IMMUNIZATION COVERAGE RATES IN MALAWI: THE OFFICIAL VIEW

Transcription

1 IMMUNIZATION COVERAGE RATES IN MALAWI: THE OFFICIAL VIEW Paper Presented at the International Conference on Historical and Social Science Research in Malawi: Problems and Prospects. Chancellor College June, 2000, Wycliffe Robert Chilowa Ph.D* *University of Malawi Centre for Social Research P.O. Box 278, Zomba, Malawi. Tel : (265)827113/ Fax : (265) / CSR@MALAWI.NET OR WYCLIFFE CHILOWA@HOTMAIL.COM

2 IMMUNIZATION COVERAGE RATES IN MALAWI: THE OFFICIAL VIEW Abstract Universally, the foal of immunization programmes in the sustainable control of vaccine preventable infectious diseases. The sustainability of any health intervention, such as the vaccination programme, ultimately depends not simply on public compliance but also on public demand and encompasses widespread acceptance of prevention and a willingness to pay for it, either through direct community funding or through government subsidies obtained from taxes, or as it has been for Malawi, through donor funding as a stopgap measure. It has been reported that the Demographic and Health Survey (DHS) of 1992 indicated that overall 82% of all children aged months and all the recommended vaccinations, 67% before their first birthday recommended by the World Health Organization (WHO). On the other hand the 1995 Malawi Social Indicators Survey (MSIS) shows that 75% of children aged months at the time of the survey had all the recommended vaccines, 61% before their first birthday, which implies a slight drop from the figures. What was the significant in the MSIS was that the figures for those children vaccinated by 12 months of age for BCG, DPT and fully immunized, showed a statistically significant drop from the 1992 DHS. This was the first time a drop had been recorded. The 1996 Malawi Knowledge, Attitudes and Practices in Health Survey (MKAPHS) reported that complete vaccination at any time before the survey among children months was 81%, while 55% of children were reported to have been fully vaccinated before their first birthday. This result confirms the contention that there has been a discernible downward trend in the Expanded Programme on Immunization (EPI) performance. As regards the official view of coverage in Malawi, coverage of children with the basic EPI vaccines appears to have reached upwards of 80 percent, but unfortunately this is by antigen and by the time of the survey. The recommended coverage figures are those where the children aged months should have been fully vaccinated by their first birthday (i.e. by 12 months). We will show in the paper that these have been consistently lower in Malawi indicating the poor EPI performance over the years due to various problems as will be elucidated in the paper. In this regard the role of social science in understanding the above mentioned issues and their impact on the delivery of vaccination services is very critical. 1 Introduction About twenty percent (20%) of the Malawi population in 1992 was composed of children under-five years of age and they accounted for fifty seven percent (57%) of all deaths in Malawi (Ministry of Health and Population, 1986). This explains why the Primary Health Care Approach (PHC) is focused towards mothers and children. The health of these children is a major cause of concern in Malawi. The country has one of the highest Infant Mortality Rates (IMR) in the world at 133 deaths per 1000 births (Chilowa et al, 1996). With such an IMR, it can be envisaged that the current health status of Malawi s Children is not satisfactory. 2

3 For a child to be considered fully vaccinated, he/she should receive BCG vaccine for protection against tuberculosis, measles vaccine, three doses of polio vaccine and three doses of DPT for protection against diphtheria, pertussis and tetanus. The Demographic and Health Survey (DHS) of 1992 indicated that overall 82% of all children aged months had all the recommended vaccinations, 67% before their first birthday as recommended by the World Health Organization (National Statistical Office, 1994). The 1995 Malawi Social Indicators Survey (MSIS) following on the Mid-Decade Goals (MDG) of the United Nations summit) which was commissioned by UNICEF and conducted by the national Statistical Office and the Centre for Social Research, shows that 75% of children aged months at the time of the survey had all the recommended vaccines, 61% before their first birthday, which implies a slight drop from the 1992 figures. What was significant in the MSIS was that the figures for those children vaccinated by 12 months of age for BCG, DPT and fully immunized, showed a statistically significant drop 1992 DHS. This is the first time a drop had been recorded. This was then seen a worrying indicator. According to the same survey (MSIS), the percentage of children aged months who died had been fully vaccinated by 12 months of age ranged from 30% (Ntchisi District) to 81% (Chitipa District). The objective behind the Mid-Decade Goal was for immunization coverage to be 80% or more. In Malawi only two district namely Chitipa and Ntcheu achieved this summit goal in 1995 (Chilowa et al, 1996). The 1996 Malawi Knowledge, Attitudes and Practices in Health Survey (MKAPHS) reported that complete vaccination at any time before the survey among children months was 81% while 55% of children were reported to have been fully vaccinated before their first birthday. This result confirms the contention that there has been a discernible downward trend in EPI perfomance. The social Science and Immunization (SSI) Survey found that 84.7% of those children aged between months had been fully immunized by the time of the survey of the survey, 56.8% by their first birthday (i.e. at the right age.) Still this depicts a gradual worsening of immunization coverage figures. UNICEF and other donor agencies have funded studies on immunization coverage, EPI disease surveillance and monitoring and evaluation of EPI. There is general lack of information regarding compliance with and social demand for immunization services, quality of care and sustainability of vaccination services. Even where the availability of vaccination services are known and accessible, 3

