In the first decade after gaining independence in 1991, Georgia faced political instability and armed conflicts as well as increased migration. The country’s health system nearly collapsed and immunization services were disrupted. Worsening sanitary conditions, widespread poverty, and inefficient implementation of preventive health measures resulted in increased incidence of infectious diseases and a major diphtheria epidemic in 1993-1999. Poor data quality and limited information management capacity impeded the ability of health workers to quickly restore proper functioning of the disease prevention and control system.
In early 2002, the Government of Georgia and PHRplus began a three-year collaboration to strengthen two components of the country’s Health Information System (HIS): the immunization management information system (MIS) and the surveillance of vaccine-preventable disease (VPD).
The work, sponsored by USAID/Caucasus, is expected to yield improvements in health outcomes by reducing VPD mortality and morbidity through improved tracking and immunization of the child population, prompt and adequate response to disease outbreaks, and increased efficiency of HIS operations.
Strategic planning is coordinated with principal stakeholders from the country’s multi-disciplinary national and regional expert groups. Participating expert group members come from the Ministry of Labor, Health and Social Affairs (MoLHSA), the Department of Public Health, the National Center for Disease Control and Medical Statistics (NCDC), local Centers of Public Health (CPH), and several international donors: USAID, UNICEF, and the World Health Organization. Implementation is the responsibility of the Curatio International Foundation, a Georgian non-governmental organization subcontracted by PHRplus.
Effective management of immunization programs is premised on knowledge of the target population. The new MIS model thus requires an accurate census of the child population be performed annually by every health facility in each catchment area. The emphasis on the accuracy of census and data verification through cross-checks has improved data quality and enabled health workers to more accurately determine target population, project vaccine needs, compute immunization coverage and evaluate performance of individual facilities and districts.
This MIS model also includes innovations that allow better immunization program management and more rational use of resources at all levels, such as:
- identification of rayon (district)-specific factors preventing children from being immunized;
- determination and monitoring of area-specific vaccine utilization/wastage patterns;
- monitoring of vaccine distribution from existing stores to the point of consumption;
- up-to-date tracking of vaccine balances in all facilities.
New MIS guidelines, work tools and a software application were developed to assist health workers in information-based program management.
After a successful year-long pilot in Kacheti in 2002, the new immunization MIS was implemented in the rest of the country in early 2003. For the first time in a decade, the Georgian routine immunization MIS estimated the actual coverage rates in the country with relative accuracy: year-end rates are 75% for DPT-3 and Polio-3, 48% for Hepatitis B-3, 82% for Measles-1. Availability of quality data has led to improved information use for management at all levels; for example, improved vaccine supply management resulting in fewer stock-outs at the peripheral level, reduction of medical contraindications as a result of careful review of their justification, and timely follow-up with poorly performing facilities.
Strengthening Vaccine-preventable Disease (VPD) Surveillance
Because no comprehensive assessment existed of the surveillance systems in Georgia, a multi-agency team including Curatio, NCDC, MoLHSA, WHO, and UNICEF and led by PHRplus conducted such an assessment in 2002. Responding to its findings, PHRplus, Curatio and the National and Imereti (region) Expert Groups developed new VPD Surveillance Guidelines for epidemiologists and a series of work tools (such as a handbook for providers, a surveillance monitoring workbook for CPH, and a software application for regions). The Curatio research team investigated community and provider behaviors in order to identify key factors that discouraged a high percentage of infectious disease patients from self-reporting to health facilities through official channels and affected motivation of providers to report cases bypassing official channels. A laboratory task force developed a laboratory surveillance reference manual which includes instructions on: sampling and sample transportation procedures; biosafety; laboratory testing methods; and internal and external quality control. Relevant material from these guidelines became a basis for revised national standards for laboratory service functioning. PHRplus led a baseline cost analysis of infectious disease prevention and control activities to identify current financing mechanisms and the fixed and variable costs of the existing VPD prevention and control system, in order to assess the efficiency and adequacy of the current use of funds and to determine ways to optimize financing in the future.
Following a comprehensive assessment of the VPD surveillance system in 2002, piloting the surveillance reforms began in Imereti Region in 2003. Implementation of the new system so far has revealed a number of structural, behavioral and technical issues, which will be addressed in the coming months. Results of the pilot are currently being evaluated and recommendations for future reform directions and possibly the national roll-out of the surveillance model will be developed.
Operations research is underway to assess effectiveness of the job aid intervention package for improving analysis and response of infectious disease surveillance at the rayon level. This research will lead to a better understanding of how such a package can be designed and implemented in the entire country to improve the functionality of the surveillance system. In addition, a follow-up costing study will be conducted concurrent with the evaluation to more accurately project the costs of the reformed surveillance system before its national roll-out.