Evaluating the Immunization Reach and Coverage: use of GIS in the context of Rural Households and Public Health System

The present study is an evaluation of the reach and performance of immunization services carried out by the public health system from district to the lowest level of its operation. The recent outbreak of paralytic Polio cases and Diphtheria affected cases form the basis for selecting one of the districts of Gujarat state, i.e., Bhavnagar district as a case study. The severity of these epidemics is evident from the information released from Commissionerate of Health, Medical Services and Medical Education, Gandhinagar. Out of 152 cases of Diphtheria in the State Bhavnagar district counts for as good as 87 cases. The total deaths occurred due to Diphtheria 50% deaths are reported in Bhavnagar district alone. The reported Polio cases in the State were 21 during the year 2002 of which 9 cases are from Bhavnagar district.
Selection of the primary survey area depended on the last five years talukawise trend for diphtheria and polio cases registered at District Panchayat. Mahuva taluka with its highest reported average of polio cases along with few reported diphtheria cases was selected for detailed primary survey. The random selection of Primary Health Centres and SubCentres under them was made from the total of 7 PHCs in the taluka. The study also carried out household survey of 35 families from these villages, which involved 92 children of 1 to 5 years of age.
The study consisted of three major levels to evaluate overall performance of immunization work in the selected settlements, they are:
1. Evaluation of the immunization reach and coverage along with socio-economic backgrounds of the households and their attitude towards the immunization activities by doing household survey.
2. Evaluation of efficiency in immunization work done at Public Health Centre (PHC) & Sub-Centre (SC) levels through survey of employee as well as physical resources involved.
3. Evaluation of logistics and administration related to immunization work in terms of their availability and condition and maintenance.
The findings of the study revealed following facts:
When the state government is claiming over 90% reported immunization in the district of Bhavanagar the primary survey from 7 villages in the district shows that immunization according to right time schedule was done in only 2.2% of children. Un-timely fully immunized children were about 9% out of the total 92 surveyed.
In case of low-income urban blocks where very small segment of the population was surveyed none of the children were immunized fully according to the correct time schedule.
An important concern that is related to infant care and immunization reach is of delivery (pregnancy iV delivery of a child) status of mother. In the surveyed rural areas deliveries by trained professionals and at institutions accounted for 56% of the total deliveries of 92 children. This is about 66% in case of the State average of the rural areas.
Vaccine wise performance reveals that on time vaccination below 15% for all the vaccinations. Although PPI rounds have made polio vaccine given to high percentage of children, it cannot be counted as a part of routine immunization because of it untimely induction. There is also a high rate of drop outs in case of DPT vaccine, which is due to fear of side reactions of injected vaccines amongst the people.
The present study shows the lowest level of immunization reach for all the primary vaccines. It is low with a substantial margin even in comparison with the similar evaluation carried out in the study of Kotecha(1999). This means an alarming situation that needs to be addressed at the earliest.
The following are the issues identified from the primary survey that account for inefficiency of immunization services:
„X Failure of Routine Immunization
o Inefficiency of Immunization Sessions & Sessions are not held on time
o No pre survey of eligible infants for session is done actively (geo-spatial data)
o No prior intimation is given to eligible families (geo-spatial references)
o Lack of awareness of time and place of immunization sessions
o High drop out rates of DPT and Polio vaccines (geo-spatial references)
o Immunization is mostly done at household level especially for polio that consumes a lot of time of FHWs and because of that they don¡¦t get time to make household visits for information spread of awareness generation, resulting in low coverage.
o Fear of wastage of vaccine by FHWs, specifically of Measles vaccine that come in the vial of 20, is directly responsible for the measles vaccine coverage.
o There is a complete lack of community involvement (geo-spatial references)
o Follow up of post session observation is lacking (geo-spatial references)
„X Socio-economic character¡¦s influence on immunization (geo-spatial references)
„X Gender bias (geo-spatial references)
„X Low Immunisation Coverage Levels
„X In efficient utilisation of Human resources (geo-spatial references)
„X Need of training of health personnel for immunization
„X Weak Logistics maintenance
„X Overburden of work at PHC levels
„X Lack of Education, Information and Awareness
„X Lack of regular monitoring & evaluation in the system

GIS has revolutionized the method of representation of geospatial information. GIS is used for applications that rely on the creation, maintenance, analysis and retrieval of spatially referenced information. Advances in GIS-based tools and databases have made it easier to construct and model the health system. At the same time, increasing concern over the traditional health system and its impact over the locals has led more efforts to consider and analyse the pattern of disease, the process and procedure for cure and prevention, the generation of awareness for health care, availability of infrastructure and staff, etc from a regional perspective and the socio-cultural attitude, gender bias in treatment, economic class and the concern for the treatment, etc from the household perspective. Hence there is an urgent need to adopt GIS in monitoring and development process for implementation of pragmatic plan of the health system.

GIS is a tool used in this study to analyse and represent the results of primary survey and secondary data analysis. The level of facilities provided by government institutions and the gap prevailing across the region of the study has been represented taking help of GIS. The house hold level information collected through primary survey. The socio-economic and cultural pattern has been represented in analyzing the level of success of the immunization and prevention system of the government health department. The GIS has helped in identifying the limitations prevail in the system at the regional level, also at the local level. GIS has proved a very important tool in analyzing regional and local variations in the traditional system and the procedure followed. GIS also has proved an excellent tool for geo-visualisation for the health care system.