4 they are often underutilized. Several authors have noted that certain factors affect demand and, hence, coverage and sustainability and these include availability and accessibility of services, quality of health education, vaccine potency, educational level of the mother (and the father), societal beliefs, attitude of health workers to users, community s perception of vaccination services etc. (Heggenhoegen, 1995; Streefland, 1995 and Nichter, 1995). It has been contended that by fully immunizing children, the spread of EPI diseases shall be stopped thereby saving the lives and protecting the future health of children. There are variations in immunization coverage rates in Malawi. It is widely appreciated that there are cultural and social variations in the manner in which societies perceive and participate in vaccination programmes. The paper analyses the social and cultural factors which determine immunization coverage from the perceptives of both quality of care of vaccination service delivery and compliance with social demand for the services amongst the people in the community. All in all, it is pointed out in the paper that the official reporting of immunization figures in Malawi is flawed in the sense that the coverage rates are those by antigen, and by the time of the survey, which are obviously higher. However, the correct figures recommended by WHO to be reported are those of children months old that have been fully vaccinated by their first birthday. These have been consistently lower in Malawi from By reporting these it will assist Government policy makers to appreciate where things are going wrong and act and plan accordingly. The current official reporting of these makes the Government complacent and wrongly believe that the EPI performance is on track, which is hardly the case. Moreover, these high officially reported figures fail to explain the HIGH INFANT MORTALITY RATES in Malawi. The paper hence recommends to the policy makers that there is need from now on to report the above-cited WHO recommended coverage rates that will assist them in the planning, designing and implementation of corrective and relevant immunization programmes. 1.1 Government Policy on EPI The Government of Malawi s health policy aims at raising the level of health of all Malawians through the provision of a sound health care delivery system. One of the strategies that Government has instituted to effect the health policy is the strengthening and expansion of the maternal and child 4

5 health. The Extended Programme on Immunization (EPI), which is an attempt to coordinate and expand a number of individual immunization programmes, has been fully integrated into the Maternal and Child Health (MCH) programme. The EPI aims at immunizing children against diseases such as measles, poliomyelitis, tuberculosis, diphtheria, pertussis and tetanus by giving them vaccinations. A plan for EPI was drawn in 1978 in collaboration with the World Health Organization. Four types of vaccines are given namely measles, polio, BCG against tuberculosis and DPT against diphtheria, pertussis and tetanus. For a child to be considered fully immunized s/he should receive one dose of BCG vaccine, one dose of measles vaccine, three doses of DPT and three doses of polio vaccine. If the vaccination schedule is to be fully followed a child should be fully immunized by the age of 12 months. The Malawi policy regarding EPI is to: (a) immunize all children under the age of twelve months with the goal of reducing morbidity and mortality due to the six preventable and infectious diseases; and (b) immunize all pregnant women and females of child bearing age in order to protect the unborn children against neonatal tetanus and the mother against tetanus (Ministry of Health and Population : EPI Unit, 1994). The Ministry of Health and Population is responsible for vaccination activities in Malawi. The head of the EPI is the National Programme Manager who reports to the Controller of Preventive Health Services. Under the National Programme Manager there are the National Logistics/Cold Chain Officer and the Central EPI Stores Officer. At regional level, there is a Regional EPI Officer and Cold Chain Officer. At district level the MCH Coordinator is responsible for day to day running of the immunization programme and reports to the District Environmental Health Officer. A Health Assistant oversees the EPI activities at the health centre level and in most cases the Health Surveillance Assistance (HSAs) are the ones who are responsible for vaccinating the children. These HSAs live in the community. 1.2 Social Demand for Vaccinations 5

6 Immunization has been recognized and accepted as one of the most important components in the prevention and control of communicable diseases. It is a basic health service, therefore it has been integrated into the health care delivery system of the Ministry of Health in Malawi. Despite the great progress that has been made in the prevention of vaccine printable diseases by vaccinating children and mothers within the child bearing age, there is still a lot of controversy surrounding the introduction of vaccination programmes in developing countries. Some of the issues raised by the clients of vaccination programmes include the development of side effects after a child has been vaccinated and misconceptions are for family planning purposes and not for disease prevention as advocated by the vaccinating regimes. It is not only in Malawi where such controversies have risen. In India, for example, the Muslim minority fear that the Hindu majority may be covertly introducing family planning through vaccination programmes to that their population should never outnumber that of the Hindus. As such during elections the Hindu should always come out victorious. Some people perceive vaccinations as a threat to traditional values, and it has been contended that after receiving the protection of vaccines and foreign medicines the population would be civilized in the western sense at the expense of their moral and ethnic identity (Nichter, 1995). Research has also shown that socio-economic factors also affect peoples utilization and acceptance of health services, use of folk remedies and self-medications. Socio-economic status also creates a feeling of social distance between the health practitioners and clients: impoverished persons feel less at ease in medical settings than more affluent persons (Mechanic, 1974). Such beliefs, practices and misconceptions can adversely affect the demand for vaccination services, hence, immunization coverage. An important point of attention is the appropriateness of provision of vaccinations. First, this concerns the so-called technical quality of care: whether providers of vaccinations did their work biomedically correct and complete, using existing professional knowledge and standards. Secondly, it regards the way in which the providers relate to their clients whether their relation is characterized by privacy, confidentiality, informed choice, concern empathy, honesty, tact and sensitivity (Donabedian 1988: 1744). This is the interpersonal quality of care. 6

