NUTRITION BULLETIN. Ways to improve Vitamin A Capsule Distribution in Cambodia HELEN KELLER INTERNATIONAL. Vol. 2, Issue 5 April 2001

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1 C A M B O D I A HELEN KELLER INTERNATIONAL Vol. 2, Issue 5 April 2001 NUTRITION BULLETIN Ways to improve Vitamin A Capsule Distribution in Cambodia Vitamin A capsule (VAC) distribution programs are considered to be one of the most cost-effective health interventions to increase child survival. In Cambodia, VAC distribution for children aged 6-59 months is integrated with immunization outreach. Helen Keller International s National Micronutrient Survey 2000 found that VAC coverage per province ranged from 10-55% while measles immunization coverage ranged from 25-90%. Based on an assessment of the National Vitamin A Program, it is concluded that immunization outreach is the preferred channel for VAC distribution in Cambodia because it is one of the very few programs that is designed to reach all communities throughout the country on a regular basis and because of the relationship found between VAC and immunization coverage rates. However, both VAC distribution as well as demand for VAC have to be improved in order to reduce the difference between VAC and immunization coverage rates, and the performance of the health care system in general has to be improved in order to increase coverage of immunization as well as VAC. From July to August 2000, Helen Keller International (HKI) Cambodia conducted a National Vitamin A Program Assessment in a subgroup of provinces representative for rural Cambodia and in Phnom Penh. In order to get a good picture of how VAC distribution occurs in the field, interviews were held at all different levels of the health care system, with staff from Health Centers (HCs), Operational Districts (ODs) and Provincial Health Departments (PHDs), different government departments at the national level, partner agencies, and with NGOs involved in vitamin A programming. Health facilities were selected in the same provinces as where the National Micronutrient Survey was conducted and selection was such that a wide range of possible performance would be included. Specific information was collected on VAC supply and distribution systems, health worker training and supervision, program personnel, reporting and monitoring systems, and social marketing strategies. The National Vitamin A Program was initiated in 1994, and in 1995, the Royal Government of Cambodia (RCG) linked vitamin A capsule distribution with National Immunization Days (NIDs). Then, in 1998, when NIDs were being phased out, Cambodia started to integrate VAC distribution with routine immunization outreach of the National Immunization Program (NIP, previously called EPI: Expanded Program for Immunization), and through special supplemental campaigns, such as sub NIDs, and measles outbreak responses. Initially, VAC were distributed 3 times per year, but in 2000 this was changed to biannual mass distribution in March and November. Currently, VAC distribution is coordinated by The Cambodia Nutrition Bulletin is published by Helen Keller International Cambodia

2 the Nutrition Unit and the NIP of the MOH. Health center staff conduct the VAC distribution. In some areas, NGOs also play an important role by facilitating outreach activities (such as providing money for transport). Immunization outreach is considered to be a good mechanism for VAC distribution, because VAC coverage and measles immunization coverage correlated well (see Figure 1). However, in all provinces, measles immunization coverage was higher than VAC coverage, which could be explained by the following. Firstly, there were more opportunities per year to contact children for immunization outreach (4 to 12 times per year, depending on the health center) and they should receive the measles immunization at any time between the ages of 9-23 months, while VAC distribution only occurred during a particular month (twice per year). Thus, a child aged months would have had a 3-5 month period during which s/he could have received the measles immunization, while for VAC receipt the opportunity only exists during a particular month. In addition, there appears to be confusion about roles and responsibilities of health center staff regarding VAC distribution (see below). The National Vitamin A Program Assessment was designed to identify constraints of VAC distribution. Its results are described below, followed by recommendations for improvement. Methods The National Vitamin A Program Assessment was conducted from July - August 2000 in a subgroup of 12 of Cambodia s 24 provinces that were selected by stratified sampling in order to be representative for rural Cambodia, and in Phnom Penh. In each province, the Provincial Health Department (PHD), 2 Operational District hospitals (ODs) and 4 Health Centers (HCs) were selected for semi-structured interviews with 1 or 2 staff members each. In-depth interviews were conducted with 1 or 2 NGOs working with the Vitamin A program in these provinces, and with staff of different units of the Ministry of Health and UN organizations involved in the Vitamin A Program. Question guides were developed in English, and translated into Khmer for interviews at PHD, OD and HC level. Interviews with representatives of the government, UN agencies and NGOs were conducted by HKI-staff at the interviewee s work place or at the HKI office, and recorded in English. Interviews at the PHD, OD, and HC levels were conducted by HKI-staff and interviewers hired from different government departments. Interviews were held in the field and answers were recorded in Khmer. After data collection, answers of interviews at the PHD, OD and HC level were tabulated by topic, and then translated into English. All interviews (n=195) were analyzed by level of the health care system. Figure 1. Coverage of VAC distribution among children aged 6-59 mo in Mar 2000 and of measles immunization among children aged mo at the time of interview in Apr-Aug 2000, by province. Bars indicate 95% confidence intervals corrected for design effect. 2

