Improving Immunization and Fighting Polio in Pakistan

Polio remains endemic in only two countries: Afghanistan and Pakistan. Apart from polio campaigns, broader support for immunization is essential to eradicate polio. Two weeks ago (on April 21, 2016), the World Bank approved an International Development Association (IDA) credit of $50 million to increase the availability of vaccines for infectious diseases, including polio, for children under two years of age in Pakistan.  Additional funding to the amount of $80 million is provided by a World Bank administered multi-donor trust fund, Gavi – the Vaccine Alliance, and the United States Agency for International Development. The Bill and Melinda Gates Foundation also participates through a buy-down mechanism (on what a buy-down amounts to, click here). Below is information on the project reproduced from the World Bank’s website (the original link for the information is here).

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The National Immunization Support Project (NISP) is supporting the country’s Expanded Program on Immunization (EPI) that aims to immunize all children against eight vaccine preventable diseases:  tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type b (Hib), and measles. Strengthening EPI will also support Pakistan’s access to newer vaccines which are either in the process of roll out (pneumococcal vaccine) or under planning (rotavirus vaccine).

The Project is also receiving additional support of $80 million grant from a World Bank administered multi-donor trust fund, Gavi – the Vaccine Alliance, and the United States Agency for International Development. The Bill and Melinda Gates Foundation is also supporting the project through an innovative partial conversion of the IDA credit into a grant upon successful achievement of project objectives.

“Pakistan is grappling with the public health emergency of polio virus transmission. Ensuring strong routine immunization services is the first essential pillar in polio eradication”, says Illango Patchamuthu, World Bank Country Director for Pakistan. “The World Bank and other development partners are working with the Government of Pakistan to strengthen routine immunization services at the critical endgame stage of polio eradication, particularly as Pakistan introduces injectable polio vaccine into its routine schedule”.

The project will incentivize provincial government capacity for rigorous monitoring and effective implementation of its program, including strengthened vaccine logistics, and deploying and expanding qualified technical and managerial personnel.

“Pakistan’s performance in maternal and child health remains weak and inadequate immunization coverage is a major challenge. Childhood immunization against vaccine preventable diseases can help in significant reductions in disability and death”, says Robert Oelrichs, World Bank Task Team Leader of the Project. “The project will establish linkages of the federal and provincial EPI cells with private sector health providers and health-related civil society organizations (CSOs) working in low coverage catchment areas – especially urban slums.”

Children under two years of age in Pakistan are the main beneficiaries of NISP – particularly children belonging to the poorest households in which immunization coverage is lowest. In addition, all children will benefit from strengthened polio and measles interventions.

The credit is financed by IDA, the World Bank’s fund for the poor, with a maturity of 25 years, including a grace period of 5 years.

Rotary’s Family Health Days Featured at the World Bank

Today, in celebration of International Women’s Day, Marion Bunch, the founder of Family Health Days, participated in a well-attended event at the World Bank about inspiring women who made a difference in the world through innovative programs in the areas of education and health. The event was streamed online through World Bank Live, and a recording will soon be available if you missed it. What are family health days? Do these days make sense from a policy point of view? And who is Marion Bunch? This blog post answers these three questions.

Family Health days

What are family health days?

Imagine hundreds of thousands of families and individuals getting free health care for two or three days. Family Health Days makes this feasible. Individuals and families can be tested for HIV/AIDs as well as receive counseling. Testing and/or screening for tuberculosis, diabetes, high blood pressure, and other conditions such as cervical and breast cancer is provided. Children receive immunizations as well as Vitamin A supplements. Some sites also include dental clinic and hygiene education as well as eye examinations. Health counseling is also provided.

The program was launched in 2011 and is now active in a half dozen countries in sub-Saharan Africa and South Asia. The program is led by Rotary in partnership with the Coca-Cola Africa Foundation, the U.S. Mission – including the Centers for Disease Control, USAID and the health service delivery expertise of their implementing partners – and Ministries of Health that provide services and supplies at the sites. Media partners promote the days in each of the countries. Thousands of volunteers in each country, including many Rotarians, help in various ways.

Do family or child health days make sense from a policy point of view?

Intrigued by the concept of family health days, I conducted a rapid search of the literature and found that for purposes such as screening for illnesses and child immunization, holding such days appears to make a lot of sense. This type of programs appear to be beneficial and cost effective if implemented well.

For example, Fiedler and Chuko looked at the reach and cost of child health days in Ethiopia in 2008. They found that the program reached more than 10 million children at an average cost of half a dollar per child (one dollar when including measles). This made the program cost-effective, with potential additional benefits to be reaped through economies of scope in increasing coverage at delivery sites.

Palmer and others note in a 2010 article that child health days are becoming increasingly popular, implemented in more than 50 countries at the time of the study. They conclude that the days are helping countries achieve high and equitable coverage of essential health and nutrition services. Child health days were also recognized as beneficial in a 2013 World Health Organization report on essential nutrition actions for improving maternal, newborn, infant, and young child health and nutrition.

Improvements could be made, however. In a 2012 review of experiences integrating the delivery of maternal and child health services with childhood immunization programs, Wallace, Ryman, and Dietz emphasize the importance of proper planning and awareness when implementing these interventions, among other actions to reduce the risks of logistical difficulties, time-intensive interventions ill-suited for campaign delivery, concerns about harming existing services, and overlap of target age groups with other service delivery mechanisms. The review also revealed gaps in information about costs and impacts.

