PART C

IMMUNIZATION PROGRAMME

2

BUDGET PROPOSAL UNDER PART C-IMMUNISATION OF NRHM

Introduction

Universal Immunization Programme was introduced in the State with all

determination and vigour along with National launching of the scheme and

could achieve set goals ahead of other States in the country. Kerala – God’s

Own Country- lies in the south Western corner of the Indian peninsula

between 8018`-120 48`N latitude and 74052`-770 22` E longitude with a

population of 3.406 crores (RGI projection for 2009). It is bounded on the west

by Arabian Sea, the State of Karnataka on the North and the State of

TamilNadu, on the east and south East. The total geographical area of the

state is 38863 sq.km.

The state population is distributed in 14 districts having 63 Taluks, 152

development blocks, 999 Panchayats, 1452 revenue villages, 5 municipal

corporations and 53 municipalities. Population density of the state as per

census 2001 is 819 persons per sq.km.with district Alapuzha having the

highest density of 1496 and Idukki the lowest population density of 252 per

sq.km. Scheduled castes and Scheduled tribe population forms 3.92 percent

and 1.10 respectively of the total population.

The state recorded the lowest population growth rate, 9.42, in the country

during the decade 1991-2001 as per 2001 census. The decadal growth rate has

recorded substantial decline over the previous census, from 14.32 (1981-91) to

9.42 (1991-2001). As per the result of sample registration survey 2007, state of

Kerala has recorded the lowest birth rate (14.7) and Infant Mortality Rate (13)

far below the National average of 23.1and 55 respectively. Death rate in the

State is 6.8 against National rate of 7.4 during the year. As per the results of

3

NFHS-3 Kerala has achieved the target of hundred percent institutional

deliveries there by reducing Maternal Mortality to considerable levels. Sex

ratio as per census 2001 is 1058 female per thousand men. Child Sex ratio (age

0-6) is 960 females per thousand male children. Female literacy rate is

(86.87%) is also the highest in the country. National Family Health Survey

2005-06 has recorded the total fertility rate as 1.9, which is below the

replacement level of fertility. SRS 2007 has recorded a further reduction in

TFR to 1.7 which is the lowest in the country.

However the results of NFHS 3 show that the state has gone down in

vaccination coverage due to many reasons. Various action plans have been

mooted to sustain the achievements already recorded and improve

performance wherever required. As a result the latest Coverage Evaluation

Survey shows that 87.9 % of children are fully immunized though the

percentage of full immunization by age 12 months is 82.9. Further the recently

concluded DLHS III shows 79.5% coverage for full immunization.

Status, Activities and resources

State Profile

State of Kerala holds a very unique place in the demographic profile of the

nation as many of its performance indicators are comparable to developed

nations.

Total Population(2009) 34063000 RGI Projection

Rural (%) 74 -census2001-

Urban (%) 26 -do-

Infant Mortality Rate(IMR) 13 SRS 2007

Below Poverty Line (BPL) (%) 12.72 Planning Comm.

Crude Birth Rate (CBR) 14.7 SRS 2007

Infants / year 500726 CBR x Population

4

Pregnancies / Year 550799 Infants x 1.1

Divisions/Taluks 63

Districts 14

Blocks 152

Grama Panchayath 999

Villages 1452

Municipalities & Corporations 58

Recent Performance

Achievement of immunization in the State during previous 5 years is given

below

As per reported figures there is slight improvement during 2007-08 in

achievement compared to 2006-07. The reason for the lower level of

achievement during the years 06-07 and 07-08 are ascribed to the strike of

Medical Officers, which affected routine immunisation. The practise in Kerala

was to conduct immunisation in the presence of a Doctor due to public

compulsion and therefore the strike directly affected immunisation coverage.

The ever swelling floating population – construction workers, labourers etc. -

have also contributed to the lower performance. Even though Kerala is a

Antigen/Year 2003-04

2004-05

2005-06

2006-07

2007-08

2008-09 (up to

Nov.2008)

BCG 96 104.3 102 94.6 98.35 62.9

OPV 3 95.14 98.96 99.98 92.13 92.72 57.6

DPT-3 95.6 99.3 99.3 92.8 92.75 56.3

Measles 86.4 95.9 97.6 88.1 88.67 59.9

Fully Immunized

86.4 95.9 90.8 85.4 87.87 57.2

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highly literate state there are some areas where people show resistance to

immunization on religious basis especially in Malappuram & Wayanad

districts

Various initiatives to bridge the gaps are taken. Immunisation camps

without the presence of Medical Officers, increased number of outreach

sessions to cover floating population, local specific IEC/BCC, awards to best

performing JPHNs are all planned to improve immunisation coverage. The

state has decided to observe October as “Immunization Month” every year.

