EXECUTIVE SUMMARY
	INTRODUCTION
	OBJECTIVES OF THE STUDY
	METHODOLOGY
	RESULTS AND DISCUSSION
	CONCLUSIONS
	RECOMMENDATIONS

EXECUTIVE SUMMARY

Kerala state of India is quoted as a model for the developing country because of its high achievements in the field of health and family welfare at a low cost. Kerala’s infant mortality rate of 14/1000 live births and life expectancy of 76 years for women and 70 years for men are close to that of developed countries. Over 95% of institutional deliveries, high coverage of immunizations, access to universal health care etc are some of the highlights of the Kerala model of health care. Some of the recent studies reported that the cost of health care has been increasing in the state and the quality and quantity of health care provided through the public sector were decreasing. As a consequence to the liberalization policies of the Indian government budget allocations to public sector specifically for education and health care has been decreasing since 1991. This affected the state of Kerala also and we wanted to study the current status of service delivery in the health and family welfare sector in Kerala with particular reference to reproductive and child health.

We selected five districts from the state, two from the north two from the south and one from the central region. We conducted household survey to find out from the people the services that they received from various health care institutions. A total of 5000 households (3500 rural and 1500 urban) were selected by a multistage random sampling and trained investigators collected information from all the households using a pre-tested structured questionnaire. We collected information on antenatal care, delivery practices including medical termination of pregnancy, immunization coverage and source of immunization, low birth weight, awareness on sexually transmitted infections and reproductive tract infections, utilization of health services from the health care institutions and the quality of health care. We collected information from selected 70 sub centres, 20 mini primary health centres, 10 block primary health centres, 4 community health centres and 4 first referral units from the five districts.  The information included infrastructure facilities in those institutions, drugs and supplies, staff strength, and services provided from those institutions. We also conducted focus group discussions (FGD) in one of the northern districts and one southern district. Separate FGDs were conducted for junior public health nurses, junior health inspectors and selected women in the age group of 15-50 years. Data entry and analysis were done using Excel and SPSS software.

The average number of antenatal visits was found to be 8 in the total sample. There was not much difference between the five districts or between the urban and rural areas. The cost of an antenatal visit was reported to be around rupees 200. There is a need to reduce the number of antenatal visits. Recent studies have shown that without any problems to the mother and baby the number of antenatal visits can be reduced to 4 or 5. This would reduce the cost of care for pregnancy and delivery and overcrowding at maternity hospitals in the state. Tetanus toxoid coverage was found to be over 95 percent with out much difference between the districts or between the rural and urban areas.

Institutional delivery was found to be 98.8% for the entire sample. Only Malappuram districts reported home deliveries (6.7%). All the other four districts had 100 percent institutional deliveries. Female obstetricians conducted over 80% of deliveries in our sample. In a poor state like Kerala over dependence on specialists is a concern because it raises the cost of health care. Over 95% of women preferred to have their deliveries conducted by a female provider. Majority of deliveries (52%) were conducted in private sector hospitals. Since over two third of hospital beds in Kerala is in the private sector this is not high as one would expect. Barring Malappuram district home deliveries are becoming extremely rare in Kerala. Sub centres and primary health centres are also not conducting deliveries particularly in southern districts. This is the reason for the overcrowding of tertiary level maternity hospitals in government sector. In spite of having a high proportion of institutional deliveries the state does not have data on maternal mortality ratio. This could be collected from hospitals easily provided the private hospitals would also report maternal mortality to the state health authorities.

Low birth weight was found to be 13.3 %. This figure was one of the lowest in recent studies in Kerala. Previous studies reported around 17% except the KSSP second study (1996) that reported 13% low birth weight. Immunization coverage of children between 12 to 23 months was found to be low in Malappuram district. In all the other districts coverage of DPT 3, Polio 3 etc were over 90%. However in Malappuram district both DPT 3 and OPV 3 coverage was less than 50%. This is surprising since the TT coverage for pregnant women in Malappuram was over 90%. After a period of ‘no polio’ case in the state for more than three years one case of polio was reported in Malappuram district recently. Therefore there is an urgent need to improve immunization coverage in Malappuram district and other areas of low coverage.

Thirty nine percent of households reported that someone from the health centre visited their house in the last one year. This is a remarkable increase from the 17% reported in 1987 and 25% reported in 1996. The decentralization process that started in the state in 1996 could be one of the reasons for this increase in house visits.

Medical termination of pregnancy was reported to be very expensive in both government and private sector. Awareness on STI and RTI was reported to be high. This was evident from the large number of reported cases of RTI and STI from many institutions.

            Infrastructure facilities in many institutions were reported to be inadequate. Many sub centres did not have minimum facilities to accommodate the junior public health nurse. This might be one of the reasons for the low proportion of house visits. The maternal mortality and infant mortality captured by the health workers was found to be only around 25% of the actual mortality. There is a need to improve the routine surveillance system by which we would be able capture this vital information. The mini primary health centres were found to be functioning as outpatient clinics only. In patient facilities were not provided. Unless inpatient facilities are provided in primary health centre, the only government institution in a Panchayath with a medical officer, people will be pushed to private sector hospitals. If this is going to be difficult in the near future inpatient facilities need to be provided at least in the block PHC level. The entire block PHCs could be converted to community health centres in a phased manner and it should provide specialists care also.