3 Components critical for the success of the VAC program The main factors contributing to low VAC coverage were shown in the diagram in Cambodia Nutrition Bulletin Vol. 2, Iss. 3, December Here, we will discuss problems and solutions for components of the VAC distribution system: aspects of the delivery system, demand from the target population, and the health care system in general. It is important to note that at the time of conducting the assessment the immunization program was being reorganized and changes both in the Vitamin A Program as well as in the health care system were being considered. The most important of these were increasing wages of health workers, and transferring most of the budget, and the responsibility for managing it, directly from the national level to the ODs. However, at the time of writing this bulletin it was not known to what extent changes had yet been implemented. Therefore, data presented below relate to the performance of the Vitamin A Program as assessed in July-August Also, answers from different respondents were not always in line with each other, especially when respondents were from different levels. In that case, an effort was made to get the best picture of the prevailing situation as reflected by the interviews. The information and conclusions included in this bulletin are based on the interviews conducted and do not necessarily reflect the Views of HKI/Cambodia. Delivering VACs Logistics Figure 2 gives a schematic overview of VAC procurement and distribution routes. For procurement of VACs, the Nutrition Unit of the MOH and UNICEF were responsible for calculating the number of VACs needed for the next year. The calculation was sent to the Drug Department, which then decided how many VACs had to be ordered and from whom. Figure 2. Procurement and distribution routes for routine VAC supplementation. Nutrition Unit Drug Department UNICEF Central Medical Store VAC sources Provincial Health Department Operational District Health Center Target groups Immunization Outreach = procurement = distribution 3

4 Figure 3. Source of the vitamin A capsule for the children that received a VAC in the March 2000 distribution round. (n=4861) Source: Cambodia National Micronutrient Survey URSRUWLRQ,PPXQL]DWLRQ2XWUHDFK 6XE1,'V +HDOWK&HQWHU 9$&VRXUFH Sources of VAC were a local company, UNICEF, Asian Development Bank, Germany and others. UNICEF and the local company were the main suppliers, and UNICEF was the main donor. The Procurement Unit (within the Drug Department) ordered the VACs, which were then stored at the Central Medical Store (CMS). Once VACs were ordered, it took approximately one year for them to arrive and because they came from different sources, they arrived at different times, which made it difficult to accurately estimate the needs for the next year. This resulted in overestimation of needs, which caused surpluses at CMS and risk of expiration of VACs. Another problem was that the color, shape and size of VACs differed by source, and hence there was a large variety of VACs of the same dosage, which caused confusion among health workers. Introduction of the 100,000 IU VAC for infants aged 6-11 months was a new initiative and not all health centers had received the new dose, since they had not yet received the necessary training. CMS distributed VACs, along with other essential drugs, directly to the ODs. This was done four times per year for provinces which could be accessed by land and twice per year for provinces which could only be accessed by plane or boat (Kratie, Mondulkiri, Rattanakiri, Stueng Treng, Preah Vihear and Koh Kong). Once the VACs were available in the Province, the ODs had to organize and finance the transport of VACs to their own OD and then to HCs. Many ODs had difficulties with financing this transport. In remote provinces, transport of VACs was difficult due to bad road conditions, bad weather for boat travelling, flooding, and long hours of travel. These problems resulted in delays of transporting VACs to ODs and HCs. At OD and HC level, VACs were stored in their original package in a cupboard. Figure 3 shows through which distribution channels children had received their VAC in March 2000 according to their mothers, as found by the National Micronutrient Survey. Immunization outreach was the most important channel of all VACs received (80%). As reported by health center staff, the frequency of VAC distribution ranged from 2-4 times per year, but some health center staff took VACs with them during monthly outreach for distribution to children who had not received a VAC during the previous 6 months. Although VAC distribution should be done bi-annually around the months March and November, many of HCs distributed in different months, which was sometimes due to particular conditions that made it difficult to reach the target population during the specified two months. Distribution A number of different materials with guidelines for VAC distribution existed, such as specific Vitamin A Program protocols and general health care manuals 4

