to measure your progress and success in each of these categories. Micro planning Cold chain and vaccine logistics Human resources and capacity building Supervision and monitoring Data for action and review meetings Social mobilization and demand generation Program review and planning % of village, hamlets, residential areas covered in micro plan % left out beneficiaries % sessions held monthly of sessions planned % sickness rates of equipment, response time, down time % cold chain points with stock outs, freezing of T series vaccines, unusable stage of VVM used in field % session sites with all vaccines and logistics available % areas with identified mobilizer % Health sub centers with two health workers or more % health workers, supervisors, cold chain handlers and medical officers trained in immunization % sessions supervised % health sub-centers with immunization monitoring chart updated % monthly reports received in time % coverage for all antigens % full immunization coverage % DPT1-DPT3 drop out rate % attendance in review meetings of expected % ASHAs with due lists prepared before session % VHSC meetings held and % attendance of expected members % drop out beneficiaries counseled by VHSC members Whether quarterly review conducted or not Whether PIP prepared for next year Whether UC and SOE prepared and submitted timely

15 14 C. Program Systematic Review and Action Plan Preparation review of the program To undertake a systematic review of the program, the health manager would have to get relevant data and review team together. This should be supported by appropriate discussions with various stakeholder groups and would aim at drawing out a plan of action for the following year. Remember to look at various process and program-wise progress and to identify successes and failures. In case of successes, reflect on how it was achieved. In case of failures, find out the reasons and bottlenecks. Ideal reviews should take place at least quarterly to track progress and make mid-course corrections; however the year end review would also have budgetary implications when the financial aspect of program management must also be kept in mind. Data sources: Monthly coverage data from HMIS and analysis Supervisory findings Records: stock records, temperature records, meeting minute s records, letters and circulars, registers from the field Tracking data such as parent child /mother newborn tracking data, list of missed children Reports of outbreaks, VPD cases and AEFI Maps Data related to any evaluations, assessments and surveys conducted Books of accounts including FMR-wise statement of expenditure. Get your review team together The team leader: Medical officer in charge; to make key decisions Program manager, accountant, data person: to assess program progress and suggest program improvements and changes Supervisors: to evaluate feasibility of field implementation of new suggestions and point out bottlenecks and deficiencies in previous strategies Point person: to put all discussions, decisions and final paper-work together Have discussions with key stakeholder groups Health workers VHSCs ASHAs ICDS workers /supervisors/officers Public representatives Based on the inputs of the discussion make list and prioritize the activities to be undertaken in the following year to improve the program coverage and quality.

16 D. Annual review for Health next Managers Modules program for Immunization 15 cycle: developing the budget plan A well structured framework exists for preparing the Program implementation plan for the Universal Immunization program within the NRHM PIP. This is called the part C of the PIP which contains the following sections which have to be prepared and submitted by January end each year. The framework of the PIP is prepared for the state level. However, in this module the same formats with suitable modification for district and state level are presented for use by the program managers in these levels. 1. Situation analysis of the Immunization Program (called C1 in PIP) (Each block and district can provide a brief write-up covering all the following issues; this in turn may be used for the larger state PIP) 1. Current scenario of implementation of immunization program a. District level coverage as per District Level Household Survey-3, Coverage Evaluation Survey 2009 & Reported coverage for previous and current financial year *(*till December is acceptable). b. District wise coverage levels of all antigens for previous and current financial year* (Including Hepatitis B & JE wherever applicable). c. Reasons for Shortfall in coverage d. Reporting and incidence of VPDs for current financial year* e. Reporting and Response to Outbreaks and AEFIs for current financial year*. 2. Strategies for further improving Routine Immunization a. What is the target of immunization coverage for this year? b. To improve the accessibility of routine immunization services (reflected by BCG and DPT-1 coverage); identify the districts with poor access and reasons thereof. c. To reduce dropouts (reflected by DPT3 coverage); reasons for dropout and specify steps taken for this. d. To create community demand for routine immunization; (write specific steps taken) e. Any other innovation started for strengthening of routine immunization. 3. Status of micro planning- Number of subunits (e.g. HSC for PHC and Block and blocks for district) where RI micro-plans have been updated in last financial year (Provide details in the format enclosed). 4. What are the roles & responsibilities, pertaining to immunization, of 1st ANM, 2nd ANM, and HW (Male)? 5. What is the mechanism of coordination & convergence between AWW and ASHA? 6. Alternate Vaccine Delivery System- what system is in place, whether it is working and what are issues faced?

