Assessment of Maung Russey Health Centres vaccination campaigns Kristin Parco Bart Jacobs Movimondo Cambodia September 2000
2 Introduction The Expanded Program on Immunisation (EPI) is one of the National Programs of the Ministry of health. Its aim is to immunise all children against the 6 preventable diseases (measles, polio, diphtheria, tuberculosis, tetanus and pertussis) before their first birthday and to vaccinate women of childbearing age (15-45) five times for tetanus. Pregnant women should receive at least 2 doses of tetanus. 1 A study was conducted during July 2000 to assess the effectiveness of the vaccination campaigns in Maung Russay Operational Health District. Methods The vaccination campaigns of nine health centres were observed using a participatory approach and the HC staff were interviewed using a structured open-ended questionnaire. An experienced translator was used during the interviews. Two Health Centres did not conduct any vaccination campaign at the time of the assessment as they did not receive an official permission to execute the minimal package of activities. 1 Clinical and therapeutic Guidelines: Referral Hospitals (1999) Ministry of Health, Phnom Penh
3 Results Coverage of EPI Table 1 displays the number of villages covered by each health centre and the respective number of staff and their qualification. Staff of all health centres reported to cover 100 % of the villages in their catchment area (table 1). Four of them reported to conduct EPI at the furthest village four times per year only. The number of staff involved in the EPI campaign ranged from 2 to 6 but was not related to the number of villages to be covered. Both Prey Svay and Prey Toch, with 8 and 6 staff respectively, have a primary nurse -in charge of the outpatient department- and one midwife remaining in the health centre during the vaccination campaign. Only two health centres involved a midwife in the campaign and sometimes during outreach activities. These midwives reported to give health education on birth spacing. The midwife of Prey Svay reported to conduct antenatal care (ANC) and birth spacing for far villages. Table 1: Number of villages covered Health Centre Villages Villages covered monthly Days of EPI Villages covered 4 x a year Staff involved Qualification of HC Staff involved in the EPI Maung 14 13 13 1 2 Primary Nurse Chrey 8 7 10 1 4 Primary Nurse Taloas 9 9 9 3 Primary Nurse P. Svay 9 8 10 1 6 Primary Nurse and Midwife R. Kraing 10 9 9 1 2 Primary Nurse P. Toch 6 6 9 4 Primary Nurse Kakos 7 7 9 2 Primary Nurse and Secondary Midwife Thippadey 5 5 7 4 Primary Nurse R.Mongkol 9 9 11 2 Primary Nurse Total 77 73 4 29
4 Administration During the vaccination campaign, a new child is given a vaccination card (yellow card) on which the EPI staff record the weight, age and type of vaccination and date. It also indicates the next date for and type of vaccination. All the EPI staff would explain the use of this card to the mothers and emphasise the date for the next vaccination of the child. For the women of childbearing age a separate card for the tetanus vaccination status is used. This card indicates the dates of the received vaccinations and the ideal date for the next one. A secondary nurse is in charge of the campaigns and allocation of the per diems at operational district level administration. Collaboration with community members Four health centres reported to collaborate with VHVs/Village Representatives/KRDA 2 when conducting the EPI Program. The collaboration existed of provision of information to the target group (women and children) and assembling them in one place during the campaign. The village health volunteers (VHV) or the Village Chief either provides this place. Two health centres reported to use the members of the Health Centre Management and/or Feedback Committee to gather the target groups. The staff of two health centres reported that the VHVs would not assist during the planting and harvesting season. One health centre reported that the VHVs halted collaboration because of lack of any financial remuneration. Programs/ Activities incorporated with the EPI The staff of two health centres reported to incorporate Birth Spacing and Health Education to women in the EPI. The staff of another 2 health centres claimed to collaborate with KRDA in weighing the children aged 0-5 years. The other did not mention any activities that were integrated with the EPI campaign. Financial incentives for the EPI The source and amount of financial incentives provided to the health centre staff to conduct the EPI campaign are displayed in table 2. Money is provided by either the Ministry of Health through the Operational Health District (OD) or by the Asian Development Bank in the form of Accelerated Development District (ADD) funds. The United Nations Children Funds (UNICEF) supports two health centres to conduct EPI in the furthest villages of their catchment area. The staff of 2 health centres claimed not to receive any remuneration from OD/ADD or other sources. The over-all monthly expenditure for the EPI campaign is R776,000 or a median of R5,333 per village (range 0-35,000); R12,000 per staff (range 0-175,000); and R48,000 per health centre (range 0-350,000). Two health centres together received almost 70% of the total monthly expenditure for a vaccination campaign. 2 Khmer Rural Development Association
