EPI--FIELD EVALUATION EXPERIENCE
This general examination of Immunization as a central modality in the prevention of common infectious diseases in the Developing World will begin with some salient extracts taken from the writer's findings in a field evaluation he carried out on a UNICEF--Expanded Program of Immunization and Primary Health Care initiative in Northeast Thailand, in March of 1990. The data derived from evaluating the EPI
component is being provided as basic background information because it provides some useful insights on comparable UNICEF-EPI initiatives that are now occurring throughout the Developing World, and points to some critical issues meriting further investigation. (EPI was one of eight components in the Integrated Services Project for Children, extending over a five year period, at a cost exceeding $8,500,000.(Cdn). This funding was primarily provided by the Canadian Government, and supplemented with public contributions. The Project was executed by UNICEF Thailand, in cooperation with the Royal Thai Government.)
The EPI in Northeast Thailand proved to be a considerable undertaking. It included: the execution of a cluster survey on immunization coverage in all 59 districts (in which there are over 900 villages); provision of EPI training for 600 Village Health Volunteers, Village Health Communicators, and religious leaders; similar training for 200 health care providers, and 40 multiple WHO staff, EPI information strengthening and finally social mobilization to vaccinate, viz. provide BCG/OPV/DPT and measles coverage for all 59 districts. It further involved the equipping of 373 Tambon (subdistrict) health centres with sufficient numbers of. refrigerators; vaccine carriers with four icepacks; BCG vaccine kits; thermometers; cold chain monitoring cards; and steam sterilizers.
The EPI initiative placed its strategic concentration on the following areas:
• EPI training of village and religious leaders • emphasis on reaching progressively higher annual vaccination targets • provision of cold chain equipment and support to targeted Tambons • information campaigns in primary and elementary schools • public education campaigns in targeted villages • increased vaccine production; and • strengthening the EPI information system at the district and provincial level. •
In reviewing figures for the project covering the first three years (1985-1987), the priority emphasis on immunization is evident. Project expenditures for this component reached 126 percent of the original target for immunization, compared to only 28 percent for primary health care. Food and nutrition fared somewhat better at 60 percent of the target, a little under the project average of 61 percent. A budget analysis conducted on the project for this period states that "Implementation of the community action component is . . . low. However, the savings obtained here will be passed on to the EPI and pre-school components . . ." The reason given for exceeding the original budget projections for EPI, was "because of the demands and opportunities for support presented."12
Recognizing the central importance of "health care outcomes," both the evaluation exercise and this broader examination of the issues have purposely focused on concerns surrounding the qualitative issue of EPI health care outcomes and effectiveness. However, it became readily apparent in the evaluation of the Program that--due to the absence of base line data on any sample of the recipients, let alone the additional need for a comparable control group, and the control or monitoring of intervening variables it was not really possible to proceed with any accurate or verifiable determination of health care outcomes (i.e., to establish a cause and effect relationship) for EPI.
This need to provide verifiable measurement of a program's health care outcomes appears to be pervasively deficient throughout most health programming directed to the Developing World. The implications of this general deficiency to the specific measurement or determination of EPI effectiveness, remains a serious one, and will be addressed more thoroughly at later points in this report.