Programmatic and Non-programmatic Determinants of Low Immunization Coverage in Bangladesh

(A collaborative study of ICDDR,B, WHO, UNICEF, IOCH, & MOHFW)

Funded by: USAID

Although health for all by 2000 has not been achieved in many countries including Bangladesh, improving child health remains one of the top priorities since signing of the World Summit for Children 1990.  To eradicate, eliminate or reduce six most common vaccine-preventable diseases, the Expanded Programme on Immunization (EPI) for vaccination of all susceptible children in the country has been introduced since the mid-1980s as an essential component of the Bangladesh Primary Health Care.  Targeted achievement of such will significantly contribute to reduce infant and childhood morbidity and mortality.

Despite the continuing concerns and interests of all stakeholders on EPI, which has made remarkable success in Bangladesh in increasing its immunization coverage among children from 2% in the mid-1980s to 95% of at least one dose, why half of the children are not fully immunized remains a key area of investigation. 

There are barriers that must be overcome to achieve optimal protection, which would result from reducing left-outs, drop-outs, and invalid doses.  The most common reasons parents give for not completing vaccination of their children have been reviewed in every Coverage Survey conducted by EPI since 1991.  These responses appear to have been somewhat consistent and relate to what is classified in these surveys as "lack of information and knowledge", i.e., being unaware of the need for immunization, and unaware of the need for subsequent dose(s) and the importance of completing the entire schedule.  What is less well understood is why does this lack of knowledge still exist, despite years of effort to provide information on immunization through education and communication via the media and through inter-personal contacts.  Routine coverage surveys are not designed to provide information to address the gaps in effective communication of immunization issues. This problem is being investigated in this study among other objectives, and the findings of the study are expected to assist programs in incorporating strategies to reduce immunization drop-outs, left-outs and invalid doses.

The overall aim of the study is to gain an in-depth understanding of the key issues affecting the current status of immunization and better understand the programmatic (supply side) and non-programmatic (demand side) determinants of immunization coverage. Included, the purpose is to review the achievements of the EPI program and identify areas where performance needs improvement with an emphasis on those aspects, which can be altered/modified by the health care systems.  The study is being carried out in six Upazilas across Bangladesh, covering high and low performing areas.  Community perceptions, knowledge, attitude and practices common to vaccination of children, are expected to be very useful findings of this study.  Factors motivating mothers/caretakers to complete immunization in 60% of cases with adherence to the recommended immunization schedule under the same umbrella of the socio-demographic conditions of our country, same program managers and vaccine providers, same EPI catchments areas and accessibility to EPI centres, where paradoxically 40% are not completing, is a cornerstone of this study.

For this endeavour, a multi-sectoral networking approach involving ICDDR,B, MOHFW, WHO, UNICEF, and IOCH in a single platform, was considered essential to generate useful information about the determinants of low immunization coverage in Bangladesh. Based on the study findings, appropriate strategies will be formulated addressing the identified programmatic and non-programmatic factors and necessary recommendations will be advocated to MOHFW as strategic plans to increase full coverage of EPI, by reducing left-outs, drop-outs, and invalid doses.