Spotlight on missed children
Although there has been a significant decrease in the number of polio cases this year - only 5 cases reported compared to 33 in 2010 - the continued poor quality of campaigns, particularly in densely populated areas of Luanda, continues to be a significant concern. While improvements in campaign quality have been made over the past quarter in rural areas, post-campaign monitoring data in Luanda shows an increase in the proportion of missed children, rising from 11% in July to 19% during the November campaign. Worryingly the November LQAS survey conducted in 10 municipalities of Luanda found that the teams missed households in 9 out of the 10 selected areas.
Why are we missing children?
Independent monitoring data confirms that the most significant reason for missed children nationally continues to be the failure of teams to visit every household (see Figure ANG1). During the November campaign, 59% of missed children were missed nationally due to unvisited houses. In Luanda, as many as 65% of missed children were not vaccinated due to this failure in team performance, including the challenge of using young vaccinators.
Although there were improvements in the capital early in 2011, thanks to the involvement of the municipal authorities, this commitment has weakened or even evaporated due to the restructuring of municipalities (from 9 to 5) with changes in boundaries and new leadership at both provincial and municipal levels. In addition, health staff are simply overloaded with work and underpaid, which impacts negatively on motivation, further reducing the time available to strengthen planning between campaigns.
The other significant reason for missed children is that children are not at home when vaccinators arrive. A recent study1 suggests that parents often don’t know exactly when vaccinators will visit the household, mostly due to poor planning, and the lack of an efficient system for interpersonal communication. Overall in 2011, 33% of children were missed due to child absence, although there was some improvement during the most recent campaigns – 22% in November. It is hoped that the recently updated independent monitoring form will be introduced during campaigns in 2012 to provide more detailed analysis of missed children to aid micro-planning.
A deeper understanding of which children are being missed is urgently needed, as well as information on where 1 Community research on Polio immunization and effectiveness of communication and social mobilization interventions, SINFICUNICEF, June 2011 children are when they are not at home during team visits. An in-depth qualitative study looking at reasons for missed children is underway in high-risk areas of the country, including Cabinda and other provinces bordering DR Congo, as well as parts of Luanda.
Refusals remain low nationally, with only 2.9% of missed children due to refusal. A three-fold increase in refusals during the October campaign was a concern with a rise to 6%, although this fell again to 2% in November, and this needs to be better understood (see Figure ANG2).
Refusals are higher than the national average in high-risk areas like Cabinda, which saw 12% of refusals in October. Uige province with 6% of refusals in October, reported the most recent case in a hard to reach area near the border with DR Congo. Resistance here could be linked to similar cultural issues influencing resistant communities in DR Congo.
“Other” social issues
In the last quarter, about 4% of caregivers nationally were afraid to give OPV to their sick child, rising to 9.5% in high risk areas like Cabinda.
When combined with the percentage of parents who actively refused OPV, the percentage of missed children due to ‘hard’ or ‘soft’ refusals rose to 8% in the past quarter nationally, and to 18% in Cabinda.
An additional 17.5% of missed children nationally were missed due to “mother unaware”, which, as was noted last quarter, does not adequately explain why the child did not receive OPV.
With this figure at 24% in high risk areas like Uige, and as high as 36% in other provinces, it is critical that this category be revised in the independent monitoring classifications. This will enable both operational and communication strategies to be designed to reach and vaccinate these missing children.
Since the November campaign, increased focus is being placed on specific interventions in the high risk areas of Zaire, Uige, Malange, Lunda Norte, Lunda Sul and Cabinda, with promising results. Many areas in these provinces are hard to reach, especially during the rainy season. Internal and external migration from these areas also needs to be better understood. UNICEF has entered a cooperative partnership with the Red Cross to build social mobilization capacity in these regions, including enhancing interpersonal communications and undertaking social mapping of high-risk populations and micro planning. In 2012, UNICEF intends to scale up this partnership in the high-risk border areas and densely populated slums of Luanda, expanding an existing alliance to promote essential household practices with the largest faith based groups in the country.