Follow-up of Vaccination Dropouts: Use of Defaulter

Tracking Bags in India

The potential “reach” of the

immunization program in India, as

reflected in BCG coverage - the first

in the series of antigens - is 78.2%

(from the 2006 National Family

Health Survey – NFHS3). A

continuing concern is the gap

between this figure and full

immunization coverage (measured

at 43.5% by NFHS3). With an annual

birth cohort of 26 million in India, a

large proportion of children remain

who could be fully immunized if

they were effectively followed up on

to complete the immunization schedule. A review of the country’s Universal Immunization

Program in 2004 also highlighted this, recommending that all health workers be provided with

tools and training on how to track every child.

Health workers are supported at session sites by a cadre of functionaries known as Anganwadi

Workers (AWWs) and Accredited Social Health Activists (ASHAs), who mobilize beneficiaries due for

immunization on that particular day. These beneficiaries are to be identified with the help of the

immunization register and the counterfoils of immunization cards. The immunization card is given

to caregivers and updated with the child’s vaccination status and a reminder to return on

scheduled dates. A counterfoil of this card is retained by the health worker to estimate the number

of beneficiaries and vaccines required for the next session and to track dropouts.

Immunization registers receive some amount of health workers’ attention but immunization cards

and, in particular, counterfoils are more neglected. Though available since the inception of the

immunization program in India, health workers have not understood their utility. Observations in

the field note that neither immunization registers nor counterfoils of immunization cards are being

sufficiently or effectively used for tracking due beneficiaries. Printed immunization registers (if

available) are bulky, and health workers often prefer not to carry them to outreach sites. As

alternatives, tallies of administered doses are noted on a scrap of paper to be copied later into the

actual register, and/or health workers use hand-made registers to write entries by session.

Although the name of every beneficiary receiving a vaccine may be written down, there is not

always a relation to entries from previous sessions. This results in numerous errors in the tracking

information, and the registers of health workers and “mobilizers” (AWWs and ASHAs) rarely match.

Some mobilizers do not use a list of due beneficiaries and rely on their memory, resulting in time

and effort lost in mobilizing beneficiaries who may not be due for vaccination that day, while

beneficiaries actually due may be missed. When issued to beneficiaries, immunization cards are

often not completed with information on the vaccines received and return dates. Similarly, the

counterfoils retained by health workers are either not filled or not correctly stored or filed.

Based on the recommendation of the Universal Immunization Program Review, these issues are

being addressed in an “Immunization Handbook for Health Workers”, developed in 2006 and

Figure 1: Immunization Coverage in India

currently in use throughout India. It includes instructions to health workers on tracking and follow-

up of due beneficiaries and dropouts. A cloth tracking bag, composed of fourteen pockets, is one

simple tool developed for follow up of beneficiaries through the filing of counterfoils from

immunization cards. Twelve pockets in the bag indicate the months of the year. Counterfoils are

filed into the pocket indicating the month when the next vaccine is due. The thirteenth pocket is

used for counterfoils of beneficiaries who have left the area or have died. The fourteenth pocket

contains counterfoils of fully immunized children. Before the session, the health worker prepares a

list of beneficiaries due on that day, based on the counterfoils in the pocket for that month. This

list is then shared with the AWW or ASHA. As children come for vaccination, their cards and

counterfoils are updated, with the counterfoil moved to the pocket for the month when the next

vaccination is due. At the end of each month, cards and counterfoils remaining behind represent

drop-outs to be followed up. Used correctly, these bags also have the advantage of reducing the

work-load of mobilizers. With a precise list of due beneficiaries, they can focus on visiting the

fifteen or so families, on average, that are due for vaccinations in the next session.

Figure 2: Tracking Bags from various Indian states

Distribution of these bags has varied, with introduction through some small-scale initiatives, such

as hand-made tracking bags by AWWs in Bharatpur (through CARE/Rajasthan) and in a model sub-

centre in Agra (with UNICEF/Uttar Pradesh support). To ensure scale and uniformity in the use of

tracking bags, Rajasthan state supplied one bag each to all health workers in 2005. This was

followed by states such as Jharkhand1 (2006), Andhra Pradesh

2 (2007), Madhya Pradesh

3 (2008).

Costing an average of about 4 US dollars each, the bags have been supplied in either a backpack

(Jharkhand) or as a foldable bag (Rajasthan) to help health workers carry these to session sites.

Use of the bags remains an issue. They are being applied largely effectively and correctly in Andhra

Pradesh. In Rajasthan, introduction has been accompanied by a short training. However, in

Rajasthan and Jharkhand, implementation has been limited due to several reasons: Health workers

conduct sessions in 5-6 different outreach sites every month. With only one tracking bag, they find

it difficult to track children in different session sites. Moreover, the bulky size of the bag

discourages them from carrying the bags on session days. Many health workers have also not yet

been trained in their use.

In response to these problems, states are devising their own solutions. Uttar Pradesh proposes to

distribute tracking bags to all health workers with a “Frequently Asked Questions” guide and

instructions on their use, developed by IMMUNIZATIONbasics and WHO-NPSP. UNICEF/Jharkhand

has supplied the bags in an innovative, smaller accordion-file design. The bags’ reduced size and

their supply for every session site ensure greater use.

The tracking bag is still a new innovation in India. Roll-out and implementation take time and

effort, particularly to change health worker and mobilizers’ behaviors and practices. Distribution

and use of the bags needs to be ensured and monitored as part of immunization program activities.

With new and expensive multi-dose vaccines poised for introduction in the immunization schedule,

such low-cost, low-tech solutions can help to reduce the large number of children lost to follow-up

in India.

Tasnim Partapuri, IMMUNIZATIONbasics, New Delhi, India

Dr Karan Singh Sagar, IMMUNIZATIONbasics, New Delhi, India (karan@immbasics.org)

Inputs from Manisha Nair, WHO-NPSP, Rajasthan (riorajasthan@npsuindia.org), Manish Jain,

IMMUNIZATIONbasics, Uttar Pradesh (manish@immbasics.org), Sumant Mishra,

IMMUNIZATIONbasics, Jharkhand (sumant@immbasics.org)

1 with support from UNICEF 2 with support from CVP/PATH

3 with support from UNICEF