5 Table 2: financial incentives for the EPI campaign per health centre Health Centre Amount provided (staff involved) total per HC (% total budget) Reason Sources Total per diem per staff Per diem per village Maung R36,000/ (2) per diem for 3 far villages OD/ ADD R26,000 R3,714 R16,000 (2) R52,000 (6.7) per diem for 10 nearby villages OD/ADD Chrey R48,000 (4) R48,000 (6.2) Taloas 0 (3) 0 (0) P.Svay R48,000 (6) per diem OD/ADD R12,000 R6,000 none none 0 0 per diem OD/ADD R14,667 R9,778 US$10 (6) R88,000 (11.3) per diem for one far village UNICEF R.Kraing R30,000 (2) per diem OD/ADD R175,000 R35,000 US$80 (2) R350,000 (45.1) per diem for 4 far villages UNICEF P.Toch R32,000 (4) R32,000 (4.1) Kakos R16,000 (2) R16,000 (2.1) Thippadey 0 (4) 0 (0) R.Mongkol R10,000 (3) per diem OD/ADD R8,000 R5,333 per diem OD/ADD R8,000 R2,286 none none 0 0 per diem OD/ADD R63,333 R21,111 US$45 (3) R190,000 (24.5) per diem for 3 far villages OD/ADD Mean Mean Total R776,000 R26,759 R10,078 OD = operational district; ADD = advanced development district, N/A = not applicable
6 Reported difficulties with the vaccination campaign The health centre staff mentioned the following as being the main difficulties with the EPI campaigns: Gathering the target groups due to the mobility of the population or non-attendance by parents who are preoccupied with work. Revaccination of the targets groups is hereby impaired. The OD/ADD money is given 3 months after the vaccination campaign; and Vaccination campaigns for the furthest villages are heavily dependent on the available OD budget and can therefore not be timely planned.
7 Discussion and recommendations The ideal vaccination campaign A previous study 3 indicated that the proportion of the population consulting the health centres was negatively correlated with the distance from the health centre. Similarly, the proportion of pregnant women seeking or receiving antenatal care from health centre staff decreased significantly with the distance from the residing villages to the health centre: from 69% in the health centre village to 27% in the furthest villages. Women who received antenatal care from health centre staff were significantly less inclined to seek assistance from a traditional birth attendant (TBA) during delivery, more so from health centre staff, and mentioned significantly less the importance to adhere to the traditional delivery protocol such as roasting. The ideal vaccination team exists of 3 staff: (1) a nurse to vaccinate children and women of childbearing age; (2) a midwife who can physically examine all pregnant women in a place with sufficient light and privacy; and (3) a nurse who treats minor ailments. These staff work effective (i.e. achieve objectives within a given time period) and efficient (being effective without wasting resources) because the target groups - children and women to be vaccinated; pregnant women to be vaccinated, examined, and convinced of the benefits of birth spacing; and people with minor ailments- are gathered in and on a predetermined place and day. These people have been informed and motivated to attend the monthly sessions by the village feedback committee members in collaboration with the TBAs and VHVs. As a result of intensive information, education and communication campaigns, 90% of the women know about the benefits of vaccination. The children of women who can not accompany them to the EPI campaigns are gathered by the VHVs/TBAs or feedback committee members. A district wide system is in place allowing migrating pregnant women and children to receive their vaccination timely. As a result of these approaches, 90% of children and pregnant women are vaccinated in accordance to the National Guidelines and 90% of the pregnant women have received antenatal care. Obstacles to be considered to achieve the ideal vaccination campaign in Maung Russay Operational Health District 1. Staff: for 9 health centres 27 staff should be involved whereas currently 29 staff spend 87 working days or 4.3 working months on vaccination to cover all the villages within 1 working month. 2. Technical efficiency: the analysis of the financial incentives provided to the health centres for the EPI campaigns reveals serious discrepancies in resource allocation and suggests a lack of any sound allocation guidelines. As such, some health centres do not receive any incentive for the EPI campaign and 2 others receive almost 70% of the operational health district's total monthly expenditure. The staff of Russay Kraign is monthly rewarded with R175,000 3 Jacobs B & Parco K (2000) Antenatal health seeking behaviour, utilisation of public health services and perceptions of their services by women with siblings younger than 5 years in Maung Russay Operational District. Movimondo Cambodia, Phnom Penh
8 each and staff from other health centres receive a fraction or nothing. Similarly, some communes are allocated more than R20,000 per village whereas other less than R5,000 per village. This indication of a complete absence of standardisation in the approach to the EPI campaign may create serious discontent amongst the health centre staff. 3. Sub-optimal linkage of outreach activities to the EPI campaign: only 4 health centres reported to link other activities such as provision of birth spacing, health education and weighing of the children. Only 1, however, took the opportunity to conduct antenatal care or treatment of minor illnesses. 4. Absence of financial remuneration for community members involved in the vaccination campaign: it is positive to note that two thirds of the health centres collaborated with other organisations or people of the community to gather the targets groups. However, the absence of any financial remuneration for these non-ngo people s contribution may impair sustainability of this approach as indicated by 3 health centres failing to motivate their VHVs to participate during the planting season. 