7 Third, there is the perceived quality of care: the perceptions that the users and the providers have of the technical and interpersonal quality of care. The mothers/caretakers who attend vaccination sessions may be called acceptors. Acceptance of vaccination does not imply necessarily that it is based on a biomedically correct and complete understanding of vaccination. In fact, at local level, within certain groups of village societies, vaccination cultures prevail, which include knowledge, beliefs, practices and experiences with regard to vaccination. Such local cultures include past experiences of side effects, rumours about intended use of vaccinations for improper purposes, experiences of epidemics preferences for certain medical technologies, folk aetiologies of vaccine preventable diseases, various lay explanations about the efficacy of vaccinations (this may, for instance, be considered disease specific or rather boosting general health improvement). But, besides the clients behaviour being grounded in the local vaccination culture, it also is related to the personal experiences and the individual vaccination history. This concerns, for instance, the personal history of side effects. Health services provide vaccinations are a preventive health intervention. They usually require the mothers to attend to vaccination sessions at certain places at certain times. The way in which compliance with the vaccination rules are regulations is encouraged may be called a vaccination regime. Such a vaccination regime may be more promote, encouraging compliance through health education and supportive follow up activities (e.g. home visits), or more prescriptive, emphasizing control through sanctions, manipulation of public opinion, or more local power structures (e.g. reminding mothers through the mediation of a village chief). Vaccination regimes may also combine promotive and prescriptive elements. The actual provision of vaccination, be it in static health centre settings or in outreach conditions, is a set of behavioural patterns of providers and consumers, based on rules regulations, expectations, experiences and assumptions of all involved. We may call this a vaccinations practice, which may be characterized and experienced as more or less campaign like (e.g. including unfamiliar locations, different timings, as in the case of National Immunization Days (NID s) or more routine, with familiar staff, using fixed timings at fixed locations. 7

8 If potential users do not come to vaccination sessions when invited to do so this may be defined as non-acceptance. There may be various reasons behind this and it is important to distinguish between them. First, non-acceptance may be based on misunderstanding, e.g. due to lack of information, or on negligence. Second, the mother may be willing, but unable to attend, due to, for instance, pressing tasks, lack of travel money, social obligation (e.g. a funeral). Third a parent may be refusing to go for vaccination. There may be different reasons for such individual behaviour, including the conviction that vaccination is not necessary or may be harmful. It may also be based on previous experiences of side effects or rude behaviour by providers. Fourth, non-acceptance may be a collective response of a number of parents. This may be the case when a joint religious conviction stands in the way of vaccination, or when a certain rumour (e.g. about vaccination being related to family planning practices) leads to a collective reaction of non-acceptance. Vaccination programmes are untended to continue for a long time. Their sustainability can be defined in two ways. First, by emphasizing the financial (financial sustainability) and political (political sustainability) support necessary to maintain immunization activities at the required scale and qualitative standards. Second, by stressing the relation with high levels of coverage and define sustainable high coverage. 2 National and Local Trends in Vaccination Coverage 2.1 Achievements of the National Vaccination Programme: The official view A number of evaluations have been carried out in Malawi since 1980 aimed at determining coverage rates as well as progress that the Immunization programme has made towards immunizing children and mothers. It will be noted that Malawi has made considerable progress since the Expanded Programme on Immunization (EPI) was officially launched in It was in 1990 that the Ministry of Health and Population carried out an evaluation of the EPI in three districts, namely, Mzimba, Lilongwe and Thyolo. The immunization coverage rates ranged from 66 percent to 79 percent for BCG, 23 percent to 50 percent for the third dose of polio, 40 percent to 51 percent for the third dose of DPT and 58 percent to 64 percent for measles. Percentages of fully immunized children ranged from 20 to 39 percent. Immunization coverage rates for 1982 were 69 percent for the third dose of DPT, 72 percent for the third dose polio, 70 percent for measles and 82 percent for BCG. The proportion of fully immunized 8

9 children was 55 percent. These results showed that there was an improvement over those figures obtained in

10 Table 1: Immunization Coverage Rates for Malawi Vaccine Coverage BCG DPT POLIO MEASLES Under 1 fully immunized Source: Chilowa, et.al (1999) It is evident from table 1 that for all antigens, there was an improvement in coverage between 1981 and However, a downward trend is discernible by In 1991 surveys were carried out in Nsanje and Lilongwe districts. Nsanje, a district in Southern Malawi, was among other districts in which surveys aimed at determining coverage rates were conducted in That evaluation revealed that 59 percent of the children were fully immunized that year. During the 1991 evaluation 77 percent (n = 211) of the children were completely immunized. The coverage for each antigen were as follows: 95 percent for BCG, 80 percent for DPT3, 83 percent for POLIO and 86 percent for measles. 1 percent of the children were not immunized at all and 22 percent were partially immunized. During the same survey, 210 women were interviewed of which 91 percent and received TT1, 79 percent TT2, 35 percent TT3, 12 percent TT4 and 5 percent (Ministry of Health and Population, 1991). The survey that was carried out in Lilongwe in 1991 showed that 55 percent (n = 210) were fully immunized, 42 percent partially immunized and 3 percent not immunized. The coverage for each antigen was as follows: 92 percent BCG, 58 percent DPT3, 56 percent Polio 3 and 49 percent measles. 43 percent of the children were fully immunized, 33 percent were partially immunized and 24 percent of the children were fully immunized, 33 percent were partially immunized and 24 percent were not immunized. 10

