An assessment of EPI situation in Sankhuwasabha district Nepal.
By: Nawaraj Subba, MPH, MA

Summary
Study design
Rationale of the study
Objective of the study
Survey Organizations/ Sample/ Instruments and Data processing
Major Findings:
Number of failing to conduct Immunization camps
Reasons of failure in conducting Immunization (EPI) camps
Practice of Sterilization
Consistency in time given to Immunization camps
Practice of Opening hours of camps
No more access and geography
Cooperation between MCHW and VHW
Cooperation with Village Development Committee
Supervision
TADA Payment
Suggestions given
Limitations of the study
Recommendations

Summary: An assessment as a cross-sectional study was made on the situation of EPI program in Sankhuwasabha district. The study was aimed in assessing the EPI status, their problems and constraints in carrying out an EPI sessions. 41 Samples were taken and HA, AHW, ANM, VHW, MCHW, Mukhia were respondents in the study. Questionnaire and forms were provided and FGD was held during study. EPI-Info software was used for data processing in computer. Major findings were - an EPI Post in an average could not conduct 3 times a year. It was due to (a) staff leave and national campaigns, (b) topographical reason and (c) lack of manpower in the district. Only 56% EPI Posts used to open regularly in time. Counseling to mother was provided in more than half EPI posts (56%) of the district. Services still not available for disadvantaged population (31%) due to remote and vague geographical areas with scattered population distribution as reported. 16 additional EPI posts were required in the district. Abscess following injection was reported only in 2.238% of vaccines injected. 82% VDCs had supported for EPI post management in Sankhuwasabha.

Study Design: It was an assessment of Sankhuwasabha district as a cross-sectional Study conducted in March 2002.

Rationale of Study: EPI is one of the cost effective public health programs in Nepal. Due to different reasons the trend of coverage of routine EPI has been decreasing over the past 6 years in Nepal¹. Problems are similar in most of the districts. However, the status of program, problems, constraints and their solutions may be different in district. The Strategic Guidelines for National Immunization Program of Nepal has set one of its objective as Universal coverage of 80% for the antigens will be achieved and sustained at the district level by the year 2002, and 90% by the year 2005, through strengthened routine immunization services.² To address the missed opportunities the guidelines has indicated that possible reasons for non-vaccination shall be identified through research and addressed³. Therefore, it's necessary to assess the general situation and district specific condition of EPI program. In order to identify the particular problem and find out the solution this study why made.

Objective of Study: Overall objective was to assess the situation of EPI program of Sankhuwasabha district.

1. To assess EPI post status with problem and constraints.
2. To assess Adverse Effects Following Immunization and practice of Sterilization.
3. To assess roles and possible contributions of DHO, HP, SHP and VDC.

Survey Organizations: Health Posts = 12, Sub Health Posts = 23

Samples: HA=2, AHW =27, ANM=1,VHW =5, MCHW =2, Mukhia = 4, Total respondents = 42

Instruments: Questionnaire, Forms.

Data Processing: EPI-Info software in Computer.

1. Failure in conducting EPI Post clinic (session) in past year in the district (Average =3 times/year).

11 EPI posts were failed one time in conducting EPI clinic during last Fiscal Year. Similarly 9 posts failed 2 times, 5 posts failed 3 times, 2 posts failed 4 times, 3 posts failed 6 times, 1 post failed 8 times and 2 post failed more than 9 times to attempt EPI sessions in their respective posts in the year.

Due to lack of manpower 6.1% EPI posts was affected to conduct sessions during last year. Similarly more than 60% EPI sessions were affected due to National campaigns such as NIDs, NLEC, Vitamin A and festivals of Dashain and Tihar.

3. Practice of Sterilization. Proper sterilization practices has been carried out by 86.6% health workers in the EPI posts as experienced by the health workers themselves. Abscess following injection was reported in only 2.238% of vaccines injected.

The time consistency is an important factor of quality of service. Mother often gets confused for next timing due to inadequate counseling and irregular timing of a clinic. Health workers have reported that about half of the total clinics (56%) of the district opens and closes routinely and rest (44%) of the EPI posts in the districts does not open and close routinely during clinic day.

5. Practice of opening hours of EPI post during clinic day. An average opening hours of a session in the EPI post has been reported as 4.75 hours (SD=1.19).

10% Posts open for 3 hours in the clinic day. Similarly 36% posts for 4 hours, 33% posts for 5 hours, 13% posts opens for 6 hours, 3% opens for 7 hours and 2% posts opens for 8 hours during clinic day.

• Tentative proportion of disadvantaged population = 31.7% (as reported by respondents).
• New EPI posts required at least in the district is 16.

It has been reported that 82% of VDCs had supported in the operation and management of EPI camps. Only 18% health institutions had failed to get good cooperation with VDCs in the district.

9. Supervision. Respondents had also reported the supervision status of district. Supervision of Health Institutions from DHO is 1.59 times/institution/year (SD=1.534). Supervision of EPI posts from HP/SHP is 5.256 times/Post/Year (SD=5.04).

10. TADA Payment. It was found that 81% respondents did not get their TADA, whereas 16% respondents had reported as they had got their TADA from district and 3% respondents had got TADA partially during last fiscal year.

• Supervision should be strengthening from district level to EPI post level.
• VDC should be mobilized from district level as soon as possible (DHO, DDC).
• Vacant post of health manpower should be fulfilled as soon as possible (RHD, PSC).

• Time constraints
• Budget constraints
• Recall bias, subject error
• Sampling Error
• Specific study for the health institutions such as Health Posts and Sub-Health Posts of Sankhuwasabha district.

Recommendations. 

Respondents have made recommendations and suggestions to strengthen the program in the district.

• Additional 16 more EPI posts and one more Vaccine sub-center are needed in the district.
• Provision of signboard labeling with name of health workers, date, place, time and service provided to be placed at EPI post. And VDC or local community should be mobilized for making signboard, supervision and monitoring too.
• Enough and all kinds of Vaccine supply are required every month. Technician rather than a peon should carry out job of Vaccine supply from Cold room in district and sub centers. There is also need of supervision, monitoring of Cold chain while vaccines being dispatch from the Cold rooms or stores.
• Vaccine or logistics in its buffer stock level should be maintained at district and sub-centers.
• Since there is no provision of manpower, an additional manpower is needed for sub-center.
• To prevent the failure of routine EPI session, further micro planning should be done while conducting national campaigns such as NIDs, NLEC and dashain festival.
• Timely Vaccine supplies to HP/SHP should be ensured.
• Make sure the Quality of Vaccine carriers and ice packs.
• TA/DA for supervision should be provided to HP/SHP. And HP and SHP in-charge should be empowered by delegating necessary power.
• Mothers group, school health and PHC-ORC should be mobilized from HP/SHP level and monitored from district level as well.

References
¹ Annual Reports, 1994-2000, Ministry of Health Department of Health Services, Kathmandu, Nepal.
^2,3 EPI/CHD, 2000, Strategic Guidelines for National Immunization Program, Ministry of Health
     Department of Health Services, Kathmandu, Nepal.

Abbreviations
AHW = Auxiliary Health Worker, ANM = Auxiliary Nurse Midwife, DHO = District Health Office, DoHS = Department of Health Services, EPI = Expanded Program on Immunization, HA = Health Assistant, PSC = Public Service Commission, VDC = Village Development Committee, VHW = Village Health Worker

©2002. Nawaraj Subba, MPH.    Go to top of the page
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