17 16 Program Review and Action Plan Preparation 7. Supervision and Monitoring-Status of Routine Immunization cell, Supportive Supervision Structure in field, Review meetings and data analysis and action taken at all levels etc). 8. Status of use of immunization data for monitoring and action 9. Co-ordination with Partners (ICDS, Public Private Partnerships, Other agencies). 10. Component-wise receipt & expenditure of funds received (format attached). 11. Status of Cold Chain Equipment i) ILRs, DF, Voltage stabilizers a) Plan for replacement of all condemned or non service able equipment which is beyond repair. b) Expansion: Need based depending on the setting up of New PHC/ cold chain points. c) All CFC equipments supplied till 1992 has been replaced with Non CFC equipment. The expansion plan should include replacement of remaining CFC equipments supplied during the period of ii.) Cold boxes, Vaccine carriers - replacement plan for expansion or replacement of condemn equipment. iv.) Mechanism for cold chain maintenance and repairs- HR structure, AMC (if any) etc. 12. Status of implementation of Procurement Management Information System (ProMIS). 13. IEC plan for strengthening UIP; however the budget for IEC is to be provisioned under RCH. 14. Infrastructural and manpower requirements that are essential for implementation of UIP (# to be budgeted in Part B under additionalities) 15. Additional support required to improve Routine Immunization; for any specific need please provide a separate write-up on objective, strategy, expected output and budgetary basis for the activities.

18 Health Managers Modules for Immunization Reporting and Planning template for PIP The following tables are also derived from the PIP templates and would help the program manager in preparing for the final year end Program Implementation plan. The template and norms may change from year to year and planners are advised to refer to the relevant years direction form Govt. of India, Ministry of Health and Family Welfare. Table 1: Estimated beneficiary targets for Immunization: S.No Beneficiaries Target 1 Pregnant women 2 0 to 1 yr infants yr yr 5 5 yr 6 10 yr 7 16 yr Table 2: Details from Micro plans previous year current year next year The following information is to be filled based on the RI micro-plans. Please provide the details of held sessions for previous and current years, while for next year the number of planned sessions is to be provided: S. No. Routine Immunization Sessions previous year current year next year 1 Total Sessions planned 2 Total Sessions Held 3 No. of Outreach Sessions 4 No. of Fixed site sessions 5 No. of Sessions in Urban Areas 6 No. of Sessions in Rural Areas 7 No. of sessions in hard to reach areas 8 No. of sessions with hired vaccinators 9 No. of hired vaccinators 10 No. of villages where sessions are held monthly 11 No. of villages (smaller) where sessions are held on alternate months 12 No. of villages where sessions are held quarterly