11 During the 1992 Demographic and Health Survey (DHS) that was conducted by the National Statistical Office, 97 percent of the children in Malawi aged between 12 and 23 months were vaccinated against tuberculosis and this information was based on availability of vaccination cards as well as the mothers report. 95 percent received the BCG vaccination by the age of 12 months according to information on the vaccination cards. Immunization coverage for the first dose of polio and first dose of DPT was 96.9 percent. However, coverage declined after the first dose with 94 percent and 88 percent receiving the second and third doses, respectively, yielding a drop-out rate of about 9 percent for the DPT and polio vaccines. Eighty six percent of children months were vaccinated against measles, 70 percent before the first birthday. Overall 82 percent of all children aged months had all the recommended vaccines during the time of the survey, 67 percent before their first birthday. Two and a half percent of the children aged months never received any vaccinations. The DHS revealed that children from urban areas (87 percent) had a slightly better coverage than rural children (81 percent). Complete coverage increased with maternal education from 76 percent among children of uneducated mothers to 96 percent among children of mothers with some secondary education. Table 2 shows the percentages of children aged months for whom a vaccination card was shown to the interviewer as well as based on the mother s report. From this table the trend on success of the immunization program in Malawi can be ascertained. The percentage of children aged months who were fully immunized by the age of twelve months is an indicator of the EPI performance in 1991 to Coverage among months old children refers to EPI performance during the late 1990 to 1991 and so on. From the figures presented in this table it can be envisaged that the immunization coverage improved considerably during the period 1988 to For example, coverage for BCG increased from 84.7 percent to 94.7 percent, measles vaccine increased from 60.3 percent to 70.1 percent and the percentage of fully immunized children by the age of twelve months increased from 52.2 percent to 67.1 percent. 11

12 Table 2: Vaccination in the First Year of Life Vaccine Current Age of Child in Months BCG POLIO POLIO POLIO DPT DPT DPT MEASLES All vaccine No vaccination Source: Demographic and Health Survey 1992 It can also be derived from the table that the percentage of children who were not immunized at all decreased from 14.6 percent to 4.8 percent over the same period. The Malawi Social Indicators Survey revealed that there was for the first time in a decade a significant drop in immunization coverage rates in Malawi. Sixty one percent of the children aged months were fully immunized by their first birthday (compared to 67 percent in 1992). 75 percent for the same age group (82 percent in 1992) were fully immunized at the time of the survey. The figures for individual antigens were higher. For those children who were fully immunized by their first birthday, coverage for BCG was at 91 percent, polio 80 percent DPT 76 percent and measles 70 percent. In terms of reporting by the Ministry of Health and Population, these are the ones that come out. 12

13 Comparisons with coverage recorded in 1992 during the DHS survey indicate that apart from measles, whose rate has been maintained at 70 percent, the rates for all other antigens have gone down. These rates are shown in figure 1 below. Figure 1: A Comparison of DHS 1992 and MDG 1995 data on immunization levels 1 One explanation could be the unavailability of some vaccines especially DPT and Measles at some periods in the country. This is a result of both financial and logistical reasons. The percentage of fully immunized children in the MSIS was showing a downward trend with only 61 percent of the children being fully immunized by 12 months of age (compared to 67 percent in the DHS). These results were the first evidence of a downward shift in the decade in EPI performance and had to be noted as a warning sign. The downward trend in EPI performance is a documentation of the effects of the budget on service delivery for which there has been anecdotal evidence through the EPI s field monitoring trips. Measles is the most likely to have lower coverage by 12 months of age since the window of opportunity to get this vaccination done before the first birthday is narrow even under the best of circumstances. Thus, any decrease in number of possible contacts (such as decreased outreach clinic visits) is likely to 1 ( i.e. Percentage of Children months who had received specific vaccines by 12 months of age) 13

14 affect measles coverage fact. The fact that DPT is less than OPV coverage is probably due to the three months-long DPT vaccine shortage which occurred in early The MSIS also revealed that 77 percent of mothers of 0-11 month olds had at least 2 doses of TTV within 3 years of child birth. At the regional level although there appears to be differences in the coverage rates of children months who had been fully immunized by their first birthday with the Northern region showing 67 percent coverage, following by the South at 62 percent and the Centre at 58 percent, these coverage levels are not significantly different. Coverage for Ntchisi (30 percent), Machinga (35 percent) and Lilongwe (50 percent) are significantly lower than for Chitipa (81 percent and Ntcheu (80 percent) which are significantly higher at the 95 percent confidence level (see Table 3). These figures, however, should be red with caution since those districts with lower coverage rates also depict somewhat higher rates of Standard Errors (e.g. the Standards Errors for Ntchisi, Machinga, Nsanje, Mchinji and Karonga are 8 percent, 10 percent, 21 percent 12 percent, respectively) These results revealed that only Chitipa and Ntcheu had achieved the Mid-Decade Goal. There is need, therefore, for a concerted effort to concentrate resources in the other district so as to achieve the Summit Goal. 14