Reported and Evaluated coverage

As per NFHS II conducted in 1998-99 % of fully immunised children in Kerala

was 79.7. NFHS III (2005-06) results, however, shows only 75.3 % full

immunisation. The reported figures of fully immunized children show 102.6

% and 90.8% against targets respectively for these years. DLHS -1 has shown

the figures as 84% (98-99) and DLHS -II has recorded 81.2 % (2002-04) fully

immunised children. DLHS-3 has reported 79.5. The Coverage Evaluation

Survey shows that 87.9 %of the children are fully immunized whereas the %

full immunization by age 12 months is 82.9. It can be seen that steadily the

programme is improving.

Reported as well as evaluated coverage figures have shown that the

achievement of Kerala has gone down in immunization coverage which

demands that added efforts are essential to regain the achievements.

Comparison of reported & evaluated coverage – Full Immunization

Evaluation survey

Year Coverage Reported coverage

NFHSII / DLHS I

1998-99 79.7/ 84 102.6

NFHSIII 2005-06 75.3 90.8

DLHS II 2003-04 81.2 86.4

DLHS III 2007-08 79.5 87.87

CES 2006 87.9 90.8

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Drop out

It is observed that though the BCG achievements are always above 90 %, fully

immunized percentage comes down significantly due to drop out at various

stages.

Item /Year 2003-04 2004-05 2005-06 2006-07 2007-08

BCG 96 104 102 95 98

DPT-3 96 99 99 93 93

Measles 86 96 98 88 89

BCG to DPT 3 dropout (%)

0 5 3 2 5

BCG to Measles drop out (%)

10 8 4 7 9

Fully Immunized 86 96 91 85 88

BCG to FI drop out

10 8 11 10 10

The extent of drop out from BCG to full Immunization is an important

indicator of the follow up activities supposed to be carried out by the field

staff. Around 10 % difference is recorded over the 5 years data given above

demands strengthening of field activities throughout the State.

Vaccine Preventable Diseases

The State has been successful in containing vaccine preventable diseases.

Neonatal tetanus and Polio could be kept away from the State. Kerala is

validated for MNT elimination in 2003. However recently Diphtheria is

reported from districts with low level of immunization coverage and the

unimmunized children are affected. Monitoring and Supervision by district

and State Officers were continuous and corrective steps wherever necessary

were taken in time.

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Vaccine Preventable Diseases (No)

Disease 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 (up to Nov.08)

Measles 4255 3212 3314 2593 2794 1225

Diphtheria 3 1 2 2 3 15 Whooping cough

168 99 217 152 145 78

Neonatal Tetanus

0 0 0 0 0 0

Polio 0 0 0 0 0 0

Outbreaks reported and outbreaks investigated in the last year

Measles surveillance has been introduced in the State from the month of April

2007 and outbreaks are reported by the surveillance unit. Other than Measles

and Rubella no other VPD outbreaks are reported from anywhere in the state.

Infrastructure & Staffing Levels

The network of medical institutions in Kerala is also following National

System in its broad framework. At the bottom sub centres are functioning

with JPHN (ANM). PHC at next level provide immediate Medical care. CHC

is providing comprehensive Medical attention at next level. Taluk and District

Head Quarter hospitals are the First Referral Hospitals. Other institutions

provide higher level medical treatment at specialist and advanced levels.

Govt. of Kerala has decided to streamline the allopathic medical institutions

in the state on the lines of Indian Public Health Standards structure and the

orders are expected to be issued soon.

8

Public Health Infrastructure*

Institution Sanctioned No.

Functioning

With Functional Cold Chain

Equipment

Proposed Expansion ( No. of Facilities)

Sub-Centre 5094 5094 5094 -

Addl. PHC or PHC(N) - - - -

PHC 818 818 818 -

BPHC 111 111 111 -

CHC 114 114 114 --

Taluk HQ. hospital 41 41 41 -

District hospital 11 11 11 -

General hospital 7 7 7 -

W & C hospital 5 5 5 -

Other Hospitals 71 71 71 -

Other institutions 95 95 95 -

*It has been decided by the Govt. of Kerala to restructure the institutions as per IPH standards Health Staff in Immunization

Details of sanctioned strength and current availability of Medical and

paramedical staff is given below. Under NRHM Medical Officers have been

appointed along with necessary paramedical staff to supplement the existing

service providers thereby increasing the coverage for immunization.

