Figure 1 illustrates the score that each PHC received (scale 0.0–1.0) for each of the six indices. Scores ranged from a low of 0.38 from one PHC in Dahod that only met 38% of the “community links with service delivery” criteria, to a high of 1.0, from 3 PHCs (1 PHC in Dahod and 2 PHCs in Mehsana) that met 100% of the “cold chain monitoring” criteria. “Monitoring and use of data for action” had the least variability across PHC sites (range 0.71 to 0.89), followed closely by scores for “re-establishment of regular outreach services” (range 0.71–0.93) and “planning and management of resources” (range 0.67–0.90). Scores for the other three indices had greater levels of PHC-based variation: “cold chain monitoring” (range 0.67–1.0), “supportive supervision” (range 0.5 to 0.94), and “community links with service delivery” (range 0.39–0.92). Dahod, the low immunization coverage district, generally had lower index scores than Mehsana, but this was not consistent for all PHCs nor for all indices.
In order to best describe the immunization delivery problems, we further examined the individual questions in each index.
Planning and Management of Resources
Four of the PHC informant groups indicated that general immunization activities were compromised due to funding shortfalls (3 PHCs in Dahod, 1 PHC in Mehsana). Stock outs of vaccines and other related supplies were identified as problems in many PHCs (4 PHCs in Dahod, 5 PHCs in Mehsana). Specifically, PHC informants indicated an inadequate supply at the time of the interview of the following: vaccines (3 PHCs in Dahod, 4 PHCs in Mehsana); safe injection equipment (1 PHC in Dahod, 1 PHC in Mehsana); fuel for vehicles (1 PHC in Dahod, 1 PHC in Mehsana); and other supplies related to vaccine delivery (3 PHCs in Dahod, 5 PHCs in Mehsana). In general, vaccine stock-related issues were problems for both Dahod and Mehsana.
Staff retention and long-term job vacancies were identified as barriers to providing consistent vaccine delivery (5 PHCs in Dahod, 3 PHCs in Mehsana). The open-ended questions identified a need for programmatic emphasis on hiring new staff as positions become available, and there was an expressed desire to receive support for this from district health officials. Since this issue came out of the qualitative questions, we were unable to determine if the remaining 2 sites in Mehsana had similar problems.
Re-establishment of regular outreach services
During vaccination sessions, six PHCs did not record dose-information in an electronic immunization registry (5 PHCs in Dahod, 1 PHC in Mehsana). Hand-written tally sheets were used by eight PHCs to keep track of vaccinations given (4 PHCs in Dahod, 4 PHCs in Mehsana). Interviewees mentioned that patients often did not have their government-issued immunization cards available during visits, which may make it difficult for immunization providers to determine which vaccines are needed during the visit. We did not assess if these cards were forgotten, lost, destroyed, or originally given to patients.
Interviewees discussed the challenges associated with delivering vaccine to various populations because of socio-demographic, geographic, and cultural barriers. The migrant population, in particular, was identified as a specific sub-population that is notoriously difficult to reach with immunization services. Staff from one PHC in Dahod suggested targeting these populations during the marriage season and during festivals since these represent events where migrant population traditionally gather. It is also a time when people go to their family home, potentially making it easier to find them, compared to other times during the year.
Community links with service delivery
Community leaders can be tremendously useful to health care providers, especially when it comes to improving vaccination coverage. In both Mehsana and Dahod, community leaders were involved in improving immunization delivery. Most PHCs included community leaders in their advisory committees (4 PHCs in Dahod, 4 PHCs in Mehsana). In Dahod, four PHCs did not include community leaders in the planning process specifically for immunization delivery, but all five PHCs in Mehsana included them in this process. Community leaders often identified populations in need of vaccine (4 PHCs in Dahod, 3 PHCs in Mehsana), secured venues for outreach PHCs (4 PHCs in Dahod, 2 PHCs in Mehsana), identified barriers to vaccination in a community (4 PHCs in Dahod, 3 PHCs in Mehsana) and provided vaccine and VPD-related health education to the community (4 PHCs in Dahod, 4 PHCs in Mehsana). Fewer than half of the PHCs had educational material for community leaders (1 PHC in Dahod, 3 PHCs in Mehsana), but many held information sessions for the community leaders to educate them about vaccination and vaccine-preventable diseases (3 PHCs in Dahod, 3 PHCs in Mehsana). Community leaders helped to identify newborns (4 PHCs in Dahod, 3 PHCs in Mehsana) and pregnant women (4 PHCs in Dahod, 3 PHCs in Mehsana). Community volunteers were used to help during immunization sessions at all sites.
Interviewees stated that the supervisors were qualified to provide supervision (all 10 PHCs), they established assessment tools to identify problems (all 10 PHCs), and most of them spent time in understanding barriers to vaccine delivery (4 PHCs in Dahod, 5 PHCs in Mehsana). Most supervisors offered guidance in overcoming these barriers (4 PHCs in Dahod, 5 PHCs in Mehsana), and PHC informants generally viewed the guidance as helpful (4 PHCs in Dahod, 5 PHCs in Mehsana). Many PHC informant groups reported that they would like to have more supervisory visits (4 PHCs in Dahod, 2 PHCs in Mehsana).
Monitoring and use of data for action
All PHC informants reported that they used data to inform immunization activities; most created monitoring charts to track immunization coverage (3 PHCs in Dahod, 4 PHCs in Mehsana). Most PHC informants reported that an electronic immunization registry was in use (4 PHCs in Dahod, 4 PHCs in Mehsana) and worked well (4 PHCs in Dahod, 4 PHCs in Mehsana). All PHC informants reported that they used paper-based systems for tracking immunizations and all reported that this type of system worked well. However, qualitative reports indicate that hardcopy immunization records were often not available during immunization sessions.
Qualitative reports stated that electricity and Internet access were not consistently available. This leads to multiple potential problems, including making immunization workers unable to reliably access electronic immunization registries. While Internet access is an issue common to many areas of India, availability of electricity in Gujarat is considered to be some of the best in the country. Some of the staff at PHCs in Dahod mentioned frequent power (electricity) cuts, but we could not get specific information of duration of such interruptions. Power cuts were not mentioned in Mehsana. With the available information, we cannot conclusively gauge the extent to which power outages were a bottleneck.
Cold chain monitoring
Adequate equipment to maintain vaccines at the temperature required for maximum efficacy (cold chain equipment) is a crucial part of an effective vaccine delivery system . While most PHCs reported having adequate staffing (9 PHCs) and equipment (all 10 PHCs) to maintain the cold chain of vaccines, only three PHCs (1 PHC in Dahod, 2 PHCs in Mehsana) stated that their cold chain equipment works all of the time. Furthermore, one PHC informant group in Mehsana stated that it rarely worked. Our data show that six PHCs mentioned some cold chain equipment malfunction, but we don’t have specific data as to the duration of the problem and the specific type of equipment that did not work.