Supportive Supervision Madhya Pradesh

Supportive Supervision Process Description and Rationale

1. Background:
In India about 900,000 children aged 1month to 5 years die annually. 1
Immunization is one of the most cost effective interventions for disease prevention.
India has more than 12million unimmunized children and most of these children are
from few low performing states2. Low full immunization coverage in some of the states
in India is a deep concern for the Government of India and State Governments and all
development partners assisting governments in implementing the routine
immunization program. There has been some improvement in immunization coverage
the poorly performing states of India between DLHS-2 and DLHS-3. Over the same
time in some of the good performing states (Tamilnadu, Kerala, Maharastra), and some
moderately performing states (Gujarat, Haryana), immunization coverage has declined
also. There has been mismatch between the reported and evaluated immunization
coverage values, especially in these low performing states. The routine reporting from
the state health system HMIS, the antigen coverage is very high, crossing 90% most of
the times. This discrepancy in the coverage levels have triggered many coverage
evaluation surveys addressing the issues of cold chain, client behavior,
manpower/vaccinator and many appropriate modifications are being tried.
Traditionally the major thrust of immunization services was to reduce infant and child
mortality. Immunization delivery is also a vehicle for health promotion and other
health services addressing morbidity of public health significance in all age groups.
Therefore, immunization is not merely an item of national expenditure but a national
investment.

India has one of the largest Universal Immunization Program (UIP) in the world in
terms of quantities of vaccines needed, used, number of beneficiaries (27 million
infants and 30.2 million pregnant women), geographical spread (29 States and 6
Union Territories) and manpower involved. Government of India’s Multi Year Strategic
Plan for 2005-10 had planned to take UIP to the next level. The overall UIP program
management requirements, over last 3-5 years have grown and diversified
tremendously. The country is considering new strategies to increase immunization
coverage and reach more children with quality vaccines. Cold chain is the most
important component to ensure quality vaccine reach to each and every child
immunized. This is also important in light of expanding the UIP mandate with thrust
on reduction and elimination of certain diseases like Measles, Tetanus etc and
introducing new vaccines.

1
UNICEF, The State of the World’s Children 2009, statistical Table 1 (p 119); calculated using U5MR of 72 per 1000
live births, NMR of 39 per 1000 live births, and an estimated 2007 birth cohort of 27,119,000.
2
Universal Immunization Programme (UIP) Review. World Health Organization. Available from:
http://www.whoindia.org/EN/Section6/Section284/Section286_507.htm.

Proposal- Dr Rajan Dubey, Sr PO, NIPI, Madhya Pradesh

Supportive Supervision Madhya Pradesh

The state of Madhya Pradesh is characterized by high prevalence of malnutrition

and high Infant Mortality Rate with significant rural-urban, socio-economic and inter
district variation. The proportion of fully immunized children in state of Madhya
Pradesh as revealed from District Level Household Survey (2007-08) is 36.2%,
with only marginal improvement from DLHS (2002-04), which was 30.4%. The
current status is far behind better performing states like Tamil Nadu, Kerala and
Himachal Pradesh (83.2%, 79.5% and 79.3% respectively, DLHS3). Significant
differences in immunization coverage rates are also observed among different divisions
and districts of the state.

For strengthening Routine Immunization status in the state, Govt. of MP with

support from Norway India Partnership Initiative (NIPI) and UNICEF, with technical
support from IMMUNIZATION basics (IB) conducted 2 rounds of Supportive
Supervision activity in district Rewa during December 07 and May 08. These 2 rounds
of activity resulted in visible improvement at programme planning and management
level. Encouraged from the results, Govt. of MP decided to replicate similar activity in
other divisions/districts of the state in a phased manner. After obtaining concurrence
from State and District officials, first round of supportive supervision was conducted
from 28th to 30th December 08, by team of NIPI, UNICEF, IB, Health officials of
Bhopal division and also officials from AYUSH, WCD, Education and PRI.

Objectives
Supportive Supervisory visits to Health Centers and Immunization sessions aimed to:

• Collect critical information to take managerial decisions and provide feedback to

concerned authorities and recommend measures for improvement

• Make onsite corrections in the field.

• Educate and provide on job training to concerned health functionaries.

The visits were made using Supportive Supervisory Checklists (one each for Health
Center and Immunization Session) that detail the recommended practices, which need
to be implemented in order to ensure delivery of quality immunization services.

The Best practices encompass all aspects of immunization including:

• Microplanning
• Programme Management
• Cold Chain Maintenance
• Injection Safety
• Supplies and Logistics
• Reporting and Surveillance
• IPC and Social Mobilization

Proposal- Dr Rajan Dubey, Sr PO, NIPI, Madhya Pradesh

Supportive Supervision Madhya Pradesh

Process to be followed in 1st Phase:

A day before the rounds, the team members will be sensitized on Routine
Immunization, use of standard check lists, and briefed on methodology to be adopted
and information to be collected. On the subsequent days, visits were made to all the
health facilities of the district and crucial information was collected on basis of check
list. Necessary onsite corrections were made by the teams and block officials were
informed about the correct practices. Few randomly selected immunization session
sites were also visited to assess the ongoing practices. Health workers were apprised
on the best practices during these visits.