Position Sanctioned

Post

In Position

Proposed Addition

Trained in immunization

activities

Medical Officers 3862 3134 Nil 0

LHI / LHS (Female Multi-purpose Health Supervisor)

1119 960 Nil 472

Male Multi-purpose Health Supervisor / Health Inspector

1044 993 Nil 211

ANM / JPHN (Female Multi-purpose Health Worker)

5583 5530 Nil 2909

JHI (Multi-purpose Health Worker)

3511 3260 Nil 1220

9

Other than the above, contractual JPHNs are engaged for outreach

immunization in urban slums for continuous field activities. Details of

dedicated immunization staff, cold storage points and areas of planned

expansion under RCH II are detailed below

Dedicated Immunization Staff

Position Sanctioned Post

In Position

Proposed Addition

Trained in last 3 years

State Immunization Officer 1 1 0 1

State Statistical Officer 1 1 0 0

State Cold Chain Officer 1 1 0 0

Dy. Director of Health Services (CH)

1 0 0 0

D.I.O 14 9 0 0

Cold Chain Mechanic 14 14 0 12

Driver(dedicated to UIP vehicles) 49 49 0 0

Cold Chain Storage Points

Recent initiatives

Service Delivery Improvements

In Kerala, like in other parts of the Nation, Private sector is emerging as the

major health care provider. Involvement of private sector institutions in

immunization is essential to increase the coverage. Interactive sessions are

conducted and training to staff on newer concepts in immunization is given to

Private sector also. Vaccines supplied by GOI are given to the private sector

Cold Storage Point Total Number

Proposed Expansion

State Store Nil Nil

Regional Store 3 Nil

District Store 14 Nil

ILR Storage Point 1046 Nil

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also and reports are being collected regularly from all private institutions

giving vaccination. In the low coverage areas, immunization activities are

strengthened with the help of NGOs and private institutions.

Outreach immunisation camps have been identified as a means to extend

immunization to floating and migrant population. Service of ASHA is utilised

in a big way to achieve maximum coverage of these groups. Immunization

sessions are organised in the remote areas giving special attention to tribal,

coastal and urban slums.

Alternate vaccine delivery programme enabled the field functionaries to carry

out immunization sessions on a continuous basis due to flexibility in making

vaccine available at sites without depending on routine governmental system.

Mobility support was ensured for staff engaged in immunization activities.

Hassle free arrangements for transportation of vaccine, maintenance of Cold

Chain etc. are ensured. Vehicle is being hired wherever government vehicles

are not available.

In order to make available enough number of service providers, JPHNs were

hired at places like urban slums.

Continuous monitoring and supervision is considered as one of the most

important component for success of any programme. Mobility support to

DMO/RCH officers/Other District Level Officers was given @ Rs.50, 000/-

p.a. per district for strengthening monitoring and supervision. The amount is

to be utilised for POL /maintenance and hiring vehicles etc.

Introduction of Hepatitis B Vaccination

As per Government of India direction Hepatitis B vaccination is

extended to all districts in the State from December 2007. It has been

monitored in the routine immunization programme constantly. Data is

captured through monthly formats used for collecting information on RI.

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Introduction of JE vaccination

JE Vaccination is carried out in Kerala on a pilot basis in Alappuzha district

during the month of September 2008. With the support of all stakeholders the

programme was successful and is expected to be included in routine

immunization programme as per plan approved by GOI.

RIMS and monitoring activities

Introduction of RIMS in the State facilitated easy monitoring up to the level of

field offices which provided leverage to the district and State officers in

reviewing achievements and timely intervention at needed places. Refresher

training was given to all Computer Assistants and Statistical Assistants at

district and state level.

Computer Assistant for RIMS

Every district was provided with funds for engaging one computer assistant

on contract basis at the rate of Rs.7000/- p.m. for helping RCH Officers in

monitoring the implementation of the programme and dealing with RIMS

reporting. One computer assistant is provided on contract basis to help the

State Immunisation Officer.

During the year 2007-08 an amount of Rs 1260000 has been paid to computer

assistants as remuneration.

Review of the activities related to immunization is done at the block and

districts every month and corrective measures are adopted in low performing

areas. Officers from State are participating in these meetings to monitor

district achievements. Immunization performance is reviewed regularly in the

monthly State Senior officer’s Conference. Special Review meetings of the

RCH Officers were conducted.

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Special IEC and Immunization month

Special IEC activities have been designed in districts like Malappuram and

Wayanad where certain religious and anti immunization groups are working

against the programme. This include exhortations by religious leaders in

religious places amidst solemn functions, community based education

programmes, use of folk arts to propagate immunization, various IEC

materials like immunization Umbrella at session sites, flip charts and posters

at public places, video films, TV advertisements etc.

The month of October is declared as “Immunization Month” and exhaustive

efforts are taken to track Unimmunized and partially immunised children for

follow up action with the help of ASHA and Anganwadi worker. This helped

a lot in finding out drop outs and immunizes them. The Indian Medical

Association and Indian Academy of Paediatricians wholeheartedly supported

these programmes. School level awareness programmes for Parent Teachers

Associations and students were done in all districts.

Monitoring of Adverse Events Following Immunization

Monitoring of Adverse events following immunization is an important

aspect of immunization programme – both to the beneficiaries and the

Department- for confidence building. As per GOI directions State level AEFI

workshop was conducted during 16-17 July 2008 to sensitize stakeholders in

the issue. State and District AEFI committees have been constituted as per

guidelines and are effectively functioning at the state and districts. The

Committees include members from Drugs Controller Dept., Medical Colleges,

Health Services Department, NPSP, IAP, IMA, and NRHM. In order to

continue this procedure further mobility support is needed.

