Afghanistan | News | Big plan, small details – how microplans ensure we can end polio

Big plan, small details – how microplans ensure we can end polio

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Herat_NID_12.3.2018_Reza_Nazeris_saughters_Saharnaz_2_and_Satayesh_4_get_vaccinated_Photo_Tuuli_HongistoReza Nazeri's saughters Saharnaz (2) and Satayesh (4) were vaccinated in Herat. Photo: Tuuli Hongisto27 May 2018 – In Afghanistan, every child needs to be vaccinated to protect them from poliovirus. To achieve this, detailed plans are prepared for vaccination teams. The aim is to find where each Afghan child under 5 years of age – around 10 million altogether – is, and to reach them with vaccines. Read how these "microplans" work. 

A heavy steel gate opens on a quiet suburban street in central Herat. The city lies in a fertile river valley in western Afghanistan, an area rich with thousands of years of history. Over past centuries, different invaders from Genghis Khan’s army to the troops of the Timurid empire, the Mughals and the Safavids have opened the gates to rule the city once known as the Pearl of Khorasan.

Now, a peaceful group can be seen walking down the streets of Herat. Equipped with blue vaccine carrier boxes and drops of polio vaccine, the teams knock on one door after another to vaccinate any children they find inside. The aim is to eradicate polio in Afghanistan.

4-year old girl Setayesh peaks behind the gate and steps out on the street, followed by her father Reza Nazeri, who is carrying sleepy 2-year-old little sister Saharnaz. 

Reza encourages the girls to open their mouths to receive 2 drops of polio vaccine, and a drop of vitamin A. The children look at the vaccinators with suspicion, but follow.  

The vaccinators thank and continue down the street.

Locating 10 million children

In March, around 10 million children were vaccinated in a national polio campaign in Afghanistan.

During the campaign week, in Herat, vaccinators gave oral polio drops to over 150 000 children, only missing less than 5000 of them.

In a country with one of the highest rates of population growth in the world and frequent population movement, it is no easy feat to tell how many children live in each province, district, village, block, house or tent.

How do vaccinators know where the children in each area are located then? It takes detailed planning and tapping into local knowledge.

No coincidence, who goes and where

A few kilometres away from Setayeshs’ and Saharnazs’ home, dr Khushal Khan Zaman is shifting through printed plans on his desk at the WHO office.

Polio eradication initiative has been working in Afghanistan for two decades — since 1997. In that time, the programme has pieced together information of areas and populations bit by bit for every vaccination campaign. There are several every year. For each campaign, new documents guiding the campaign called “microplans” are drawn.

Dr Kuhshal explains, that once a year, the cluster supervisors physically count the houses. Then they check that their plans match the numbers. Every house is assigned to a team in a specific area to visit on a particular day during the campaign.

Before each campaign, supervisors update the microplans. The cluster supervisors know the approximate number of children in each house from last campaign, but as they are locals, they often know if and when new children have been born and also know, if for example nomadic tribes have settled in the area.

Any new settlement, tent or group is added to the microplan. If the tents stay in the area for a longer time, they are added to the house-to-house microplan, but for shorter stays, a separate checklist used to monitor nomadic population movement is used. It is crucial to reach every child, even if they are on the move.

The supervisor marks down which house is visited with which team and on which specific date.

16.3.2018_NID_Herat._Vaccinators_Marziya_and_Permilla_Timuri_see_plans._Photo_T_Hongisto_twitterVaccinators Marziya and Permilla Timuri examine a microplan in Herat. Photo: T Hongisto In the final plan, not only the numbers of houses and children is indicated, but the microplans also include details on how many vaccine vials, vaccine carriers, ice packs (to keep the vaccines at optimum temperature), chalks, tally sheets, pens, leaflets, finger markers, plastic bags and scissors are needed by each team.

A few years ago, the plans used to just list the name of the area with the estimated number of the target population to be vaccinated. The plans have now been developed further to include even the smallest villages and individual houses. They also include information on the closest mosque and local elders.

As a final step, the plans need to indicate, which teams visit which house and when.  

“It needs to be clear to everyone, which team is responsible for which area. We mark where the teams start and which direction they take by arrows”, Dr Khushal explains

It is no coincidence who goes and where. It is important to ensure that the vaccinators are accepted by the local populations. Usually the teams consist of local people.

Sometimes as a final check, the teams meet each other in the borders of their areas to check and confirm which team goes to which house so that no house is missed.  

When all pieces come together, the microplans can be finalised and vaccinator teams can start their work.

Last day, last children

16.3.2018_NID_Herat._Cluster_supervisor_Ahmad_Rashid_examines_map_on_revisit_day._Photo_Tuuli_Hongisto_twCluster supervisor Ahmad Rashid examines a microplan on the last day a campaign. Photo: T Hongisto At 9.30 am on a sunny Friday morning, Ahmad Rashid stands in a busy junction in the centre of Herat city and examines his plan for the day. He works as a cluster supervisor. Together with his colleague Ahmad Mujiib, they check where their teams are headed today.

It is the last day of the vaccination campaign, and the last chance to reach all children in this round. Some of the children have not been home, or their parents might have refused the vaccine when the teams have visited during the campaign. The missed children are marked in the vaccinators’ tally sheets during the campaign days, so today the teams will revisit those houses.  

The men start their motorbikes and get on with the day’s work. A few blocks away they stop their engines, hop off and meet one of their vaccinator teams to follow them down a narrow alleyway. In the end, the group stops to knock on a red door. They know that this house has one more child unvaccinated.

The door opens, and noisy a group of kids appears from a dark back room. The house is a home to a large extended family.

16.3.2018_NID_Herat._Team_convinced_3-y_Moheburrahmans_mom_to_allow_vacc_Photo_Tuuli_Hongisto__2Success! The vaccinator team convinced 3-year-old Moheburrahman's mom to allow vaccination. Photo: T Hongisto3-year-old Moheburrahman stands among his cousins and looks shyly at the door. His cousins have received their polio drops in the previous days, but his own mother is unsure about the vaccine’s safety.

The team explains patiently that this is the only way to protect the boy from life-long paralysis. Thankfully, the mother agrees to allow vaccination.

After all the hard work put into planning, this is the best reward.

Text and photos: Tuuli Hongisto / WHO Afghanistan 

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Key health-related statistics

Population (m) 29.7
Health expenditure (% of GDP) 9.5
Adult (15+) literacy rate (%) 34.8
Life expectancy at birth F/M (2010) 63.2-63.6

Sources: Central Statistics office, Afghanistan National health Accounts, Afghanistan Living Conditions Survey, Afghanistan mortality survey. 

Framework for health information systems and core indicators for monitoring health situation and health system performance, 2018

Afghanistan country health profile

Regional Health Observatory

WHO Afghanistan Programme Overview 

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