The information collected was entered in the MS Excel based template with facility of
ready generation of necessary figures and graphs. Debriefing was done with the DM,
SEPIO, and the CMO of the district. The action points were discussed and managerial
decisions will be taken.

Process to be followed in Continuation:-

Improving routine immunization has been a key activity in the RCH-II program. For
improving routine immunization under NRHM, manpower, cold chain equipment,
micro-planning and effective coordination between health and ICDS workers have
been emphasized. Hence, there has been an effort towards making the system ready
for optimal service delivery. But, the system is still largely failing to deliver. Now the
possible services are being integrated at village level through the Village Health and
Nutrition Day (VHND), which includes the immunization, ANC, nutrition, family
planning, giving antiTB drugs, counseling and health education services targeted at
children and mothers and community level discussion and data collection.

In the 6th Joint Review Mission on RCH-II of NRHM (May-July 2009)3, it was observed
that across India about 70% of the planned sessions were being held. Also the Joint
Review Mission (JRM) observed that the logistics support for of vaccine and other
supplies were poor in several states. If the current immunization outreach sessions
have problem in covering all the eligible children and pregnant mothers, it is obvious
that there will be concern for integrating so many services along with this and
delivering them.

Under NRHM some managerial inputs have been added to the health system and
program management. But it seems that that is not enough. To improve the efficiency
and reach of the services much more is still to be added. NIPI Madhya Pradesh plan

3 th
6 Joint Review Mission, National Rural Health Mission, Reproductive & Child Health Program Phase II, May–July,
2009, Ministry of Health & Family Welfare, Government of India.

Proposal- Dr Rajan Dubey, Sr PO, NIPI, Madhya Pradesh

Supportive Supervision Madhya Pradesh

has already placed BCHM and DCHM in BPMU and DPMU. NIPI MP plan also wishes
to strengthen cold chain handling and assessment of focal points with more than 10
sessions handling.

Some areas that have been proposed for improving immunization coverage are:
(i) bringing immunization closer to communities;
(ii) increasing demand for vaccination;
(iii) improving practices at fixed sites;
(iv) better monitoring and supervision, and fixing accountability at various levels; and
(v) exploring and adopting innovative methods and practices.

In this MP NIPI wishes to expand scope of Session to full VHND coverage in

combination with focused supervision of HBPNC by trained supervisors.

NIPI Madhya Pradesh also plans to prepare its districts to take maximum advantage of
Measles SIA in Coming months in India. This exercise will pave way for effective
implementation of Measles SIA.

Phases
This Process will be undertaken in 3 phases.

Phase 1 Training of the Supervisors and Managers for data collection,

(3 days) Testing of new check lists developed, expansion of regular tool used
for monitoring to include VHND services

Rapid assessment of vaccine storage status at all focal points

Analysis and report writing---- ACTING as BASELINE REPORT

Phase 2 Regular Monitoring through VHND formats and supervision tools

(6 mons) developed

Phase 3 Follow up of phase 1 and writing process for further improvements

(2 days) from baseline

Proposal- Dr Rajan Dubey, Sr PO, NIPI, Madhya Pradesh

Supportive Supervision Madhya Pradesh

Proposed Area and Budget for the process:-

In 1st phase District Narsinghpur will be taken for the ease of Administrative
compactness and smallest of four NIPI districts. All BCHM positions are filled and
DCHM is present.

Phase -1 cost:-

S
Topic Estimation Cost
No
Training of 25 supervisors. 5 Books and Materials on
supervisor per block at immunization and VHND donated
One day costs for
district Training center to DTC and educational material
this training
Trainers, and NIPI managers to participant trainers from NIPI
Extra= 15 Secretariat, New Delhi
Food and snacks
=40*400*3
1 cost Rs 400 Per
48,000
Person Per day for
INR Forty Eight Thousand only
three days
=40*180
Stationary Cost and Training
Rs 180 Per 7200
Material including Training
Participant INR Seven Thousand Two
Certificates
Hundred only
= 2*5*2@3000
Cost of Hiring Vehicle for 2 Each Block to have
2 60,000
days 2 Vehicles for 2 days
INR Sixty Thousand Only
=20*400
Report Writing and Printed
3 20 Copies INR 8000
Copies of Report to all levels
Eight Thousand Only
4 Contingency INR 15,000
Total INR 1,38,200/-
Rs One Lakh Thirty Eight Thousand Two Hundred Only

Proposal- Dr Rajan Dubey, Sr PO, NIPI, Madhya Pradesh