19 18 Program Review and Action Plan Preparation Table 3: Logistics details Sl No Item Stock (functional) as on 31st current year 1 Cold Chain Equipments - a) WIC b) WIF c) ILR d) DF e) Cold Boxes f) Vaccine Carrier g) Ice Pack h) Vaccine Van 2 Vaccine stock and requirement (including 25% wastage and 25% buffer) a) TT b) BCG c) OPV d) DPT* e) Measles f) Hep B g) JE (Routine) 3) Syringes including wastage of 10% and 25 % buffer a) 0.1 ml b) 0.5 ml c) Reconstitution Syringes 4 Hub Cutters Requirement previous year current year next year Remarks *Note: DPT is to be given instead of DT at 5 yrs once the current stock of DT Vaccine is exhausted Service Delivery: Mobility support for supervision Supervisory visits by state and district level officers for monitoring and supervision of RI Cold Chain maintenance Focus on slum & underserved areas in urban areas NORMS ARE FIXED ON ANNUAL BASIS BY THE GOVT OF INDIA. THEY MAY VARY FROM YEAR-TO-YEAR AND FROM STATE-TO -STATE. Rs 50,000 per District for district level officers (this includes POL and maintenance)per year By state level Rs.100,000 /year Rs 500 per PHC/CHC per year Hiring an for four sessions/month/slum of population slum of i.e. total expense of Rs. 1400/- per month per slum of population. Expenditure Expenditure & Achievement Previous year Current year (till 31st Dec) Next year Achievement Expenditure Achievement Target No of sessions No of districts visited for RI review % Funds used No of sessions with hired vaccinators No of sessions No of districts visited for RI review Funds requirement No of sessions No of districts visited for RI review % Funds used % Funds used No of sessions with hired vaccinators No of sessions with hired vaccinators

20 Health Managers Modules for Immunization 19 Mobilization of children through ASHA/ mobilizers Alternative Vaccine Delivery: Rs 150/session (for all Geographically hard to reach areas (eg. Session site>30 kms from vaccine delivery point, river crossing Rs 100 per RI session No. of sessions with ASHA No of C.A. in position No. of sessions with ASHA No of C.A. in position No. of sessions with ASHA No of C.A. in position NE States and Hilly per RI session For RI session in other Rs.50 per session. Support for Computer Assistant for RI reporting (with annual increment of (with annual increment of 10% w.e.f. from ) 12,000-15,000 p.m. Rs ,000 p.m No of C.A. in position No of C.A. in position No of C.A. in position Printing and dissemination of immunization cards, tally sheets, monitoring forms, etc. Rs 5 per beneficiary Review Meetings Support for Quarterly State level Review Meetings of district Rs 1250/ participant/day for 3 persons (CMO/DIO/Dist Cold Chain Officer) No of meetings held No of meetings held No of meetings held Quarterly Review & feedback meeting for exclusive for RI at district level with one Block MO.s, ICDS CDPO and other Rs 100/- per participant for meeting expenses (lunch, organizational expenses) Quarterly review meeting exclusive for RI at Block 50/-pp as honorarium for ASHAs (travel) and Rs 25 per person at the disposal of MO-I/C for meeting expenses (refreshments, stationery and misc. expenses)

21 20 Program Review and Action Plan Preparation Service Delivery: - Norms* Expenditure & Achievement Trainings District level orientation training for 2 days ANM, Multi Purpose Health Worker (Male), LHV, Health Assistant (Male / Female), Nurse Mid Wives, BEEs & other specialist (as per RCH norms) Three day training of Medical Officers on RI using revised MO training module One day refresher training of District RI Computer Assistants on RIMS/HMIS and Immunization formats under NRHM Two days cold chain handlers training for block level cold chain handlers by State and District Cold Chain Officers and DIO for a batch of trainees and three trainers. One day Training of block level data handlers by DIO and District Cold chain Officer to train about the reporting formats of Immunization and NRHM Microplanning To develop subcenter and PHC microplans using bottom up planning with participation of ANM, ASHA, AWW POL for vaccine delivery from State to District and from district to PHC/CHCs As per revised norms for trainings under RCH As per revised norms for trainings under RCH Rs 100/- per subcentre (meeting at block level, logistic) Expenditure Previous year Current year (till 31st Dec) Next year Achievement Expenditure Achievement Target No of persons trained No.of Districts have updated microplans this year No of persons trained No.of Districts have updated microplans this year Funds requirement No of persons trained No.of Districts have updated microplans this year For consolidation of microplan at PHC/CHC Rs 1000/- block & at district Rs 2000/- per district Rs100,000/ district/year % Funds used % Funds used % Funds used