5. Payment of incentives to health centre staff involved with the vaccination campaign: ideally, provision of the financial remuneration for the vaccination campaign to the health centres occurs prior to the start of the activities as to facilitate a smooth performance. This, however, is not the case in MROHD, except for the money allocated by UNICEF, whereby the staff have to advance the costs incurred during the campaign. 6. Non-centralised approach to the vaccination campaign by 3 health centres: it is commendable that 6 health centres gather the target groups in a predetermined place in the village. The effectiveness of the other three is debatable 7. Allocation of money by UNICEF to 2 health centres only: additional financial support to only two of the 9 health centres for the vaccination campaign creates imbalances between the health centres and does not allow for standardised and weighted allocation of combined resources for EPI to the health centres. 8. Absence of Standard Operating Procedures: Standard Operating Procedures allow for an optimal effectiveness and efficiency of the activities to be undertaken and facilitate their supervision. Various health centres reported to undertake various activities during the EPI campaign, some reported to focus solely on EPI, but none of the staff was able to give the rationale leading to these decisions to do so. 9. Migration and prioritisation: little is known about the migration pattern of certain population subgroups within the operational district but these groups may reduces the effectiveness of the campaign. The prioritisation of women with siblings to work rather than to attend vaccination campaigns suggests a lack of knowledge regarding the necessity to be present.
9 10. Not all villages are visited monthly and not all villages of the operational district are covered: four of the 77 villages are only visited on a quarterly basis which may indicate an absence of community involved in the organisation of transport for the health centre staff. This absence may also indicate a poor knowledge regarding the need for vaccination and antenatal care amongst the population. Of the operational health district s 108 villages, 29% are not included in the vaccination campaign. What can be done in MROHD to conduct the vaccination campaigns ideally 1. Staff and outreach activities and EPI: Standard Operating Procedures A Standard Operating Procedures manual should be developed as to allow for smooth performance of the activities and to serve as a reference document. This should be uniform for the whole operational district and as such adhered to by all the health centres. The following should be outlined: Members of the Health Centre EPI team Role and tasks of the members of the Health Centre EPI team Activities to be conducted during the vaccination campaign Medication to be taken for treatment of minor illnesses, including STDs 1 Equipment and medication to be taken for antenatal care, including STDs Vaccines, stationery and materials to be taken for vaccination Materials and stationery for child weighing Contraceptives and educational materials Approach to be used to identify and secure a place for gathering of the target groups and with sufficient privacy for physical examination of pregnant women and STD patients Description of the roles of the community members involved in the informing and gathering of the target groups Detailed description of the budget allocation system to the health centres for the vaccination campaign (see below) Description of the remuneration system for the community members involved in the EPI campaign Recommendation 1 To develop a Standard Operating Procedure Manual for the vaccination campaign 1 to be calculated for 50 consultations taking into account the most commonly reported diseases (for minor ailments) and STD syndromes as indicated by the monthly reports
10 2. Technical efficiency The allocation of the budget for the vaccination campaign to the health centres should occur according to clear guidelines based on acceptable indicators. Amongst the 77 villages that are covered by the health centres 3 indicators for budget allocation have been distinguished: (1) sixty two accessible villages, (2) 11 remote villages for which a higher amount is given to some health centres, and (3) four difficult to reach villages that are quarterly visited. When allocating a difficulty factor of 2 to the difficult to reach villages, a factor of 1.5 to the remote villages and a factor of 1 to the accessible villages, a total of 86.5 units can be considered for allocation of the total budget 2. For a total monthly expenditure of R776,000, each unit represents R8,971. The consequent allocation of the budget to the respective health centres is displayed in table 3 and table 4 gives the resulting medians of the amount given per health centre, per staff and per village for EPI. Table 3: budget allocation per health centre with the use of difficulty factors Health centre QVV 1 Remote villages Accessible villages Total units Total sum Amount per staff 2 Amount per village Maung 1 3 10 16.5 148,000 49,333 10,571 Chrey 1 0 7 9 80,700 26,900 10,088 Taloas 0 0 9 9 80,700 26,900 8,967 P. Svay 1 1 7 10.5 94,200 31,400 10,467 R. Kraign 1 4 5 13 116,600 38,867 11,660 P. Troch 0 0 6 6 53,800 17,993 8,967 Kakos 0 0 7 7 62,800 20,993 8,971 Thippadey 0 0 5 5 44,900 14,967 8,980 R. Mongkol 0 3 6 10.5 94,200 31,400 10,467 Total 775,900 1 Quarterly visited village, 2 assuming 3 staff per health centre The proposed allocation system allows for a more equitable allocation of resources. 2 4 difficult to reach villages x 2 = 8 units (+) ; 11 remote villages x 1.5 = 16.5 units (+); 62 accessible villages (= 86.5 units)
