1. Snapshot of RI’s Current Situation in Afghanistan (Main Constraints & The Way Forward) 2 nd Dec,2018 Afghanistan By: Dr. Ismail Zubair MD. MSc HPM

2. Presentation Outlines: 1.Introduction 2.Current EPI Status 3.Barriers to Better RI Services 4.The Way Forward 2

3. Introduction:  Afghanistan's Expanded Program on Immunization (EPI) performance has a significant impact on global and regional immunization indicators such as poliomyelitis eradication, maternal and neonatal tetanus and measles elimination.  Despite significant efforts by the government and partners, Afghanistan’s immunization indicators have not met the expected benchmarks.  With sustained government commitment, predictable partner support and by adopting effective strategies, Afghanistan can achieve the immunization targets set at the regional and global level and make strong progress towards achieving SDG 3. 3

4. Basic Childhood Vaccinations PentavalentPolio Source: NEPI Administrative Data

5. Basic Childhood Vaccinations Pentavalent Polio Source: NEPI Administrative Data

6. Source: Administrative and NDSR Data

8. Barriers to Better RI’s Services at Different Levels Community/ Field Level Barriers Health Facility Level Barriers REMT/PEMT Level Barriers Health System Level Barriers 8 Main Constraints

9. Community/ Field Level Barriers:  Peoples’ Perception about Immunization  Reasons:  Low community awareness  Habitual Trends  Myths/ Propagandas  More focus on supply side/less on demand side  Travel distance Solutions: Balance b/w Demand side and supply sided interventions Need to change perception and behavior of People Demand Generation IEC BCC campaign BCC Theory Long time strategy (Theory of Change Steps)

10. Health Facility and HR distribution per population Province Estimated Population- 2017-18 Area (Km2) Gov.Health Facilities No.Vaccinator %Coverage Penta3 Nangarhar 1573973 7641.113124697 Kunar 465706 4925.9458279 Nooristan 152845 9266.7334562 Kandahar 1279520 54844.59813977 Helmand 955970 58305.18513768 Farah 524657 49339.1658369 Zabul 524657 17471.8587771 Source of Data: CSO,HMIS and EPI-MOPH

11. Issues in RI Services at field level:  Microplanning  Not Properly done ( on the desk activity)  Not timely updated  Location of HFs  Not according to MP  Reasons:  Rented House (Urban Areas/Kabul)  Personal Preference  Others Influence Solutions: Proper/Actual MP Community Involvement Timely update MP Regular Monitoring of Outreach and Mobile activities

12. Health Facility Level Barriers:  Outreach Services are weakly provided  Mobile Services are almost ignored  Reasons:  Personal Preference of Vaccinator  No Facility for Vaccin…  No involvement of EPI sup in Planning  Weak feedback & follow up  HF head weak accountability Solutions: Jointly development of outreach & mobile plan Proper Involvement of HF head Joint M&E Proper follow up and feedback

13. Mid Level(REMT/PEMT/NGO) Barriers:  Different management style  Salary Issue  Less than vaccinator  No clear PEI to EPI support mechanism & vice versa  Low Priority of IR to NGO  Low performance accountability Solutions: Continues Education Unify strategic and operational planning Healthy salary package Team work Strengthen coordination & communication

14. Senior Management Level (NEPI/MoPH)Barriers: 1.Issues in Management Approach:  Half Cycle Management Approach  No Performance Accountability at different levels  Weak Coordination and Communication  M&E system  Data Quality X

15. The Way Forward:  Top evidence-based strategies for better RI services: 1.Find Immunization Champions in our practice 2.Integrate IR outreach and mobile with other basic health services (nitration, ANC, PNC) 3.Hold Vaccine clinics at hours convenient for families 4.Quarterly Joint RI monitoring ( NEPI, EOC, GCMU, NGO) 5.Debits on TV/Radio

16. Sources of Data:  M&E Findings  FGDs & IDIs with EPI Staff  Observations  Documents Review  EPI Comprehensive Multi Year Plan 2015-2019  National EPI Strategy  EPI Coverage Survey 2013  Afghanistan Demographic & Health Survey 2015  Top Strategies for Increasing Immunization Coverage Rates 16

17.  Thank you  Comments and questions 17