22 Health Managers Modules for Immunization 21 Consumables for computer including provision for internet access for RIMS Injection Safety Red/Black Plastic bags etc Bleach/Hypochlorite solution Twin bucket Any State Specific Need with justification (Please provide a separate write-up on objective, strategy, expected output and outcomes, basis for cost estimates etc.) Rs 400/ - month/ district Rs 2/bags/session % Funds used % Funds used % Funds used Rs 500 per PHC/CHC per year Rs 500 per PHC/CHC per year 10 % of total amount of approved PIP Table 5: Coverage data % Funds used % Funds used % Funds used S. No Name of Subunit Yearly Target ( ) BCG Coverage (in Numbers) OPV - 1st Dose Coverage (in Numbers) OPV - 3rd Dose Coverage (in Numbers) DPT - 1st Dose Coverage (in Numbers) DPT - 3rd Dose Coverage (in Numbers) Infants Pregnant women Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) TOTAL S. No Name of Subunit Measles Coverage (in Numbers) TT2 Booster Dose Coverage (in Numbers) Hepatitis B Birth dose Coverage Hep B- 1st Dose Coverage (in Numbers) Hep B - 3rd Dose Coverage (in Numbers) JE Routine Dose Coverage (in Numbers) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) Previous Yr Current Yr (till Dec 31st) TOTAL

23 22 Program Review and Action Plan Preparation Table 6. Vaccine Preventable diseases S. No Name of Subunit Diphtheria Whooping Cough Neonatal Tetanus Tetanus(Other) Measles Polio AES Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths I. Budgeting for Supplementary Immunization rounds and new vaccines Apart from the budget and other planning and reporting templates for the Universal Immunization Program, Part C of The NRHM PIP is also the correct place to plan for other immunization activities such as Pulse Polio rounds, Supplementary vaccination drives for Japanese Encephalitis and Measles catch up rounds. In states where newer vaccines have been introduced, budget for conducting workshops as well as any additional operational costs should be included in Part C of the PIP. Additional templates needed for these are usually available in the operational guidelines of these special activities which may be used for planning and reporting purposes. II. Other budgetary provisions in NRHM PIP The Universal Immunization Program should not be taken as a stand-alone vertical program within the NRHM although a special provision has been made in a separate section of The Part C of the NRHM PIP to budget for certain operational aspects of the program. Certain items like procurement of vaccines and cold chain equipment need not be budgeted by the states as these are procured and supplied by the Government of India centrally. Other expenditure like salaries of contractual staff, infrastructure related costs, IEC and even running costs of program management units are common to all program and are budgeted elsewhere (often in Part B). These need not be separately budgeted for the immunization program, but care must be taken to ensure that any immunization related expenses (such as special IEC material for immunization) must be included while making the overall program budget. Occasionally special needs such as refurbishment of cold chain rooms or hiring of ware houses for vaccines during supplementary drives need also to be budgeted within the infrastructure costs. The need special mention and explanation as to why they are critically needed. III. Funds and resources from other sources. As a manager of child health programs you should also keep in mind that there could be several resources that could be tapped to improve the immunization program. This may not be from the regular NRHM funds. You could consider other stakeholders and partners, who could possibly commit their resources, expertise, funds and manpower towards improving the quality and coverage of health programs in general and the immunization program of your area more specifically. The following stakeholders are suggested to you who may be of help to the program. a. The ICDS scheme b. The local panchayat raj institutions and peoples representatives

24 Health Managers Modules for Immunization 23 c. The department of education d. Development partners like UNICEF, WHO, PATH, CARE, USAID, UNOPS-NIPI. e. Local NGOs f. Self help groups. g. Philanthropists h. Boy scouts and girl guides, National Cadet Corps, Nehru Yuva Kendras. Some examples of help from other stakeholders are as follows: The Anganwadi workers from the ICDS scheme have often helped the immunization program as mobilizers. They have helped in conducting survey of beneficiaries, maintaining tracking line-lists of beneficiaries and mobilizing beneficiaries in VHND and outreach immunization sessions. The Anganwadi Kendras of ICDS are also suitable locations to hold immunization sessions. Supervisors and officers of the ICDS scheme can help in supervising vaccination sessions and VHNDs. Local elected representatives have helped in addressing village health and sanitation meetings, counseling drop-out beneficiaries and sometimes giving their vehicles like tractors and boats to transport vaccines and health workers in difficult conditions and terrain. Primary schools have sometimes been used as vaccination centers and teachers have helped in raising health, nutrition and sanitation related awareness. International Development partners have helped the immunization program in several ways: UNICEF has provided cold chain equipment; others have helped in program improvement through technical support, material and manpower. Local NGOs, NCC, NYK, Self help groups have helped in raising awareness and mobilization of beneficiaries. A meeting of stakeholder before the next financial year would help in understanding the type of commitments other partners would like to make. If clear cut and much required commitments are clearly expressed then it would be good to document the expected resources from external sources within the overall budget.

