Concepts in evaluation of vaccination programs in low income countries
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“Concepts in evaluation of vaccination programs in low income countries" . Jagrati Jani Section for International Health Department of Community Medicine Institute for Health and Society Faculty of Medicine University of Oslo. Presentation Outline Introduction

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Concepts in evaluation of vaccination programs in low income countries

“Concepts in evaluation of vaccination programs in low income countries"

JagratiJani

Section for International Health

Department of Community Medicine

Institute for Health and Society

Faculty of Medicine

University of Oslo


Concepts in evaluation of vaccination programs in low income countries

  • Presentation Outline

  • Introduction

  • Epidemiological transition

  • Evaluation conceptual framework

  • Expanded Program on Immunisation Goals and main Indicators

  • Vaccine Coverage and health Information System

  • Disease surveillance and health Information System

  • Final remarks


Concepts in evaluation of vaccination programs in low income countries

Transition in thepopulation

DemographicEpidemiologicalNutrition

transitiontransitiontransition

Highfertility/mortalityHighincidenceHighprevalence

ofcommunicablediseasesundenutrition

SocioeconomicVaccinationSafe water Improved diet

Decreasedfert./mortReduction in infectiousdiseasesReducedundernutrition

Increasedovernutrition

Rise ofChronicDiseases

Popkin et al


Evaluation

Evaluation

  • Is a systematic investigation of the structure, activities and results of public health programs

    • Achieve its goals and objectives

Source: Center for Disease Control (CDC) Atlanta 2009


Evaluation methods

Evaluation methods

  • MethodQualitative, Quantitative or Both

    • “HARD AND OBJECTIVE, SOFT AND SUBJECTIVE”

    • Cross sectional

    • Retrospective

    • Prospective

    • Data collection instrument

  • Primary data (use of research instruments)

    • Questionnaire

    • Interviews

    • Observations

  • Secondary data (data already existing)

    • Statistics on health

    • Reports

StartAIM Planning an evaluation

$

Field work

Data collection

Data analyze

Interpretation of findings

Report

  • How to apply the findings

  • Dissemination


Conceptual framework

Conceptual framework

Impact evaluation

Aim of

the program

  • Impact

  • Disease incidence

  • Mortality, morbidity

Process evaluation

  • Outcomes

  • Targeted population

  • receiving the intervention

  • Vaccine coverage

  • Vaccine Effectiveness

Impact

  • Outputs

  • Plans

  • Number of vaccines

  • administrated

  • Number train staff

  • Health system

  • Service availability

  • Quality of services

Formative

evaluation

Activities

Effectiveness

Inputs

Data

Finances

Sustainability

Efficiency

Adapted from the source: Health Care Evaluation. Open University Press, 2005


Concepts in evaluation of vaccination programs in low income countries

EPI goal

To reduce mortality and morbidity from the targeted diseases

among the target group.

Indicators

Vaccine coverage and vaccine efficacy

Incidence of the disease


Output service availability

Output: Service availability

  • Health system

Health facility

Curative

care

Preventive

care

vaccination

Outreach program

Supplementary vacc. program

Health facility


Concepts in evaluation of vaccination programs in low income countries

Immunization Program

  • Data collection

  • Data register

Knowledge

information

management & register

  • Condition and

  • maintenance

  • of the equipment

Cold Chain

Vaccine & transport

management

  • Availability

  • Inventory

  • stocks

Vaccine admin

And safety

Contact with the client

demand,

risk factors for

not immunize

  • Community level


Concepts in evaluation of vaccination programs in low income countries

  • Factors influencing the programme performance:

  • Intrinsic factors

  • Change in resources

  • External donors

  • National commitment

  • Programme structure, management or activities

  • Changes in vaccination schedule

  • Vaccine shortage

  • Additional activities- campaigns

  • Human resources

Extrinsic factors

Political stability

Population accuracy

Accessibility to the HF

Acceptability ( BCG Magude)


The reasons not to vaccinate

The reasons not to vaccinate

Source: J. V. Jani, C. De Schacht, I.V. Jani and G. Bjune: Risk factors for incomplete vaccination and missed opportunity

for immunization in rural Mozambique. BMC Public Health, 2007


Concepts in evaluation of vaccination programs in low income countries

The Cow-Pock. The Cow-Pock or theWonderfulEffectsofthe New Inoculation!

by James Gillraywaspublished in England in 1802 by theAnti-Vaccine Society.