On costs, a 2014 paper by Fiedler and Semakula suggests that part of the reason why costs may appear so low in some countries (US$0.22 per child in their analysis for Uganda) is because of underpayment for Ministry of Health staff and volunteer allowances. Still, the authors find that child health days are successful in saving lives, making them highly cost-effective. Vijayaraghavan and others in a case study for Somalia also find child health days to be cost-effective in addressing leading causes of child mortality in a conflict settings. They rate child health days as one of health sector’s best buys in sub-Saharan Africa.

Who is Marion Bunch?

What is also interesting – especially as we celebrate International Women’s Day and the power of women to make a difference in the life of the less fortunate, is the personal story of Marion Bunch. Marion is the Chief Executive Officer of the Rotarian Action Group Rotarians for Family Health & AIDS Prevention. She has received numerous awards on behalf of her work for AIDS. But first and foremost, she simply considers herself a mother who helps in representing the human face of AIDS. She started her work after losing her son to the disease in 1994. As she explained it in an interview. “I never thought I’d do anything about it until one day, three years after his death, I felt a tap on the shoulder, and a voice in my ear said, ‘Mom, get up and get going; you haven’t done anything, and it’s been three years.’” Since then, the reach of Family Health days has expanded every year, in close partnership with Ministries of Health in the countries where the program is running. Marion’s story has been told in a documentary film that won two 2015 Telly Awards.

What can be learned from Marion’s project?

On the occasion of International Women’s Day, at least two important lessons emerge her project. The first lesson is that we can expand access to health care for children and families through Child and Family health Days, and we should invest in the expansion of these programs. But the second and most important lesson is that beyond the important role of the state that we often emphasize in development work, committed individuals can truly make a difference in the life of the less fortunate. The theme of the event at the World Bank was “Inspiring Women of Action”. There is no doubt that Marion is such a woman.

If you were not able to watch the event live, a recording will soon be made available here.

This post is adapted from a post published today on the World Bank’s Investing in Health blog.

Providing Water and Sanitation in Uganda (Partnerships Series No. 3)

As in other low income African countries, access to water and sanitation remains limited in Uganda, especially for the poor. This third post in a series on partnerships, innovation, and evaluation tells the story of how Rotary is playing an important role in helping to meet some of the water and sanitation needs of Uganda’s population.

Apac

Water Projects

A first important initiative is the Uganda Rotary Water Plus (URWP) program. URWP coordinates work on water and sanitation done by 78 Rotary clubs (virtually all the clubs in Uganda). The program was launched by the Ugandan Minister for Water and Environment in October 2011. It promotes effective service delivery to rural and less privileged communities.

Clubs develop projects for the communities they wish to serve. For this purpose, they must first build strong relationships with the community and develop a needs assessment. Having identified needs, clubs then select partners to meet those needs, including other Rotary clubs for fund raising, non-profits and/or business partners for implementations, and local authorities. Co-funding is typically provided by the Rotary Foundation (TRF) and in some cases other funding agencies.

The design of projects must be based on adequate technologies for the community context, with attention paid to gender and environmental issues. Clubs are encouraged to link the projects to other areas of focus of TRF, for example by providing water and sanitation to schools or health clinics.

The idea is that water and sanitation alone can’t transform a community; the “Plus” in URWP refers to other areas of focus of TRF such as supporting education or fighting disease.

The model also encourages local management committees to oversee facilities cost recovery through tariffs so that funds are available for maintenance.

URWP aims to raise $7 million for more than 30 projects. Rotary International is also partnering in Uganda with USAID to invest $4 million over four years through additional projects, following previous successful similar collaborations in the Dominican Republic, Ghana, and the Philippines (this broader partnership is referred to as the International H20 Collaboration).

Beyond the mobilization of funds, the URWP initiative has also succeeded in uniting 4,000 Ugandan Rotarians, more than 3,000 Rotaractors and many members of Rotary Community Corps (RCCs) behind countrywide water and sanitation initiatives. Many have volunteered their time and financial resources to support the projects.

Community Needs Assessments

Another interesting initiative that is part of URWP has been the implementation of a detailed diagnostic of water and sanitation facilities in communities of Apac District located 250 kilometers north of Kampala.

The idea behind the water and sanitation community needs assessment was to prepare an inventory of resources as well as gaps to be used by the Ministry of Water and the Environment as well as Rotary and other funders for the prioritization of investments. Teams visited communities. After an initial meeting in each community, data collection involved implementing a survey, conducting interviews and focus groups, establishing an inventory of all water and sanitation assets in the community, and conducting community mapping exercise.

Data were collected using the FLOW (Field Level Operations Watch) system developed by Water for People. The application relies on Android cell phones together with GPS data and Google Earth software to document water and sanitation infrastructure as well as its functionality.

The community needs assessments was implemented with support from the Apac government and 16 organizations. Rotaractors served as field enumerators. Data were collected for communities as well as public institutions such as schools and health centers, with ratings provided on the quality of facilities and the satisfaction of users. Tests of water quality have also been conducted in some of the areas.

Conclusion

URWP represents a prime example of efforts by Rotary to invest in projects that have a larger impact through partnerships, innovation, and monitoring and evaluation.

The URWP team has established partnerships with multiple NGOs as well as USAID and Ministry of Water and the Environment. It has been innovative in project design to ensure a higher likelihood of sustainability. Evaluations of the projects are not yet available (many projects are still at the design or implementation stage), but monitoring systems are being put in place.

Finally, in the case of Apac district, extensive data collection has been conducted on water and sanitation assets and gaps at the level of communities in order to inform prioritization of future investments. This should also help in achieving higher impact through targeted interventions.

A brief on the URWP initiative as well as the water and sanitation context in Uganda is available here.