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Two State level meetings were conducted during the year 2008-09. All the

districts conducted AEFI training to the Medical Officers. A special training

was conducted by Kozhikkode DMO for the Medical College faculties and PG

students of paediatric department during September 08.

AEFI reports are regularly received from most of the districts. However there

is a felt need to further train the remaining Medical officers and field staff in

this regard to make them fully equipped in reporting and follow up actions.

Two state level workshops are planned during 2009-10 for public and private

practitioners and other programme officers.

Partnerships with other agencies / organisations (e.g. ICDS, IAP, etc.)

Activities in close coordination with departments directly engaged in welfare

of the children are planned and conducted to promote immunization. Service

of the Anganwadi workers is ensured. The support of PRIs, NGOs,

Kudumbasree, ICDS, IMA, IAP, Rotary and other agencies for ensuring 100%

immunisation coverage is also ensured. Public Private Partnership in the

immunisation programme is being explored. Necessary training is imparted

to all stake holders.

UIP related trainings conducted in the last 3 years

Training is imparted to all category of staff engaged in immunization

activities on a continuous basis. However as many number of batches as

planned are not trained due to lack of time and other constraints

The details of RCH Immunisation Trainings imparted are as below.

Position No.

DIO (Mid Level Manager)

0

MOs 0

14

LHI/LHS 472

ANMs 2909

Other – MHW 1220

HI/HS 211

District level Cold Chain Handlers Training

All the districts have given training to the cold chain handlers. A total of 600

Persons have been trained in 14 districts in various courses conducted during

the year.

Assessment of critical bottlenecks for full coverage

Availability

- Interrupted supply of vaccine

� Now, vaccine is supplied centrally to the Headquarters at Trivandrum from

where the same is distributed by road through out the state. The State has

three regional stores at Trivandrum, Kochi and Kozhikode, which are well

connected by Air. Previously, vaccines were delivered to all the three regional

stores. This has been discontinued for the last few years in spite of Regional

store wise indent. To ensure speedy, adequate and quality supply of vaccines

all over the state, the vaccines are to be supplied to the three regional stores as

was done previously.

� Non-Availability of Medical Officer in hard to reach area PHCs. Even though

various steps have been taken to ensure posting of Medical Officers in these

areas like quota for PG admission, Compulsory rural service after course

completion, preference in transfer and postings etc., there exists vacancies in

rural medical institutions which acts as a bottleneck in implementing

immunization programmes in full swing.

Non Availability of Infrastructure/Manpower in urban areas

� In Corporations and Municipalities with Urban slums, primary health care

institutions are either inadequate or absent. The state health services do not

cover urban areas due to the fact that municipal health services comes under

the municipal administration system which is beyond the purview of the

Department.

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� Shortage of Medical officers and field staff in urban area.

� In tribal and coastal areas, there are shortage of Medical Officers and

supporting staff.

� Also accessibility to the service point is another issue to be sorted out in the

above mentioned areas. Utilization / Adequate Coverage

� Lack of awareness and anti propaganda from certain vested interest groups

affects routine immunization programme in certain areas of the State. Though

there is positive response from religious leaders certain groups keep away

resulting in unimmunized children in the society. Special IEC programmes

are planned and awareness programmes conducted in such areas to overcome

this.

� Non availability of MOs usually results in cancellation of sessions. To

overcome the problem orders have been issued to the effect that presence of a

Doctor is not mandatory.

� Low coverage of hard to reach areas and increasing migrant/mobile population

is adding to the hurdles in achieving complete coverage.

Effective Coverage / Quality

Adequate training is to be provided to the health provider. Necessary modern

equipments to facilitate quality immunisation are to be provided. Protective

devices are to be ensured to the provider. The beneficiaries are to be reassured

of the quality of services by providing effective follow up and medical care

free of cost in case of any untoward incidents following immunization.

The Community is to be protected by disposing the waste materials properly

as per WHO standards.

Objective

State of Kerala had always held the top position in immunization

coverage in the country. Due to reasons associated with development,

migration of population into the State, growth of urban slums and other

reasons like lethargy of staff and consistent anti propaganda achievement is

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slowly dipping. The immediate need is to increase immunization coverage

rates. Based on review of past performance, assessment of critical bottlenecks,

activities have to be planned to achieve maximum coverage. Current year

performance indicated below (2008/09 up to 11/08) is expected to push

forward achievement over 90% by end of the year.