15 Table 3: Percentage of children months who had received specific vaccines by 12 months of age Fully Vaccinated BCG DPT 2 OPV 3 Measles Number of children in the Sample Malawi 61 (2.3) 91 (1.1) 76 (1.8) 70 (2.1) 975 Region North 67 (4.5) 93 (2.4) 83 (3.0) 81 (3.4) 71 (4.7) 186 Centre 58 (2.9) 91 (1.5) 71 (2.9) 78 (2.5) 71 (2.6) 438 South 62 (4.0) 92 (1.7) 80 (2.8) 83 (2.7) 69 (3.7) 351 District Chitipa 81 (7.6) 92 (4.7) 93 (3.9) 89 (4.6) 84 (7.2) 33 Karonga 52 (11.6) 100 (0.0) 78 (8.2) 74 (7.4) 59 (8.7) 24 Rumphi 74 (5.0) 88 (7.0) 87 (7.3) 86 (7.7) 67 (8.9) 29 Mzimba 63 (7.0) 91 (4.3) 78 (3.7) 77 (5.5) 71 (9.1) 72 Nkhata-bay 74 (13.1) 98 (2.7) 90 (8.4) 90 (8.4) 81 (9.1) 28 Kasungu 59 (10.3) 97 (2.2) 78 (8.6) 87 (4.7) 66 (7.4) 35 Mchinji 41 (12.3) 89 (5.1) 62 (8.7) 62 (8.7) 51 (14.2) 34 Lilongwe 50 (4.8) 86 (4.1) 62 (5.5) 71 (5.4) 69 (4.7) 127 Dowa 57 (6.8) 91 (3.6) 71 (11.5) 80 (8.9) 75 (4.4) 47 Nkhota-kota 59 (12.6) 88 (4.5) 77 (7.7) 73 (10.5) 68 (9.6) 33 2 Three doses of DPT 3 Three doses of Polio 15

16 Salima 68 (6.0) 98 (1.9) 70 (5.0) 85 (1.6) 74 (6.8) 43 Dedza 72 (5.8) 89 (2.7) 80 (4.7) 85 (2.4) 80 (2.9) 36 Ntcheu 80 (6.8) 97 (0.9) 87 (5.4) 88 (4.2) 83 (6.4) 40 Ntchisi 30 (8.0) 88 (4.1) 59 (5.7) 67 (3.4) 50 (8.7) 43 Mangochi 63 (9.6) 94 (3.8) 88 (7.0) 77 (10.1) 69 (7.8) 37 Machinga 35 (10.6) 89 (4.9) 54 (6.8) 77 (8.5) 48 (12.9) 37 Zomba 73 (7.2) 91 (5.3) 80 (2.5) 77 (4.7) 81 (2.5) 49 Mwanza 64 (11.4) 92 (4.2) 72 (8.2) 83 (4.9) 78 (6.9) 41 Blantyre 71 (6.4) 94 (3.3) 91 (4.6) 89 (5.1) 74 (6.1) 53 Mulanje 58 (12.9) 87 (7.4) 78 (8.4) 81 (7.9) 58 (12.9) 23 Thyolo 63 (13.9) 87 (5.3) 83 (11.3) 86 (10.6) 72 (14.9) 23 Chiradzulu 79 (10.3) 100 (0.0) 87 (8.9) 93 (7.2) 82 (8.6) 22 Chikwawa 56 (10.7) 98 (2.1) 78 (10.2) 91 (4.4) 80 (5.8) 30 Nsanje 58 (21.3) 83 (3.6) 71 (10.1) 78 (5.0) 56 (17.4) 36 Residence Urban 69 (7.6) 86 (5.8) 78 (7.4) 79 (7.5) 78 (7.6) 108 Rural 60 (2.4) 92 (1.0) 76 (1.9) 80 (1.7) 69 (2.1) 867 Sex Male 59 (2.9) 90 (1.8) 75 (2.6) 80 (2.5) 68 (2.7) 482 Female 62 (2.8) 93 (1.4) 76 (2.3) 80 (2.0) 72 (2.5)

17 The full coverage rate for the urban area was 69 percent whereas that for the rural was 60 percent. This difference though is not significant. The MSIS is survey further revealed that of the months olds 59 percent of the male children and 62 percent of the females were fully immunized by 12 months of age. Figure 2 shows the percentage of children months old nationally, by residence and region, who were fully vaccinated by the time of the survey. It is clear that apart from the Northern Region where the coverage rates were the same as of the DHS in 1992, all the other rates were lower in Figure 2: Percentage of Children Months who were fully vaccinated by the time of the survey. Percent 17