5 that included guidelines for VAC distribution. Thus, different guidelines for VAC distribution were being used and approximately half of the health workers did not use any particular guidelines, because there were no materials available at their HC. This means that the most recent policy guidelines were not followed consistently and that there was confusion about procedures, roles and responsibilities at the lower levels. For example, managers of the immunization outreach program were not always clear about their responsibilities regarding VAC distribution, or health workers were not aware that they should bring VACs during immunization outreach. Additionally, the distribution schedule was often not clear to health workers, and not all of them were able to correctly mention the target groups (i.e. some thought that 0-6 months should be included or 6-11 months should be excluded). In addition, most health workers experienced serious constraints with reaching the target population. There was not sufficient budget for outreach, especially in remote areas where road conditions were poor and access was difficult and therefore expensive. In addition, health workers were hampered by flooding and insecurity on roads (in particular robberies). People could also be difficult to reach because of seasonal migration related to rice planting and/or harvesting. Reporting VAC distribution at HC and OD levels was recorded in order to know VAC coverage and be able to request new VACs, and reports were prepared at HCs and ODs respectively. The number of VACs distributed during outreach was counted by ticking the number of VACs distributed on a form and VAC coverage was then calculated using the estimated size of the target population. But many health workers reported to have problems with calculating coverage, because it was difficult to obtain an accurate estimate of the size of the target population. In January 2000, a new Child Health Card was developed that included a space for recording VAC receipt. However this new card was not yet in use by health centers during the time of conducting the assessment. At the national level, all reports (both HC registration forms and tally sheets of supplementary immunization data) were gathered to calculate VAC coverage per round of distribution. Training and Supervision The purpose of training should be to teach health workers about the guidelines for VAC treatment and prevention and management of mass distribution. However, due to insufficient resources, training activities were very limited, for example only one, outdated, training manual was available for all levels of the health care staff, and there were no refresher courses. The short training course of one day was found to be inappropriate because not all knowledge and skills needed for VAC distribution could be transferred. In addition, only one health worker was trained per HC; in many HCs none of the health workers had been trained, and at most HCs the latest guidelines for VAC distribution were not available. Besides, health workers often resigned early, without transferring their knowledge acquired from training to their successor. Recently, training about the new VAC policy was developed, which was more structured, and had already been conducted in four provinces. It was also found that there was a lack of coordination of supervision of VAC distribution between the Nutrition Unit and NIP staff at the higher levels, because not all higher level NIP staff were clear about their responsibilities regarding VAC distribution. It was not clear how and by whom supervision of VAC distribution was conducted at OD and HC level, and there was no feedback system in place to inform lower levels about outcomes of supervision. However, interviewees that had been supervised reported that it had been important for their motivation, because advice was given, corrections were made, and problems had been solved. Demand There was little community participation in mobilization for VAC receipt, because understanding and awareness of the importance of vitamin A and VAC was very limited. According to the National Micronutrient Survey only 30% of the mothers had heard of vitamin A or VAC. Most of them (80-85%) had received this information from health workers (see Figure 4). There was a shortage of social marketing activities, mainly because of lack of budget at the national level. Only a few information, education and communication materials about VAC were available, one of which was a poster to educate people about vitamin A that was widely known and used by health workers. 5