25 24 Program E. Action Review and Action plan Plan Preparation preparation 1. Looking at the bigger picture: The manager while beginning with the preparation of work plan preparation would need to look at the larger picture of maternal and child health programs. While the Universal Immunization program would be going on in his area for several years, if not decades, he would also have to see how it fits with newer program packages which have been recently introduced. Newer programs related to child and maternal health such as the Janani Surksha Karyakram, the Janani Suraksha Yojana, setting up of facility based maternal and child health centers, Integrated management of newborn and child hood diseases, safe delivery packages and other community based activities like home based newborn care and antenatal care would also need the managers attention. Overseeing other on-going activities like payment of incentives to ASHAs and salaries to contractual workers, regular reporting through HMIS and maternal newborn tracking, organizing review meetings as well as any infrastructure renovations and building activities would be part of the health managers responsibilities. Exercise: list all health programs and activities you are involved in and break them up into percentage as per the time you devote to each of them. Do they correspond to the impact the activities have on saving lives and disabilities? How much do you think the time spent in your work relate to MDG 4 and 5 goals? All these activities need prioritization and planning for. The example of the Immunization planning is used in the following sections but can be generalized for other activities as well. 2. Reviewing status of coverage and quality: With the existing data and information derived from coverage reports, supervisory and monitoring findings, external surveys and assessments if any, the manager would have to ascertain the possible level of vaccination coverage for vaccines and the full immunization status of his area. These have been dealt in earlier modules. The final (probable) status would help in determining how future strategies are chalked out. Some examples are: a. Full Immunization coverage: over 80% b. Full Immunization coverage between 60-80% c. Full Immunization coverage between 40-59% d. Full immunization coverage less than 40% The strategy and attention needed at each of these levels would differ. While higher coverage would indicate maintaining and consolidating the gains, lower coverage would mean that considerable more amount of planning, management, time and effort would be needed to accelerate coverage. Supervisory visits and review meetings may also reveal qualitative findings. Some examples are: a. Need for further capacity building of health staff on safe injection techniques b. Need to change systems for alternate vaccine delivery as more than 80% health workers are carrying their vaccines to the session sites. c. Need for additional equipment and proper stock management

26 Health Managers Modules for Immunization 25 d. Special drives in hard to reach areas e. Initiation of outreach activity in new peri-urban areas f. Chronic absenteeism of certain staff Exercise: From monitoring reports and minutes of review meetings enlist problems and mark the number of times similar problems have been reported from the field. Then rearrange the problems based on maximum to minimum number of times the problem type has been reported. 3. Work prioritization (left out, drop out) Another way of looking at the coverage data is to see the left out and drop out levels. The program manager would need to determine which of these, is a greater priority for program planning in immunization vis-à-vis the current level of coverage. The main problem may vary from place to place and the program manager needs to understand where his problems lie. Based on coverage rates of various antigens and computation of left out and drop-out rates a fair idea of the problems may be arrived at. High left out rates (>20%) would indicate that there are problems of access and there may still be areas where immunization program needs to reach. High drop-out rates (>10%) would mean beneficiaries are not returning for successive doses and may involve quality issues. Coverage (DPT1) High (80%) Low (<80%) Access or Utilization Problem Dropout Rates (DPT1-DPT3) Low (10%) High (>10%) A. Good access B. Good access Good utilization Poor utilization C. Poor access D. Poor access Good utilization Poor utilization Exercise: For each subunit of your area and then for your total area calculate the left out and dropout rates. Prioritize areas according to high drop-out and left out status. You can place them in boxes A, B, C and D above. Determine why some areas have more problems than others. 4. Determining causes of poor coverage and quality What can be seen with the relevant data as an issue of low coverage may in fact be the result of several activities which a poorly undertaken. The adjacent figure shows an iceberg where the visible problem of low coverage may actually have other invisible problems like training, stock control, equipment maintenance, manpower issues and reporting issues contributing to it!. The health manager therefore also needs to have relevant data of program activities such as % of health workers trained % of villages with Outreach immunization planned % of Cold chain points having above buffer stock levels for all antigens Sickness rates of equipments according to cold chain points Regularity and correctness of HMIS data.