18 The results of this survey (MSIS) reveal that under five cards were retained by 88 percent of the children months, up by 2 percent from the 1992 DHS survey Mother s TTV card retention was 85 percent The Malawi Knowledge, Attitudes and Practices in Health Survey (MKAPHS) of 1996 reported that complete vaccination at any time before the survey among children months was 81% while 55% of children were reported to have been fully vaccinated before their first birthday. This results confirms the contention that there has been a discernible downward trend in EPI performance (table 4). Table 4: Trends in immunization Coverage for Children Aged months from 1992 (%) COVERAGE RATES YEAR By 12 Months By Time of the Survey 1992 (DHS) (MSIS) (MKAPHS) (SSI) Source: Various reports namely Demographic and Health Survey (DHS); Malawi Social Indicators Survey (MSIS), Malawi Knowledge, Attitudes and Practices in Health Survey (MKAPHS) and Social Science and Immunization (SSI) study. It is evident from the coverage rates by 12 months (since the objective of the EPI in Malawi is for children to receive all the recommended vaccines by their first birthday) that the EPI performance has been going down. The official view has always been that the coverage rates in Malawi are high, this is as a result of officials mostly reporting these rates by antigen and by the time of the survey which is usually higher. However, looking at the recommended rates by 12 months, i.e. by the first birthday, these have been consistently lower in Malawi and are not usually reported accordingly by authorities. These recommended coverage figures never feature prominently when Government is reporting on 18

19 immunization coverage rates officially, in Malawi. It is only those coverage figures by the time of the survey (see table 4) that are officially reported It should be noted, however, that these comparisons should be read with caution since the DHS, MSIS and MKAPHS covered the whole country and used almost the same sampling frame and the difference in the findings are significant. There was also an element of weighiting. On the other hand, the SSI study only covered two districts, however, the downward trend in EPI performance is very clear. 2.2 Current local Immunization Situation in Malawi: Social Science View In this section we analyse the immunization status of the sample population of the Social Science and Immunization (SSI) study that was carried out in Chitipa and Ntchisi district in 1997 by the author. The figures herein reported to Government policy makers and other stakeholders in this area at a workshop on Social Science and Immunization Study Findings, Capital Hotel in Lilongwe on 21 August, Various reports were also written on the same so as to emphasise to them the true coverage rates to be reported officially. However, this did not seem to find takers in Government since the subsequent reporting by the then Controller of Preventive Health Services on radio and in papers soon after the workshop was on the higher rates by antigen and by the time of the survey. Figures 3 and 4 below depict immunization status of children aged and months by the right age (12 months) and by right age (12 months) and by the time of the survey. Overall, 84.7% of those children aged between months had been fully immunized by the time of the survey, 56.8% by their birthday (i.e. at the right age). This finding also confirms the discernible downward trend in coverage over the years from 1992 as is evident from Table 4 above. 19

20 Figure 3: Immunization status of children aged between months Site of Survey Figure 4: Immunization status of children aged between months Site of Survey Both figures 3 and 4 depict differences between and within district. For immunization status of children aged months (Figure 4) it is clear that although there are high coverage rates by the time of the 20

21 survey (average 87.8%), coverage rates at the right age (i.e. 12 months) in this age cohort are very low (average 47.7%. This says a lot about our sample population in that although by the age of five the majority are fully immunized, only a few are fully immunized at the right age, although there are discernible differences between and within districts. Relatively, coverage rates in this age cohort are higher in Chitipa (a high coverage district) than Ntchisi (a low coverage district), as is to be expected. Children aged months are more likely to be fully vaccinated at the right age in Chitipa than in Ntchisi District. There are also significant differences in coverage rate between males and females in Ntchisi where a higher proportion of females (60.8%) were fully vaccinated when they were over 12 months than males (52.9%). Overall, more males (49.9%) in this age cohort (12-59 months) were fully vaccinated at the right age than females (45.2%) (See Table 5). Table 5: Immunization Status of Children (Vaccinated at the Right Age) Aged Between months by sex of child (Chitipa and Ntchisi) District (%) Immunization status Chitipa Ntchisi Total Male Female Both Male Female Both Male Female Both Vaccination by 12 Months Over 12 Months Total Number of Children Source: Social Science and Immunity 1996 MKAPHS results (88.4%). Another 11.1% of the children did not have a card when surveyed in 1997, but were reported by their mothers to have received the BCG vaccine, for which a scar was checked. This, therefore, implies that overall all (100%) children aged months in or sample were vaccinated against tuberculosis, up 6% on the 1995 MSIS figure and 2% on the 1996 MKAPHS figure. Coverage for the courses of polio and DPT stands at 88.9% (according to information from the cards). This figure is the same as that of BCG (88.9%). What is of concern, though is that coverage of DPT and polio decline with subsequent doses. Measles coverage is the lowest. This is to be expected since there are always confounding factors such as unavailability of vaccines and mother s fatigue. 21