Immunization Coverage Targets

Indicator

Current 2008/09

(up to 11/08)

Expected 2008/09

Planned 2009-10

BCG coverage (%) 63.9 100 100

DPT-1 coverage (%) # 60.9 <90 100

DPT-3 coverage (%) # 57.2 <90 100

Measles coverage (%) 59.9 95 100

Hepatitis B (%) 48 >80 90

Vitamin A coverage (%)* 18.4 >50 80

Drop-out rate BCG – Measles (%) 4 <10 0

Districts with more than 10% BCG- Measles Drop Out

0 0 0

Fully Immunized children (%) 57.2 >90 100

# Shortage in DPT vaccine supply affected coverage * Vitamin A supply suffered shortage limiting coverage Improve Vaccine / Supply Logistics

Vaccine supply logistics of the State is rather foolproof. Normal supply is

ensured by continuous monitoring. Movement of vaccine from regional stores

is as per requirement and demand of the districts. However there was a long

spell of shortage in Vaccine supply especially DPT & DT during current year

which affected immunization programme in a big way. All districts were

affected.

Supply of vaccine to all the regional stores will have to be restored instead of

supplying centrally to the headquarter store.

17

Key Performance Indicators

Indicator Current 2008/09

Planned 2009-10

Districts with any antigen stock-out more than 1 month in the last 12 months – Number (%)

14 NIL

Districts with AD syringe stock-out more than 1month in the last 12 months – Number (%)

NIL NIL

Expand Cold Chain Reach and Improve Performance

Key Performance Indicators

Indicator Current 2008/09

Target 2009/10

Cold Chain assessment done within last 3 years (exact year done or planned)

_ _

Proportion of ILR registered (not condemned) non- functional (%)

Less than 1%

Less than 1%

Regular Cold Chain assessment was being done by sending OPV samples to

PIL Coonoor, Nilgiris. This has been discontinued as instructed by

Government of India

Key Performance Indicators

Indicator Current 2008/09

Target 2009/10

% Districts with routine immunization micro-plans available 100 100%

% Villages (over 1,000 population) covered 1 or more times a month

100 100

% Villages (under 1,000 population) covered 1 or more times a quarter

100 100

% Slums / high risk areas covered monthly 50 100

% Urban areas covered monthly 40 100

% Sessions planned versus sessions held 90 100

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Improve injection safety by introducing AD-syringes and proper waste disposal.

Key Performance Indicators

Indicator Current 2008/09 Target 2009/10

PHCs using ADs for all immunizations (%) 100 100

PHCs with appropriate waste disposal in place (%)

60 100

Ensure accurate record-keeping/monitoring with improved supervision

Key Performance Indicators

Indicator Current 2008/09

Target 2009/10

Gap between reported and evaluated full immunization coverage (%)

2.9 0

(Comparison is between evaluated coverage CES, 2006. and reported figure 05-06)

Training of Immunization staff

Key performance indicators

Indicator Current 2008/09

Target 2009/10

ANMs having received refresher trainings in immunization within that last 3 years (%)

53 100

DIOs having participated in mid level managers (MLM) training within the last three years (%)

NIL 50

Action Plan

New initiatives proposed

Newer concepts in immunization and injection safety training will be given to

the Private sector also. Streamlining in urban area, Implementation of

immunization in low coverage areas with the help of NGOs is also envisaged.

Training camps for the private sector staff is planned in a phased manner.

During the year 10 such trainings are expected to be completed. A total of 300

persons engaged in immunization are proposed to be trained this year.

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Outreach immunisation camps will be organised in the remote areas giving

special attention to tribal, coastal and slums. It is planned to organise four

outreach immunisation sessions under every sub centre area on a fixed day,

fixed time and fixed place every month in consultation with the PRI’s. Due to

the increased cost of POL an amount of Rs.75/- has to be provided to each sub

centre per session for alternate vaccine delivery (Rs.300 per sub centre per

month).There are 5094 sub centres functioning in the state. District wise break

up of sub centres, sessions and expected cost is as follows

Sl No. District No. of sub centre

Sessions planned

Expenditure

1 Thiruvananthapuram 455 21840 1638000

2 Kollam 449 21552 1616400

3 Pathanamthitta 260 12480 936000

4 Alappuzha 368 17664 1324800

5 Kottayam 359 17232 1292400

6 Idukki 231 11088 831600

7 Ernakulam 351 16848 1263600

8 Thrissur 492 23616 1771200

9 Palakkad 471 22608 1695600

10 Malappuram 508 24384 1828800

11 Kozhikkode 389 18672 1400400

12 Wayanad 204 9792 734400

13 Kannur 352 16896 1267200

14 Kasaragod 205 9840 738000

Total 5094 244512 18338400

Mobility support for district staff, transportation for vaccine, maintaining the

Cold Chain etc will be ensured. Vehicles are to be hired when and where

necessary.

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For strengthening monitoring and supervision, District Medical Officers /

District RCH Officers/other district level officers should be given Rs.75, 000/-

p.a. which can be utilised for POL /maintenance and hiring of vehicles etc.

Every district has to be provided with funds for engaging one computer

assistant on contract basis at the rate of Rs.8000/- p.m. for helping RCH

Officers in monitoring the implementation of the programme. Also one

computer assistant will be provided on contract basis for helping the State

Immunisation Officer.