27 26 Program Review and Action Plan Preparation When these program progress indicators are also considered, the manager gets closer to the activities that need strengthening to improve overall coverage and quality. Exercise: The fishbone and 5 whys technique can be used to determine root causes. The root cause analysis helps us to see beneath the surface and understand the causes of the problem or obstacle. The procedure is much like arriving at a medical diagnosis. We need to explain why to understand the disease behind the external symptoms. Draw on a flip chart or paper a picture of a tree, showing its roots. On each root, much like a fish-bone put the labels service providers, beneficiaries, materials, management. For each root (fish bone) ask why up to five times. The last why would often give you the root cause to the problem! Why? Why? Why? Why? Why? Why? Why? Why? Why? Why? Poor management Poor service delivery Poor coverage Poor Material supply Poor Demand generation Why? Why? Why? Why? Why? Why? Why? Why? Why? Why? An Example is given below Poor coverage Poor Material supply Why? Irregular vaccine supply Why? No stock at district level Why? Indent sent late to state Why? Poor stock register maintained Why? New Logistics manager at district, needs training 5. Prioritizing activities to improve coverage and quality At a district or block level, a manager usually has to ensure the implementation of all the activities as determined at the state and national levels. This is also true for the immunization program where the manager has to ensure that all components listed out in Part C are carried out. However, the amount of effort and time to be given on each activity can be decided at the implementation levels. These may be put in direct relationship to the weak areas that the manager has diagnosed and determined earlier. E.g. If health workers poor injection skills are leading to high drop-out rates then extra effort should be undertaken to improve the quality and coverage of these trainings. Again, if some areas in the block and districts have no outreach sessions organized leading to high left out, a detailed micro planning exercise could help.

28 Health Managers Modules for Immunization 27 Example: A prioritization matrix like the one below may be used to determine which activities need more intensification; Objective: decrease drop out in Block A from 25 % to 5% Priority activities Criteria Rank from 1 to 4 Time to implement 1. Train health workers on safe injection practices 2. Train ASHAs for effective mobilization 3. Ensure effective tracking mechanisms 4. Address VHSC meetings 1= most time 4= least time Availability of resources 1=least available 4= most available Potential for decreasing dropout in long term 1= least potential 4=most potential Total The points above are to be given based on experience of a group of managers (the management team at one place) and not on actual calculations. For each of the activities 1-4 the managers prioritize the activities from 1 to 4 as given in the criteria column. The activity with the highest marks would suggest that it should be given the highest priority. The other activities would follow in order of priority from most marks to the least. 6. Defining deliverables: Success criteria For each activity to be undertaken to improve immunization quality and coverage, it would be useful to determine the result that is sought concerning the activity at the end of the implementation year. These should be determined at the beginning of the year and the progress measured on a monthly or quarterly basis. Like all good indicators they should follow the SMART criteria. That is S: Specific M: Measurable A: Achievable R: Realistic T: Time bound

