Spotlight on missed children
Afghanistan has had a disappointing fourth quarter, mirroring many of the same challenges faced in Pakistan. Some 63% of its annual caseload was reported in the last three months of 2011, resulting in a total of 76 cases for the year. This is more than three times the number of children paralyzed in 2010.
Some districts in the Southern Region, including Maiwand with Afghanistan’s most recent case, have been consistently missing as many as 20% of children since June. This figure, too, only represents the proportion of children missed in accessible areas of the district. Many more children are missed in communities the teams cannot reach or monitor (see Figure AFG1). Approximately 89,114 children in inaccessible areas of the Southern Region were missed in December. This figure has ranged from 72,423 to 272,905 throughout the year.
While insecurity continues to pose huge challenges for vaccination teams, over 20% of cases have been reported outside of the conflict-affected Southern Region, demonstrating Afghanistan’s growing vulnerability in previously polio-free areas. The GPEI partners have recently intensified talks with anti-governmental elements (AGE) in an effort to increase coverage among all children in the country, even those affected by conflict.
Children not available
A growing proportion of children are being missed each month because they are unavailable when teams visit the household (see Figure AFG2). Between 50 and 60 percent of children are missed for this reason, and anecdotal data suggests that children are often at relative’s homes, traveling, or in the market when the teams arrive.
As in Pakistan, extensive discussions about revising Afghanistan’s independent monitoring forms have not yet led to any outcomes. Data that shows how children may be reached outside the homes does not exist, and it is urgent that monitoring systems are developed that can regularly collect this information.
A range of refusals
Overt refusals make up a very small percentage of missed children in Afghanistan, with only about 5% of missed children in the 13 high risk districts not vaccinated for this reason.
But variations among the districts are significant. Many show almost negligible figures of less than 1% and others, like Spin Boldak, display concerning rates nearing 20% each month. Other districts, like Musaqala, fluctuate wildly from one month to the next (see Figure AFG3).
Reasons for refusal in the conflictaffected Southern region of Afghanistan are diverse, and empirical evidence on social issues does not yet exist in sufficient depth. Anecdotal evidence from the field suggests that some parents here, like their neighbors across the border in Pakistan, believe OPV is an American ploy to sterilize or poison their children. Rumours about OPV safety spread freely between the border area of Killa Abdullah in Pakistan and Spin Boldak in Afghanistan, where refusals are among the highest rates in both countries. In Afghanistan, vaccine coming from Pakistan is generally thought to be safer than that coming from Afghanistan, as the latter is considered more susceptible to “tampering” by Americans. According to field staff, where the vaccine comes from is a common question asked by communities.
Multiple rounds also cause concern among some caregivers, leading to fatigue and suspicion about the one public health service that is offered frequently amidst a lack of other, more urgent and life-saving needs. In the highest risk areas of Afghanistan, children have been vaccinated five times in the last four months. Communities in Spin Boldak routinely refuse vaccine as a bargaining-chip to demand other development services, such as additional vaccines, bed nets, and clean drinking water.
In Kandahar City, refusals have been creeping up steadily each month, from 0% in May to 5.6% in December. Field staff say development concerns are growing here in the wake of increasing insecurity.
Where refusals spike up and down from one month to the next, it is more difficult to attribute this to deep-rooted beliefs or misconceptions about OPV. In areas like Musaqala, where refusals have gone from 0% to 18% and then back down to 1.2% in a 4 month period, refusals are either documented inaccurately, influenced by a one-off event, or could even be prompted by disgruntled staff that were once hired
Data quality issues are so common in security-compromised areas of Afghanistan that it is difficult to correlate data fluctuations with specific events. However, turnover of staff in the Polio Communication Network (PCN) is worryingly high. When a high level of coverage is attained in a particular cluster, that cluster has, in the past, been no longer considered by the partners to be high risk for communications, and the PCN has been disbanded and reassembled from one month to the next. Findings from the Communication Review suggest that PCN staff who are frustrated to be let go could be generating rising resistance for the programme. This might at least partially explain the sporadic spikes in refusal in some districts from one round to the next. Addressing this disincentive for good performance must be an urgent recommendation for the programme to implement.
Since the September review, a revised high risk analysis has been completed by the partners, identifying permanent clusters to be prioritized for communications and operations. PCN mobilizers will now be fixed in these locations, and the network as a whole will be managed more professionally to ensure it is targeted and effective. Because the PCN covers only 24% of all high risk clusters in the 13 High Risk Districts, UNICEF and Government are reorganizing the network to distribute staff more effectively across the high risk areas to help increase coverage.
In December, 23% of missed children in the 13 High Risk Districts were not vaccinated because they were newborn, sick or sleeping. Together with refusals, social reasons have accounted for over 25% of missed children in high risk districts over the past year (see Figure AFG4).
It is even more critical in this context to find innovative ways of engaging with mothers and school-aged children. Although it is extremely difficult to find women who are allowed to work outside of the home, opportunities do exist to involve women more than present levels (see AFG2Box). Interactive polio programmes in schools need to be expanded. Radio stations targeting women need to host engaging polio content, and must go beyond simple didactic public service announcements. These recommendations were identified by the Communication Review and are being incorporated into the 2012 Communication Strategy. Their urgent implementation is critical.