Regular review of achievements will be conducted in the district level and

state level routine meetings. Special review of RCH Officers will be conducted

periodically. MIS will be strengthened. RIMS is fully functional during 08-09

in all the districts. All the districts have uploaded data continuously. During

2009-10 the same will continue.

Mobilization of Children by Anganwadi workers etc.

There is a well maintained network of Anganwadi which spreads into the

nook and corner of the state. Workers of these institutions are well known

and each and every family and child is reportedly known to the worker.

Recently ASHA has also been appointed in the state for every 1000 population

in most of the districts. Social mobilization plans using AWW / ASHA and

other link worker can help in achieving 100 % immunization coverage. A

present we have 22949 ASHA workers as against the target of 32672 and the

selection of 9723 will complete in February 2009. They are working in the

community and for mobilising children to the monthly immunisation camps

an amount of Rs.100/- is proposed as incentive. There is 28651 Anganwadi in

the State. An amount of Rs. 50/session per Anganwadi per month for

mobilization is proposed.

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Slums & Underserved areas

As per data available there are 1169 slums in the State. About 4 lakhs people

are estimated as living in these slums. These slums are underserved areas and

needs specific intervention plans to bring immunization status to state

average.

Out of these 105 slums are situated in coastal areas covering 10 districts

through out the state. In slum areas primary Health Care Institutions are

either not existing or grossly inadequate. Shortage of Medical Officers also

affects effective and total immunization. Hence alternate vaccination system

has to be developed to support Routine Immunization Programme to achieve

desired results. Out reach camps will have to be organised in these areas.

Trained ANMs are to be hired for conducting the camps. Medical Officers of

nearby institutions will be put in charge of these camps.

The expenditure for alternate vaccine delivery includes mobility support for

staff and transportation of vaccine to session sites. It is proposed to hire one

ANM for three days per session and four sessions will be conducted in a

month. Three days combination is (1) previous day for mobilization, 2nd day

immunization and post immunization day for follow up activities. In Kerala

the Minimum daily wage fixed Rs. 175/- Hence an amount of Rs.525/- is to be

earmarked per session. Rs. 200/- per month per session is to be provided as

contingency. District wise break up of slums and estimated expenditure for

conducting outreach camps are detailed below.

Sl No. District Number of slums

No of sessions

Expenditure

1 Thiruvananthapuram 122 5856 4245600

2 Kollam 71 3408 2470800

3 Pathanamthitta 51 2448 1774800

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4 Alappuzha 92 4416 3201600

5 Kottayam 66 3168 2296800

6 Idukki 17 816 591600

7 Ernakulam 339 16272 11797200

8 Thrissur 57 2736 1983600

9 Palakkad 124 5952 4315200

10 Malappuram 83 3984 2888400

11 Kozhikkode 89 4272 3097200

12 Wayanad 28 1344 974400

13 Kannur 24 1152 835200

14 Kasaragod 6 288 208800

Total 1169 56112 40681200

Strengthening monitoring and supervision and surveillance

State Level and district level monitoring, supervision and surveillance of

immunisation programme is to be strengthened. In districts where

achievement is showing continuous low performance special programmes are

planned. Periodic visit up to low performing districts from the Directorate to

assist in plugging the gaps have been decided. The Districts of Malappuram,

Wayanad, Kozhikkode and Kannur will be subjected such constant vigil. At

the district all Programme Officers will be put in charge of specified areas to

monitor immunization over and above routine supervision.

State Task Force

State Task Force is planned for the coming year to gear up immunization

activities of identified districts. This will be in addition to the existing routine

monitoring system. Periodic meetings with religious leaders, Local Self Govt.

members, Programme Officers are expected to boost the morale of staff and

thereby improve the achievement. It has been observed that intervention by

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headquarter officers reduces non cooperation of the reluctant groups/

communities to a great extent. The Task Force consists of minimum three

State Level Officers for each district. Mobility support for the state level team

and support for state level supervision is to be provided. An amount of Rs.

25000/- per district is proposed for the same during the year for the 4

northern districts.

Further for district level monitoring, supervision and surveillance all Districts

Medical Officer / District RCH Officer/ other Districts level officers will be

provided a lumpsum amount of Rs.75000/- p.a. for mobility support as well

as hiring of vehicles in contingencies.

Introduction of RIMS software for monitoring UIP

RIMS (Routine Immunization Monitoring System) have been fully functional

in the state. Government of India has provided training to the staff of the state

for RIMS launching. Software installation is completed in all the districts and

the upload of data has been continuing from all the districts. State Nodal

Officer has also been nominated to monitor data entry and uploading of data.

Staff trained in RIMS has been shifted in many places and new computer

assistants have recruited also. Hence refresher training is proposed for the

supporting staff (Statitistics personnel, computer assistant) to be given at the

state level. Training in RIMS to Medical Officers is also essential. Logistic

support will be provided to RIMS at state and district reporting units.