29 Facilitators Guide 28 Program Review and Action Plan Preparation Some examples are as follows: Activity Indicator Level at beginning of year Level hoped to be achieved Health workers training % health workers trained 25% 95% in GoI Immunization handbook for health workers Improve supervision % outreach session sites supervised and checklists submitted 2% 20% Improve alternate vaccine delivery Improve safe injection practices % outreach sessions with vaccines delivered by alternate mechanisms % sessions with hub cutters used to dispose sharps 10% 95% 15% 95% 7. Making specific person responsible for each activity Each activity will be undertaken only if a specific person is held accountable for it. This will include identifying one person to do the task or activity and another person to supervise it. A two tier accountability should be put in place at the beginning of the year itself. This will help someone be responsible for the success or failure of the activity itself. e.g. Activity/task Person responsible Person supervising Checking of twice daily Cold chain handler Block Program manager temperature of ILR and Deep Freezer Preparation of due lists prior to sessions ASHA Health worker 8. Gantt chart with quarter wise progress A work plan with outputs defined, activities listed along with timelines and persons responsible would be useful for a manager. The type of format where activities and tasks are marked along a timeline is called a Gantt chart. The sample given below may be followed once activities, timelines and persons responsible to improve the immunization program are identified.

30 Health Managers Modules for Immunization 29 District.XXXXX Block level sample Workplan for Immunization Program Block.YYYYY Expected Outcome: Improve Full Immunization coverage to >90% Activity Timeframe (in months) Activity 1: Microplan review and revision Health sub-center and PHC micro plans reviewed and revised with participation of Health worker, ASHA, AWW Activity 2: Cold chain and logistics management All cold chain points maintaining stock of all vaccines and diluents above buffer levels All ILR and DF functional with twice daily temperature recording Outreach Sessions sites where logistics delivered through Alternate Vaccine Delivery Safety pits constructed and functional at each PHC Functional hubcutters, red and black bags available Twin buckets and disinfectants procured and available Immunization waste materials disinfected and disposed as per CPCB guidelines Activity 3: Social Mobilization ASHAs preparing due-lists before every sessions and mobilizing the beneficiaries Activity 4: Supervision and monitoring? % of HSC and PHC microplans reviewed, revised and submitted to block???? % ILR points with stock outs observed during supervision???? % Cold chain equipment functional???? % of outreach sessions with AVD mechanism???? % of PHCs with safety pit constructed and functional???? % of HWs with hub cutter, red and black bags functional???? % of PHCs with twin buckets and discinfectants used??? % of PHCs with Immunization wastes disposed as per guidelines???? % of sessions supervised where ASHA has prepared due-lists Indicator Baseline yr Person Responsible 0 100% Block Program Manager 40% 100% Cold chain handler 80% 0 Cold chain handler 10% 100% Block Program Manager 20% 90% Block Program Manager 20% 100% Block Program Manager 20% 100% Block Program Manager 0% 100% Block Program Manager 30% 90% All Supervisors

31 30 Program Review and Action Plan Preparation Each health worker is supervised once a quarter during session day Review meetings held at village, PHC and block Activity 5: Trainings related to immunization Health workers training as par Gol handbook Medical officers trainings as per GoI handbook Cold chain handlers trainings as per GoI handbook ASHAs training in Immunization???? % of health worker supervised each quarter???? % of meetings held as per plan??? % health workers trained??? % Medical officers trained??? % Ciold chain handlers trained??? % ASHAs trained 60% 100% All Supervisors 70% 100% Medical officer 50% 80% Medical officer 25% 75% Medical officer 20% 100% Medical officer 0% 100% Medical officer

32 Final Assessment Health Managers Modules for Immunization Reduction in incidence of vaccine preventable diseases is a a) Output b) Goal c) Impact d) Outcome 2. Percentage ILR points with no stock outs is a a) Process b) Output c) Outcome d) Impact 3. Percentage of health workers, supervisors, cold chain handlers and medical officers trained in immunization is an indicator of a) Cold chain and vaccine logistics b) Supervision and monitoring c) Human resources and capacity building d) Social mobilization and demand generation 4. The Program Implementation Plan and Budget preparation is made during the a) Quarterly review b) Annual Review c) Six-monthly review d) Monthly review 5. Which indicator is used to measure the progress of social mobilization and demand generation? a) % ASHAs with due lists prepared before session b) % sessions held monthly of sessions planned c) % coverage for all antigens d) % health sub-centres with immunization monitoring chart updated 6. The village Sitapur has full immunization coverage of less than 40%. As a manager, your focus would be on a) Focus only on finding incompetent persons and punishing them b) Focus only on ensuring better monitoring of on-going activities c) Focus only on repeated meetings d) Focus on substantial amount of planning, management, time and effort to accelerate coverage