22 Another cause of concern is late vaccination. It is clear from Table 6 that only 61.6% of children were given their measles vaccination before the recommended age of one year, while another 27.3% received it between their first and second birthdays. Slightly over half (56.8) of children had all their vaccinations before their first birthday, compared to 84.7% by the time of the survey. None of the children in our sample had no vaccination at all, though some did not complete all the vaccinations both at the right age and by the time of the survey. Table 6: Vaccination by source of Information Percentage of children months who had received specific vaccines at the time before the survey and the percentage vaccinated by 12 months of age, by whether the information was from a vaccination card or from the mother (Chitipa and Ntchisi), 1997 Percentage of Children who received DPT Source of information BCG Measles All None No. of Children Vaccinated at any time before the Polio Vaccination Card Mother Report Either Source Vaccinated by 12 months of age *BCG, Measles, three doses of DPT and Polio vaccine Source: Social science and Immunization Study Tables 7 and 8 present the same data but disaggregated at district level. Chitipa district (Table 7) has higher coverage rates on all antigens than Ntchisi district (Table 8) for the children aged months. Full vaccination at the right age for Chitipa is 58.2% while for Ntchisi the proportion is slightly lower at 56%. 22

23 Table 7: Vaccination by source of Information Percentage of children months who had received specific vaccines at the time before the survey and the percentage vaccinated by 12 months of age, by whether the information was from a vaccination card or from the mother (Chitipa, 1997) Percentage of Children who received DPT Source of information BCG Measles All None No. of Children Vaccinated at any time before the Polio Vaccination Card Mother Report Either Source Vaccinated by 12 months of age *BCG, Measles, three doses of DPT and Polio vaccine Source: Social science and Immunization Study The percentage of children aged months who had received specific vaccines at the time before the survey and the percentage vaccinated by 12 months of age, by whether the information was from a vaccination card by 12 months of age, by whether the information was from a vaccination card or from mother for both Chitipa and Ntchisi, is presented in Table 9. The results clearly indicate that by the age of five, the proportion of children receiving specific antigens, apart from measles, declined. This decline is quite marked for children months who had been vaccinated are the right age. It is also evident that for this age cohort (12-59 months), a higher proportion of children are vaccinated late (i.e. not at the right age compared to those children in our sample aged months). For the children aged months, therefore, only 50.3 % were vaccinated at the right age, although 87.6 % were vaccinated by the time of the survey. 23

24 Table 8: Vaccination by source of Information Percentage of children months who had received specific vaccines at the time before the survey and the percentage vaccinated by 12 months of age, by whether the information was from a vaccination card or from the mother (Ntchisi, 1997) Percentage of Children who received DPT Source of information BCG Measles All None No. of Children Vaccinated at any time before the Polio Vaccination Card Mother Report Either Source Vaccinated by 12 months of age *BCG, Measles, three doses of DPT and Polio vaccine Source: Social science and Immunization Study Table 9: Vaccination by source of Information Percentage of children months who had received specific vaccines at the time before the survey and the percentage vaccinated by 12 months of age, by whether the information was from a vaccination card or from the mother (Chitipa and Ntchisi), 1997 Percentage of Children who received DPT Source of information BCG Measles All None No. of Children Vaccinated at any time before the Polio Vaccination Card Mother Report Either Source Vaccinated by 12 months of age *BCG, Measles, three doses of DPT and Polio vaccine Source: Social science and Immunization Study 24

25 Table 10 presents information on the proportion of children months who had been fully vaccinated by 12 months of age, by their current age. This information has been found to be useful for assessing trends (DHS, 1992). The table also resents the percentage with a vaccination card shown to the interviewer. The coverage figures are based both on card and information and mothers reports. For 88.9% of children aged months, cards were shown to the interviewer by their mothers. The trend also shown that over time there has been an improvement in card retention. Cards were also shown to interviewers by mothers for 75.7% of the children aged months. It is clear from Table 10 that the percentage of children with vaccination cards decreases with increasing age. A greater part of the decrease in card retention is probably as a result of card loss among the older cohorts. Mothers may also be inclined to retain cards only as long as they need them to present to health staff. There is always a tendency, that once children are fully vaccinated and/or reach a certain age, to discard the cards. According to DHS (1992), by comparing vaccination coverage among the various age cohorts of children, it is possible to obtain a picture of changes in the success of the vaccination programme overtime. For or samples, the proportion of fully vaccinated by 12 months of age among children months old, refers, on average, to the EPI performance during 1996 to 1997, coverage among the months old children refers to performance during 1995 to 1996, etc. Our analysis suggests that though there has been a general decline in EPI performance up to in our sample, the EPI Programme has shown signs of improvement during the period An interesting finding in or sample is that no child had received no vaccinations in our sample, as stated earlier. Table 10 Vaccinations in the first Year of life Percentage of children one to four years of age for whom vaccination card was shown to the interviewer and the percentage fully vaccinated during the first year of life, by current age of the child, Chitipa and Ntchisi District. 25

26 Table 10: Vaccination in the first Year of life Current Age of Child in Months Months All children Vaccine Vaccination card shown to interviewer Percent Vaccinated at 0 11 All vaccinations No vaccinations Number of children In the sample Source : Social Science and Immunization study Other Social and Cultural Factors Determining Immunization Coverage This section looks at some of the findings of the SSI study as regards other factors, both social and cultural, that determine immunization coverage, from the perspectives of both quality of care of vaccination service delivery and compliance with social demand for the services amongst the people in the sample community. 26