Periodic visits to the district for review and supervision of RIMS will be

undertaken by the state nodal officer and other state officer. Mobility support

is proposed for the same.

Computer Assistant to RCH Officer

Based on Government of India direction one computer assistant has been

provided to every RCH Officer to ensure data entry of RIMS and other related

24

immunization monitoring activities. One computer assistant is posted to help

State Officer too.

Remuneration of the computer assistant needs to be enhanced to a minimum

consolidated amount of Rs. 8000/- The present amount of Rs. 7000/- is found

quite inadequate as the volume of work assigned to these persons is fairly

large. Unlike the previous year computer assistants are in position in all

places and the requirement of fund will be more.

1. One Computer Assistant each to 14 District RCH Officers @

Rs. 8000/-per month is proposed at an estimated cost of Rs. 1344000/

annum.

2. One Computer Assistant for the State Immunisation Officer is

proposed @Rs. 8000/- per month at an estimated cost of Rs.96000/

annum.

Recruitment of these computer assistants will be done on contract basis.

Review meetings

Regular review of the activities and achievements of immunization

programme will be conducted at state, district and Block levels along with

routine meetings. 2 Special review meetings of the district RCH officers at

state headquarters is proposed to assess the activities at State level.

Participation of the State Level officials, District Medical Officer of Health,

DIO, will be ensured during these meetings. One state level review meeting

for the other programme officers-MCH Officer, DPHN, and DNO-is also

planned to analyse more specifically the activities and discuss and concretise

interventions required in the field.

During 2008-09 only two meetings could be convened due to paucity of

funds. Financial support to the three meetings involving 40 participants per

RCH review meet and 75 participants for other programme officers meet is

proposed during the year 2009-10. Review meetings are proposed in all

25

districts. In addition, monthly block level, PHC level review meetings are also

proposed. .

Provision for additional support

Vaccine supplies - routine (doses in lakhs)

Vaccine 08-09 09-10

OPV * 40 40

Measles 8 8 BCG 12 12

DPT 32 32

DT 8 8 TT 32 32

* Requirement of vaccines for OPV is calculated including zero-dose as about 99.5% of the births take place in institutions.

Vaccine supplies – additional required (doses in lakhs)

Vaccine 08-09 09-10

Hepatitis B 24 24 JE 8 8

Cold Chain Strengthening

Replace CFC equipment with non-CFC equipment

Replacement Required with Non- CFC

Sl. No.

Item

2008-09 2009-10

1 ILR (Large) Nil Nil

2 Deep Freezer (Large) 10 Nil

3 ILR (Small) 200 150

4 Deep Freezer (Small) 100 100

Replacement of non-functional (Beyond repair) equipment

Replacement Required

Sl.No.

Item

2008-09 2009-10

1 ILR (Large) 5 5

2 Deep Freezer (Large) 10 10

3 ILR (Small) 20 120

4 Deep Freezer (Small) 20 120

26

Expansion of cold chain storage points

Additional Requirement Sl.No. Item

2008-09 2009-10

1 Walk-in-cooler 1 Nil

2 ILR (Large) 14 Nil

3 Deep Freezer (Large) 14 Nil

4 ILR (Small) 28 Nil

5 Deep Freezer (Small) 28 Nil

Cold Chain maintenance

� Cold chain technicians

Technicians are in place- 14 numbers in 14 districts.

� Cold chain Maintenance fund

Total requirements – Rs. 1000000/-

Rs. 700000/- annum is required for maintenance of cold chain equipments at

CHC /PHC/PP unit and district level.Rs.210000/- is required for maintaince

and repairs of three walking coolers at regional level. Rs.90000/- is required

as mobility support for transport of vaccines under cold chain from

Trivandrum to regional vaccine stores at Kozhikode and Ernakulam The

amount will be utilised for procurement spare parts, arranging repairs and

maintenance, mobility support for District Refrigeration Mechanic and State

Cold Chain Officer and all activities connected with maintenance of cold

chain

AD Syringes

Requirement Sl.No. Antigen

2008-09 2009-10

1 DPT 2400000 2400000

2 DT 600000 600000

27

3 TT 2400000 2400000

4 BCG 600000 600000

5 MEASLES 600000 600000

Total 6600000 6600000

AD Syringes supplied was contaminated at times with fungus. In certain AD

Syringes, manufacturing defects were noticed. It may be ensured that these

problems are not repeated.

Bio medical waste management on immunization

Biomedical waste management has become a major problem area to be

handled properly to fulfil the requirements of Pollution control activities of

the Government. The main initiatives in this regard are

(1) Construction of waste disposal pits. At present only less than 60% of

the requirement of waste disposal pits are constructed. During the year 2009-

10 attempts will be made to construct another 400 pits. An amount of Rs. 16

lakhs is proposed for the activity @Rs.4000/- per pit.