33 32 Program Review and Action Plan Preparation 7. Percentage sickness rates of equipment, response time, down time is an indicator of a) Micro planning b) Cold chain and vaccine logistics c) Supervision and monitoring d) All of the above 8. Which all factors can contribute to low immunization coverage? a) Inappropriate health workers training b) Lack of equipment maintenance c) Improper reporting issues d) Disorganized stock control e) All of the above 9. Full and timely vaccination of all children under five years with vaccines as per Universal Immunization Program Schedule is a a) Impact b) Output c) Outcome d) Process 10. The root-cause analysis helps us to a) See beneath the surface and understand the causes of the problem or obstacle b) Analyze relevant data as an issue of high immunization coverage c) Analyze the need for additional equipment and proper stock management d) None of the above 11. What is the difference between high left out rate and high drop-out rate? a) High left out rate would mean that there are problems with utilization of services while high drop-out rate would mean that there are problems of access b) High drop-out rate would mean that there are problems with both access and utilization of services while high left out rate would mean lack of availability of vaccines c) High left out rate would indicate that there are problems of access and there may still be areas where immunization program needs to reach while high drop-out rate would mean beneficiaries are not returning for successive doses i.e. poor utilization d) High drop-out rate would indicate lack of availability of vaccines at the session sites while high left out rate would mean under utilization of vaccines

34 Health Managers Modules for Immunization While determining the progress of immunization coverage and quality, at the beginning of the year and on a monthly and quarterly basis, the indicators should follow SMART criteria. In this SMART is a) S Safe; M Managerial; A Accountable; R Responsible; T Timely b) S Specific; M Measurable; A Achievable; R Realistic; T Time Bound c) S Supervision; M Monitoring; A Activity; R Reviewing; T Tracking d) S Service; M Micro planning; A Alternative; R Resources; T Target 13. What is a Gantt chart? a) An additional template used for listing expenditures like salaries of contractual staff, infrastructure related costs, IEC and others b) A format to record data such as parent child / mother newborn tracking data, list of missed children c) A format to book all accounts related issues including FMR-wise statement of expenditure d) A format where all activities and tasks are marked along a time line 14. In order to develop a budget plan for next program cycle, what all sections should be prepared and submitted? a) Reporting and planning templates for PIP b) Budgeting for supplementary immunization rounds and new vaccines c) Funds and resources from other sources d) Situation analysis of the immunization program e) All of the above 15. The 5 Ws technique is used to determine root causes of the problem or obstacle of poor immunization coverage or quality. What is W symbolizing for in above statement? a) What b) When c) Why d) Where e) None of the above

35 Facilitators Guide 34 Program Review and Action Plan Preparation Section Method (time) Tool A. Introduction Module reading and exercise that follows (15 minutes) Module and following exercise B. Setting program outcomes, outputs and goals C. Systematic review of Program Module reading and discussion by groups (15 mins) Module Module reading and discussion by groups (15 mins) Module D. Developing Budget plan E. Developing action plan Explanation of NRHM PIP and understanding Part C preparation in detail through discussion of formats. The actual; preparation of PIP would be done at the end of the year and not during the training (15 minutes) Module reading (15 minutes) Group wise exercise on making action plan, where each group has to come up with a gannt chart as shown in the final figure Group1: Micro plan including special areas plans and trainings Group 2: Logistics and Cold chain management Group 3: Supervision and monitoring (including review meetings and use of data for action) Group 4: Social Mobilization (1hr 15 mins) Module and PIP templates Module and group works