The etching, which shows Edward Jenneramongpatients in theSmallPox and Inoculation Hospital at St Pancras (London),

suggests thetransformationintocowsofindividualsvaccinated by Jenner

Vaccinesafety–vaccinebenefits: science and thepublic’sperception. Nature ReviewImmunology, Nov 2001


Output challenges

Output Challenges

Vaccination

Cold chain

Vaccination technique

Vaccination at right age

(Mab interference)

Immunization

Outcome

Vaccine effectiveness

Impact


Concepts in evaluation of vaccination programs in low income countries

Conceptual framework

Aim of

the program

Impact

Process evaluation

  • Outcomes

  • Targeted population

  • receiving the intervention

  • Vaccine Coverage

  • Vaccine Effectiveness

Impact

  • Outputs

Activities

Inputs

Effectiveness

Efficiency

Sustainability

Adapted from the source: Health Care Evaluation. Open University Press, 2005


Outcome challenges

Outcome Challenges

  • Accessibility (hard-to-reach pop)

  • Health services

  • ( coverage, staff, availability of vaccines etc.- MOV)

  • Unstable vaccine supplies

  • (stock out, release of funds)- MOV

  • Demand/utilisation still low

  • due to lack of awareness

  • or illegal payments or side

  • Effects

  • Weak register management

Outcome

Vaccination

Vaccine coverage

Immunization

Impact


Concepts in evaluation of vaccination programs in low income countries

Challenges outcome

Cold chain

Vaccination technique

Vaccination at right age

(Mab interference)

Health status of the individual

Vaccine failure

(hard-to-reach population)

Genetic determination of MHC

Major Histocompatibility Complex (MHC)

Human Leukocyte Ag

Vaccination

Disease control

Vaccine coverage

Vaccine effectiveness

Immunization

Herd Immunity

Demand Laboratory surveillance

Disease elimination


An example of vaccine coverage

An example of Vaccine Coverage

Sum (n* of children vaccinated)

Vaccine coverage =____________________________

Sum (n* of children in target group)

Mathematician (exact number)

Clinician

EPI technician (work performance indicator)

Mother

Evaluator (hot issue)


Concepts in evaluation of vaccination programs in low income countries

Methods of assessing immunisation coverage

Administrative method

Sum ( n* of children vaccinated)

Vaccine coverage % = __________________________

Sum ( n* of children in target group)

  • Integral part of service delivery

  • Data useable at all levels

  • Prompt analyses and action is possible

  • Is a complementary method

  • and addresses denominator

  • Issues

  • Recall biases RH card

  • 30 by 7 cluster sample

  • N= 210

Survey method

Sum ( n* of children vaccinated)

Vaccine coverage % = ________________________

Sum ( n* of children surveyed)


Concepts in evaluation of vaccination programs in low income countries

Vaccine coverage

  • Numerator issues

  • Vaccination after target age included?

  • Campaigns included? ( polio-measles plus Vit A)

  • Private sector included?


Vaccine coverage

Vaccine coverage

  • How good is the denominator?

    • Quality of census data/ Vital registers

    • Method of population projection ( 2,6%)

    • Uncertainty at the local level

    • Migration

    • Major population shifts ( refugees)

    • Births or surviving infants


Concepts in evaluation of vaccination programs in low income countries

Coverage more 100%

Problems with denominator

Problems with numerator ( the case of Magude District)

Strategies to reach high coverage

All opportunities to immunised

National vaccination days


Fragmentation of different data sources

Fragmentation of different data sources

Demographic Health Survey

PopulationCensus

Vital Registration

Health System

Routine information system

HR IS

Finance IS

Disease Surveillance

Vaccine IS

Other PHC

programs IS

Other HH

Surveys

HH survey


An example of dtp

An example of DTP


Dtp coverage trend

DTP coverage trend

1990

2000

Figs: Survey-based coverage of DTP3 from bidirectional distance

dependent regression with 95% uncertainty intervals from

1986-1996 by Global burden of disease study

Source: The Lancet 2008; 372: 2031-72


Concepts in evaluation of vaccination programs in low income countries

Additional children immunized

and immunization service support

payments in countries receiving

GAVI support up to 2006

Source: The Lancet 2008; 372: 2031-72


Challenges to explain vaccine coverage discrepancies

Challenges to explain vaccine coverage discrepancies

  • Intentionally over report or

  • Errors in stages of the data gathering or reporting process.


Challenges to evaluate outcome ve

Challenges to evaluate outcome ( VE)

  • Surveillance system

Challenges

Information gap on new diseases

Depends on the coverage of the health system


Flow of the disease surveillance in the health system mozambique

Flow of the disease surveillance in the health system, Mozambique

Source: BMC Infectious Diseases 2006, 6:29


Concepts in evaluation of vaccination programs in low income countries

Source: BMC Infectious Disease, 2006; (6)-1-9


Final remark

Final remark

  • Vaccine coverage is not the only indicator (immunity, equity, efficiency and sustainability all matter)

  • December 2008 was 60th anniversary of the Universal Declaration of Human Rights –right to health.


Vaccine coverage challenges

Vaccine Coverage Challenges

  • There are problems with data quality and unharmonized donor requirements for M&E—a situation of too much data, not enough information

  • Indicators that need more than one data base


Concepts in evaluation of vaccination programs in low income countries

Millennium Development Goals

Unprecedented commitment by the world’s leaders to tackle the most basic forms of injustice and inequality in our world: poverty, illiteracy and ill-health.

Globalization of humanities basic values: human rights and human development including human health of all

The MDGs are drawn from the actions and targets contained in the Millennium Declaration that was adopted by 189 nations-and signed by 147 heads of state and governments during the UN Millennium Summit in September 2000

The eight MDGs break down into 21 quantifiable targets that are measured by 60 indicators


Concepts in evaluation of vaccination programs in low income countries

Knowledge

Standardized packages of information

Vaccine supply

Cold Chain

Disease surveillance system


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