27 Mother s knowledge of the age at which a child is supposed to get polio and measles vaccinations, in the sample, was relatively higher than for the other types of vaccination. However, the baseline survey report has pointed out that this knowledge still needs consolidation. It was, therefore, recommended that there is need to intensify the education of mothers with regard to the correct age at which their children should get the various vaccinations (Chilowa and Munthali, 1998h) It as also found disturbing to note that mothers knowledge of the correct age at which a child should get pertussis and diphtheria in Ntchisi district was very low. As a consequence, it was recommended that there is need for consolidation and intensification of this knowledge through mass education, among others, and that this should target Ntchisi district as a priority area. It was again clear from these findings that mothers knowledge of the diseases which vaccinations protect against was very low in the sample population. Only measles, polio, tuberculosis and tetanus (in Ntchisi only) are relatively a bit known in the sample population. On the other hand, pertussis, Diphtheri and Tetanus (in Chitipa) are relatively unknown. Paradoxically, in Chitipa, relatively most people mentioned other diseases other that the six vaccine preventable diseases. As a concomitant of this lack or scanty knowledge of diseases which vaccines protect against, a recommendation was made to the fact that mass education campaigns should be conducted to sensitize the mothers as well as impart them the necessary knowledge of the six Vaccine Preventable Diseases. In both districts more focus should be on imparting knowledge of pertussis, Diphtheria and Tetanus diseases, among others. Overall, the behaviour of the staff was found to be good by the mothers although there were differences between the districts. Relatively more mothers in Ntchisi found the behaviour of the staff to be not good and bad than in Chitipa. This could also partly explain the discerned low coverage rates in Ntchisi district. 27

28 The majority of mothers in the sample (60%) were able and willing to pay a small fee for a vaccination service if the Government introduced the same. Most (97%) of these, though, would only be willing to pay less than K20 for the service. About 45% of the mothers have ever failed to get their child immunized when they came for the vaccine service. This is more pronounced in Chitipa where it has happened to only 39% of the mothers. Mothers in the sample have received mostly messages on what diseases immunization protects against as indicated by 57% of them. The other messages include causes of these diseases (28%). How many vaccines a child should get (4.8%), at what age a child should get various vaccines (5.1%), dangers of vaccine and other side effects (0.6%) and other non-specific messages. There is need, therefore, to intensify the health education to mothers especially on the causes of these diseases, number of times a child should get various, the side-effects of the same, and age at which a child should get the various vaccines. It is hoped that this knowledge, as well as their willingness to pay for services, will go a long way in assuring sustainability of the EPI. All in all, it can be contended that coverage rates are higher in Chitipa than in Ntchisi because of the following reasons, among others. General education levels of mothers are higher in Chitipa than Ntchisi; District level management and planning is relatively better in Chitipa; Waiting time before a child is vaccinated is relatively shorter in Chitipa; Behavior of staff is generally better in Chitipa, entailing that users perceive the quality of care to be in this district, etc. It is our hope that the results of this study (SSI) will go a long way in assisting Government of Malawi achieve high coverage rates and sustain such rates technically, programmatically and financially. Furthermore, it is hoped that the study findings and recommendations will contribute towards requisite changes in Government policy formulation and planning with respect to immunization. Social sciences plays a pivotal role in informing in immunization services, it is hoped, therefore, that policy makers in 28

29 immunization services will heed the messages that research has brought forward, especially the finding that there has consistently been a declining trend of EPI performance due to the consistently low levels of immunization coverage as recommended by WHO, as opposed to what is hitherto being presented officially to the public at present. 3 Conclusion The worrying trend of EPI downward performance since 1992 has been alluded to in the paper. It has been stated in the paper that the Demographic and Health Survey (DHS) of 1992 indicated that overall 82% of all children aged months had all the recommended vaccinations, 67% before their first birthday as recommended by the World Health Organization. On the other hand the 1995 Malawi Social Indicators Survey (MSIS) shows that 75% of children aged months at the time of the survey had all the recommended vaccines, 61% before their first birthday, which implies a slight drop from the 1992 figures. Furthermore, it has been said that what was significant in the MSIS was that the figures for those children vaccinated by 12 months of age for BCG, DPT and fully immunized, showed a statistically significant drop from the 1992 DHS. This was the first time a drop had been recorded. The 1996 Malawi Knowledge, Attitudes and Practices in Health Survey (MKAPHS) reported that complete vaccination at any time before the survey among children months was 81% while 55% of children were reported to have been fully vaccinated before their first birthday. This result confirms the contention that there has been a gradual and consistent downward trend in EPI performance. The recent Social Science and Immunization Survey also reveals and depicts the same scenario. As regards the official view of coverage figures in Malawi, coverage of children with the basis EPI vaccines appears to have reached of 80 percent, but unfortunately this is by antigen and by the time of the survey. The recommended coverage figures, as pointed out in the paper, are those where the children aged months should have been fully vaccinated by their first birthday (i.e. by 12 moths). We have shown in the paper that these have been consistently lower in Malawi indicating the poor EPI performance over the years due to various problems, which include logistical, technical, financial, social-economic and cultural. The present public acceptance of vaccination in Malawi is vulnerable to critical questioning of is motives, benefits and safety, and in many cases to be founded on relatively incomplete knowledge. An 29