(2) Purchase of puncture proof containers for disposal of AD syringes

and needles. An amount of Rs. 100000/- is proposed for the activity

(3) Purchase of Hub Cutter. This is proposed to be supplied to all

institutions. An expenditure of Rs. 100000/- is expected under the item.

Printing of mother -child vaccination card, MCH Registers, Immunization reporting

Formats and dissemination of tally sheets

� Supply mother-child card / vaccination card

Proposed printing during the year 2007-08 could not be

materialized due to circumstances. Printing of mother-child

vaccination card, 650000 nos. during 2008-09 is completed and

28

supplied to the field offices. The same number of vaccination cards

will be printed and supplied during the year 2009-10 too.

MCH registers and Immunization reporting formats were printed

during the year. The reporting formats have been revised and hence

have to be printed and supplied to the field functionaries during 09-

10 for prompt reporting. Printing of mother-child register and other

allied registers etc are also proposed to be printed. It is proposed to

print these by the State in vernacular language wherever necessary.

Re-orientation of ANMS

Re-orientation training for ANMs is proposed. Though the programme is

running for last few years, the no. of ANM not given re orientation continues

to be substantial. Hence additional efforts to cover as many ANMS during

this year are planned.

Additional trainings

� Refresher trainings to DIO / Regional Store on supply formats

Government of India has agreed to arrange the training for DIO /

Regional Store at the national level. No cost incurred by the State

State Specific strategies

Funded by State Budget

NIL

Funded by State Development Partners

A proposal for strengthening Immunization in low coverage districts has been

submitted to UNICEF and tentative approval received. Final approval and

release of fund is awaited.

Additional State Schemes Requiring Additional Funding From

Central Government

a) In addition to the State level review meetings, it is proposed to

conduct district level review meetings and PHC level review

29

meetings to ensure that the project is moving in the right direction.

Funds for the same are proposed. Further, each district will be put in

charge of a State level officer for effective supervision, monitoring

and surveillance. Mobility support will be provided. This was not

permitted by Government of India in the PIP for 2008-09. It is

requested that the activity may be sanctioned.

b) To ensure that the mother child register, other allied registers,

mother-child card / vaccination card etc. are available at all the

places in the vernacular language, budget for printing the same is

proposed.

c) Also, organisational cost for all the trainings i.e. honorarium for

resource persons, institutional overheads and logistics are proposed.

d) Renovation of district Family Welfare Stores has become necessary as

most of the stores are in very poor structural conditions.

4. Annexure

1. Budget for Immunisation

30

IMMUNISATION BUDGET 2008-09

Particulars Amt

Funds for cold chain Maintenance 1000000

Support for Computer Assistant at state &District level 15x8000x12

1440000

Support for State Level Task Force 100000

Mobility support for Special Review Meeting (3 meetings -115 participants (2X30+55)

175000

Mobility Support for supervision- for district level officers 75000/-x14

1050000

Alternative vaccine Delivery (75x4x12x5094): Alternate vaccine Support for 4 sessions p.m.@ Rs.75 / sessions =Rs.300 per sub centre per month

18338400

Focus on slum & underserved areas in urban and Tribal area Hiring an ANM@ Rs 525/session for four sessions/month in 1169 slums and Rs 200/- per month per session as contingency per slum i.e., total expense of Rs.2900/- per month per slum.(2900x12x1169)

40681200

Mobilization of children through AWW. (Rs. 50/-p.m.for one session) (50x12x28651)

17190600

Incentive for the social mobilisation of children for Immunisation by ASHA Workers ( 32672 x 12x100)

39206400

Training No.1:District level orientation training for there days ANM, multi Purpose Health Worker(Male),LHV, Health Assistant (Male/Female), Nurse Mid Wives, BEES& other specialist (as per GOI norms)-25 participant per batch, 80 batches in 2008-09

3953700

Training No. 2: Cold chain handles training-One day training with per diem Rs125/- and contingency Rs.100 per participant, Honorarium Rs.300/- per session for 4 sessions for 1 day, IOH/ Logistics Rs.1500/-,25 per batch, 34 batches

283050

AEFI workshop at state level for district programme officers and members of Committees and other stakeholders (2 X Rs. 50000)

100000

Support for RIMS- procurement of accessories ongoing expenses, and related expenditure 10000x15

150000

Refresher training for RIMS support staff state level 2 trainings (1 day, 25 participants each) Rs.30000 per training.

60000

Mobility support of State level Officers for review and Supervision of RIMS

100000

31

Waste disposal activities (Rs. 1600000 for pit construction +100000 for containers+ 100000 for hub cutter

1800000

Printing & issue of folders & Posters (Rs.100000 per district) 1400000

Printing of mother-child card/vaccination card (650000 nos. each year)

1700000

Printing of MCH registers and formats 1000000

Renovation of family Welfare Store (500000 per district for 5 districts)

2500000

Total

132228350