Analysis of Routine Immunization in Afghanistan

1. Snapshot of RI’s Current Situation in
Afghanistan
(Main Constraints & The Way
Forward)
2nd Dec ,2018 Afghanistan
By: Dr. Ismail Zubair- NEPI

2. Presentation Outlines:
1. Introduction
2. Current EPI Status
3. Barriers to Better RI Services
4. The Way Forward
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3. Introduction:
 Afghanistan's Expanded Program on Immunization (EPI)
performance has a significant impact on global and regional
immunization indicators such as poliomyelitis eradication,
maternal and neonatal tetanus and measles elimination.
 Despite significant efforts by the government and partners,
Afghanistan’s immunization indicators have not met the
expected benchmarks.
 With sustained government commitment, predictable partner
support and by adopting effective strategies, Afghanistan can
achieve the immunization targets set at the regional and global
level and make strong progress towards achieving SDG 3.
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4. EPI Coverage Overview
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5. 95
106
82 82
275
162
27 32
15 9 4 5
0
50
100
150
200
250
300
Nangrahar Kunar Lagman Noorsitan
South Region MCV-1 Coverage, Cases & Outbreak
2018
Coverage MCV-1 Cases Outbreak
Source: Administrative and NDSR Data

6. 69
82
100
80
82
31
43
15
62
39
4 5
3
9
5
0
20
40
60
80
100
120
Hilmand Kandahar Nimroz Zabul Uruzgan
South Region MCV-1 Coverage, Cases, Outbreaks
2018
Coverage MCV-1 Cases Outbreak
Source: Administrative and NDSR Data

7. Main Constraints
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8. Barriers to Better RI’s Services at Different Levels
Community/
Field Level
Barriers
Health
Facility Level
Barriers
REMT/PEMT
Level
Barriers
Health
System Level
Barriers
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9. Community/ Field Level
Barriers:
 Peoples’ Perception
about Immunization
 Reasons:
 Low community
awareness
 Habitual Trends
 Myths/ Propagandas
 More focus on supply
side/less on demand
side
Solutions:
• Balance b/w Demand side and
supply sided interventions
• Need to change perception and
behavior of People
• Demand Generation for
immunization should be
programmatically focused
• IEC ( Information, Education and
Communication
• Behavior Change Communication
campaign
• BCC Theory
• Long time strategy (Theory of
Change Steps)

10. Health Facility and HR distribution per population
Province
Estimated Population-
2017-18
Area (Km2)
Gov.Health
Facilities
No.Vaccinator
%Coverage
Penta3
Nangarhar 1573973 7641.1 131 246 97
Kunar 465706 4925.9 45 82 79
Nooristan 152845 9266.7 33 45 62
Kandahar 1279520 54844.5 98 139 77
Helmand 955970 58305.1 85 137 68
Farah 524657 49339.1 65 83 69
Zabul 524657 17471.8 58 77 71
Source of Data: CSO,HMIS and EPI-MOPH

11. Issues in RI Services at field
level:
 Microplanning
 Not Properly done (
on the desk activity)
 Not timely updated
 Location of HFs
 Not according to MP
 Reasons:
 Rented House (Urban
Areas/Kabul)
 Personal Preference
 Others Influence
Solutions:
• Proper/Actual MP
• Community Involvement
• Timely update MP
• Regular Monitoring of Outreach
and Mobile activities

12. Health Facility Level Barriers:
 Outreach Services are weakly
provided
 Mobile Services are almost ignored
 Reasons:
 Personal Preference of
Vaccinator
 No Facility for Vaccin…
1. No Vehicle/fuel/ repair
2. No Perdiem /delay
 No supervision/ involvement of
EPI sup in Planning
 Weak feedback & follow up
 HF head weak accountability
Solutions:
• Jointly development of outreach &
mobile plan
• Proper Involvement of HF head
• Joint M&E
• Proper follow up and feedback

13. Mid Level(REMT/PEMT/NGO)
Barriers:
 Low management and technical
capacity of REMT/PEMT staff
 Different style of management
 Salary Issue
 Less than vaccinator
 No clear PEI to EPI support
mechanism & vice versa
 Low priority of IR to NGO
 Low performance accountability
 Weak coordination &
communication
Solutions:
• Continues Education
• Unify strategic and operational
planning
• Healthy salary package
• Balance b/w PEI & EPI
• Team work
• Strengthen coordination &
communication

14. Senior Management Level
(NEPI/MoPH)Barriers:
1. Issues in Planning Approach:
 Action oriented Vs Result oriented?
 No clear strategic direction
 Different mindsets/objectives among stakeholders
 Planning in Isolation/No involvement of staff
 Strategic areas and objectives are not translated into annual
planning
2. Issues in Management Approach:
 Half Cycle Management Approach
 Every dep develop their own plan
- the next door dep is not aware of it

15. Senior Management Level
(NEPI/MoPH)Barriers:
Solutions:
 Paradigm Shift:
 Action Oriented to Result Oriented Management
 ( Result Based Management Approach)
 Bottom Up Planning Approach
 Unity of Strategic Planning guidance Documents
 Plan together/ Involve all

16. Senior Management Level
(NEPI/MoPH)Barriers:
 Issues in Organizing & Leadership:
 Better technical & management capacity
 But no job security
 No continues education opportunity
 No recognition & punishment ( Carrot & Stick Policy)
 No performance accountability at all level
 Weak coordination & communication at different level
 Within EPI
 With GCMU and other departments
 B/w Central and provincial level
 B/w EPI & implementing NGOs

17. Senior Management Level
(NEPI/MoPH)Barriers:
 Issues in Controlling:
 Though having strong and regular Sup-Super & Monitoring
 M&E objectives are not inline with NEPI strategic objectives
 Result/findings are not translated in to NEPI planning ( data
driven decision making)
 Need for annual outcome evaluation and mid term (5 year )
impact evaluation.
 Need for Third Party Evaluation

18. Senior Management Level
(NEPI/MoPH)Barriers:
 Issues in Data Quality Management:
 Improvement has been made in data quality, data reporting, and
data availability
 Data management system is in place
 However, for data accuracy, validity, reliability, timeline and
completeness, we have a long way to walk!

19. The Way Forward:
 Top evidence-based strategies for better RI services:
1. Result based management approach
2. Develop actual and unify EPI strategic plan
3. Find immunization champions in our practice
4. Integrate IR outreach and mobile with other basic health
services (nitration, ANC, PNC)
5. Hold vaccine clinics at hours convenient for families
6. Semi-annual strategic achievement workshop
7. Quarterly joint RI monitoring ( NEPI, EOC, GCMU, NGO)
8. Debits on tvs/radios

20. Sources of Data:
 M&E Findings
 FGDs & IDIs with EPI Staff & Community
 Observations
 Documents Review
 EPI Comprehensive Multi Year Plan 2015-2019
 National EPI Strategy
 EPI Coverage Survey 2013
 Afghanistan Demographic & Health Survey 2015
 Top Strategies for Increasing Immunization Coverage Rates
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21. Thank you
Comments and questions
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