6 Figure 4. Source of information on vitamin A or vitamin A capsules for the mothers that reported to have heard about vitamin A. Note that it was possible to mention more than one source of information. (n=4552) Source: Cambodia National Micronutrient Survey URSRUWLRQ +HDOWK:RUNHU 79 5DGLR 6RXUFHRILQIRUPDWLRQRQ Health care system in general Because VAC distribution is linked with immunization outreach, VAC Program performance is also influenced by constraints related to the health care system in general. It was frequently reported that the lack of sufficient, consistent and sustainable funding was a major constraint, which especially affected outreach activities because there was little budget for transport at OD and HC level, and wages of health workers were too low. Budget constraints also limited the possibility to plan activities for the next year, conduct training and supervision, and schedule other activities. It was also found that there was a lack of higher qualified staff at the OD and HC level, and the Nutrition Unit was reported to be understaffed. And, a high turnover rate of staff at OD and HC levels resulted in early loss of skills and knowledge about vitamin A and VAC distribution gained by training. Although most staff said to be motivated, low wages and high workload were found to limit work performance and increase staff turnover rate. Cooperation between different levels of the health care system and NGOs seemed to be good. Although, there was a high commitment to combat the problem of vitamin A deficiency, interviewees at the national level reported problems with cooperation and coordination between different departments and organizations involved in the Vitamin A Program at this level and said that collaboration needed to be strengthened in order to improve program performance. Conclusion Immunization outreach appears to be the best strategy for delivering VACs in Cambodia, because it is one of the very few programs that is designed to reach all communities throughout the country on a regular basis, and because of the good relationship found between VAC coverage and immunization coverage. However, VAC coverage was consistently lower than immunization coverage. Increasing VAC coverage should be done by improving three different aspects of the program: the delivery of VAC, the demand for VAC, and the health care system in general. The main factors limiting immunization coverage appear to be the lack of budget for outreach activities and the low wages of the health workers. 6

7 Recommendations VAC distribution through immunization outreach has to be continued and be strengthened, through improvement of: Delivery of VACs Logistics Develop a systematic process for VAC procurement and improve the way the needs for VAC in future years are estimated There should be one type and color of VAC per dose Make VAC of 100,000 IU available throughout the country, and train health workers in use Distribution Improve the performance of health staff, through training and systematic dissemination and implementation of the VAC policy Assess, per province, whether March and November are the most appropriate months for VAC distribution in light of having best access to villages and the target population Strengthen cooperation between health center staff, local authorities and community-based workers (e.g. village health volunteers, traditional birth attendants and village chiefs), in order to inform people in advance about VAC distribution and to increase community mobilization Reporting Improve recording and reporting of VAC on the Health Information System reporting forms Provide training on how to record child VAC receipt on new Child Health Card Training and Supervision Develop a systematic plan for providing regular training and refresher courses, including the development of appropriate training manuals, to ensure that all actors know their roles and responsibilities for VAC distribution Monitor and evaluate staff performance by strengthening supervision activities and developing a system for recognition Strengthen cooperation and coordination between NIP and Nutrition Unit by clearly defining their roles and responsibilities in distribution and supervision of the VAC program Demand for VAC Create demand for VAC at the community level by increasing awareness of the importance of vitamin A and VAC through social marketing activities Health care system in general to improve both VAC and immunization coverage Map HCs and villages, including estimation of target population, to ensure that the health care system is able to cover the whole population and that villages are accessible for outreach teams Increase the budget for outreach activities, including for transport and for training, supervision, reporting and social marketing Consider increasing salaries for health staff in order to motivate them and reduce high turnover Increase cooperation of the health care system with other agencies and NGOs by organizing regular meetings at both the national level and the provincial level in order to share information and conduct activities effectively Surveys and Surveillance In order to assess whether the performance of the VAC program improves, and how, where and among whom, surveys and surveillance need to be conducted 7

8 HKI Cambodia Nutrition Bulletin Vol. 2, Iss. 5, April 2000 CAMBODIA Helen Keller International Nutrition Bulletin For information and correspondence, contact: Helen Keller International, Cambodia P.O. Box 168, Phnom Penh Kingdom of Cambodia Telephone: Fax: Ms. Dora Panagides, Country Director Ms. La-Ong Tokmoh, Program Manager Helen Keller International, Regional Office P.O. Box 4338, Jakarta Pusat Indonesia Telephone: / Fax: Dr. Martin W. Bloem, Regional Director Dr. Regina Moench Pfanner, Regional Coordinator Dr. Saskia de Pee, Regional Nutrition Research Advisor Ms. Lynnda Kiess, Regional Advisor Ms. Ans Eilander, Vitamin A Assessment Manager hki@bigpond.com.kh 2001 Helen Keller International Reprints or reproductions of portions or all of this document are encouraged provided due acknowledgement is given to the publication and publisher. The Cambodia National Micronutrient Survey was made possible through funding from the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. HRN-A Helen Keller International A division of Helen Keller Worldwide This publication was made possible through support by the USAID/Cambodia Mission under the terms of Award No. 442-G The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of USAID.