11 Table 4: Medians of resource allocation to the health centres, staff and villages with the old and proposed system Old system Median (range) Proposed system Median (range) Total monthly amount per health centre 48,000 (0-350,000) 80,700 (44,900-149,000) Monthly amount per staff 12,000 (0-175,000) 26,900 (14,967-49,333) Monthly amount per village 5,333 (0-35,000) 10,088 (8,967-11,660) This proposed allocation system, however, requires census of the staff regarding the definitions of remote and difficult to reach. Recommendation 2 To realistically adjust the per diem allocation system for the vaccination campaigns The proposed allocation system is further based on the assumption that UNICEF allows for a pooling of their financial contribution: i.e. that the monthly sum allocated to the two concerned health centres can be pooled to allow equal distribution to all health centres. Recommendation 3 To obtain permission from UNICEF to pool their financial contribution as to allow for a balanced operational health district allocation system Planning of the EPI/outreach activities can be greatly facilitated when paying the quarterly sum at the beginning of each quarter instead of afterwards. It avoids having the staff to advance all costs incurred. Alternatively the per diems are monthly allocated.
12 Recommendation 4 To pay the quarterly allocated money at the beginning of each quarter 3. Financial remuneration and organisation of community members Following the creation of Health Centre Management and Feedback Committees in all communes of MROHD and the additional establishment of DICOCOM 4, a considerable forum for the exchange of information between the communities and the District Health staff has been created. This should facilitate the gathering of the target groups in one central place. When the EPI budget is timely and correctly allocated to the health centres, Feedback Committee members will be able to timely inform the community members. The tasks of the community members involved with the EPI campaign will include the dissemination of information and assembling of target groups, including children of mothers who can not attend. As to assure sustainability and smooth performance, a financial remuneration system should be developed for the participating community members. Recommendation 5 To develop a remuneration system for community members participating in the EPI campaign and to integrate this in the Standard Operating Procedures Manual 4. Full immunisation coverage Of the operational health district s 108 villages, 77 (71%) are covered by the current vaccination campaign. In two communes with health centre and two without, vaccination campaigns are non-existing. The two health centres are waiting for official permission to conduct vaccination campaigns and no budget can be released until such authorization is obtained. Movimondo Cambodia should give due consideration to financially support these two health centres in conducting the vaccination campaigns, until government funding is made available. One commune has no health centre but is relatively easy accessible from the hospital. This enables a limited EPI/outreach campaign to at least the central village of the commune and requires a team of 3 staff from the hospital and/or a health centre to be assigned by the Senior Management Team. The duration of such monthly EPI/outreach should initially be not more than two working days. To obtain the required financing for this outreach activity, use should be made from 4 District Coordination Committee: comprised of representatives of all district ministerial departments and local NGOs
13 existing sources of income for the operational health district or through mobilisation of community resources. Consultation of the DICOCOM members should be seriously considered for the latter. Exploration of existing social networks within the commune may facilitate dissemination of information to its members and increase the vaccination coverage rate. The opportunity to create Village Vaccination Committees in this commune as well as others should be explored. The same approach should be considered for the other commune without health centre. For this commune it is recommendable that the nearest health centre, Thippadey, provides similar services. This can happen only when the staff are able to conduct their monthly EPI campaign in 5 days (1 per village) instead of 7. 5. Workshop Numerous facets of the vaccination campaign in Maung Russay Operational Health District require modification to increase their effectiveness. The first requirement is the development of Standard Operating Procedures with consensus on the activities to be undertaken, followed by a rearrangement of the financial allocation system and the development of a remuneration system for the community members. Lastly, a strategy should be elaborated to increase the vaccination coverage to all communes of the district, be it with or without health centre. It is recommendable that a 3 days workshop will be conducted to address all these issues. Participants of the workshop should include the Health Centre Chiefs, one midwife per health centre, MCH Coordinator, the Senior Management Team, EPI Coordinator, DICOCOM members and representatives of UNICEF. Recommendation 6 To organise a 3 days workshop to address all the identified issues with the vaccination campaign