INTRODUCTION

Kerala State in India is often quoted as a model for the developing world because of its high achievements in the field of health and family welfare with low cost ^1,2.  Kerala’s infant mortality rate of 14 per 1000 live births, life expectancy of over 71 years (69 for male and 74 for female) and a total fertility rate (TFR) of 1.7 are some of the indicators far superior to the Indian national averages and close to that of the developed countries. This has been achieved against a low state domestic product of US $ 275³ per capita per person per year in Kerala against a national average of US $ 350 and the US $ 23090 for the developed countries². Further Kerala ranks highest among the Indian states in Human Development Index with a value of 62.8 followed by Maharashtra (55.49). The gender-related health index that measures the gender equalities in health and education is also highest in Kerala followed by Tamil Nadu (62.13). As regards the reproductive health index, Kerala ranks again on the top (84.61) ⁴.  However, studies in Kerala have shown that the utilization of primary health centres and sub-centres in the state have been lower than expected levels ^5-7. There was a gradual shift of utilization of certain type of health services from primary health centres to higher centres over time. This was probably due to the increase in literacy levels and expectation of high quality care. For example, institutional delivery was moving to major government hospitals like women and children hospitals, district hospitals and medical college hospitals in the government sector and private hospitals. Majority of pregnant women were consulting obstetricians compared to MBBS doctors leave alone the female health workers. Fall in fertility rate might have also played a role in this. Each couple has only one or two children and they would like to get the best quality care for antenatal, natal and postnatal services. Although the state has been spending a substantial proportion of its budget to health only around a third of the population is covered by the public sector.  Due to a reduction in the public health sector allocation the quality of care in the government services was gradually coming down and there was a shift from government to private sector for antenatal and natal services⁸. Globalization has been reported to adversely affect the Kerala model of health that was developed on equity and justice over a period of time ⁹.  In order to understand the current status of service delivery under the health and family welfare sector with particular reference to the reproductive and child health (RCH) services in Kerala we conducted a study in five selected districts of Kerala.

OBJECTIVES OF THE STUDY

The major objective of this study was to find out the current status of service delivery in the health and family welfare sector with particular emphasis on RCH and to come out with suggestions to redesign the service delivery system for better quality client responsive services.

METHODOLOGY

            In order to collect information from the clients and health care providers we decided to use both qualitative and quantitative methods of data collection. We used a multistage sampling process to select the sample households for data collection.

Districts

Two districts each from Malabar region of the state namely Malappuram and Kannur (north of Ernakulam district) and two from the Travancore Region namely Ernakulam and Alappuzha were selected for the study. Kollam District was also selected for the study since this was taken up by the state to implement the project supported by the European Economic Community (EEC). Thus we had representation from the erstwhile Malabar region, Travancore Region and Cochin Region in the study.

Institutions

From each of the selected district we selected two community development blocks randomly. One First Referral unit (FRU), one Community Health Centre (CHC) nearest to the selected block, Two block Primary Health Centres (PHC), two mini primary health centres under the selected block PHC, and 7 sub centres each under each of the block PHC were selected for the institutional survey. Thus it was decided to collect information from 14 sub centres, 4 mini primary health centres, 2 block PHCs, 1 CHC and 1 FRU from each selected district.  The institutional survey included the facilities available at each of the selected institution, which was obtained both by interviewing the personnel at the institution using a structured questionnaire, and by personal interview undertaken by one of the investigators of the team and from the records kept in the institution. A total of 108 institutions were covered in the survey. (Table 1)

Household survey

Rural area

From each of the selected sub-centres, one-day block each  (the households under the sub centres are divided into 20 day blocks for field work by the staff of the sub centre) was randomly selected for household survey. All the households in the selected day block (approximately 50 households in each day block) were surveyed using a pre-tested structured questionnaire. The total number of households in each district was expected to be around 700 in the rural area making a total of 3500 households in the five selected districts.

Urban area

In the urban area one ward of Municipality or Corporation was selected randomly and a cluster of 300 households were selected from that ward. In districts with more than one municipality one municipality was selected randomly. Thus we decided to cover a total of 1000 households in each of the selected district (700 in rural area and 300 in urban area).  This proportion of households was based on the rural urban population distribution in the state.  Total sample size for the state was 5000 households. Population in each of the selected district ranged from 2.11 million in Alappuzha to 3.63 in Malappuram district.   For each district there were 2 field investigators for data collection. They were trained at the Achutha Menon Centre for Health Science Studies (AMCHSS) of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram.   

Questionnaire for household survey.

The questionnaire for the household survey was discussed and finalized in two workshops organized in Trivandrum. In addition to the faculty of AMCHSS senior medical officers from directorate of health services, public health nurse from district medical office Trivandrum, and health and family welfare training centre people also participated in the workshops.  A separate instruction manual was printed and circulated to all field investigators to ensure uniformity and accuracy of information.

Household information included age, sex, number of individuals, occupation, monthly household income, and awareness and utilization of sub centres, primary health centres, community health centres, and first level referral units. The kind of health services that the household was receiving from each level of organization and the quality of each service was also assessed using a three-point scale. There were questions to collect information on family planning services, adolescent health services, and other services.

Information on antenatal care including frequency of check ups, Tetanus Toxoid  (TT) immunization, iron and folic acid supplementation, source of care (private or public) etc was collected. All mothers in the selected day blocks who delivered within a period of two years from the date of survey were included in the survey.  Information on delivery care included place of delivery, who attended the delivery and complications during delivery. In the postnatal period information on birth weight of the baby (the youngest baby if there were more than one baby) breast feeding, family planning and their preference for a female health provider to conduct delivery was collected.

Information on immunization coverage was collected from mothers of children between 12 to 23 months of age only. This age group was fixed for comparison of our survey results with previous surveys and considering the timings of each immunization in the national immunization schedule. If a child follows the schedule by the end of one year each child could receive 3 doses of DPT, 3 doses of Polio, one dose of BCG and one dose of Measles vaccine. Availability of an immunization card at the time of interview, vaccination date and source of vaccine was also collected with regards to all vaccines in the immunization schedule. In addition information on MMR (Mumps, Measles, Rubella) and Hepatitis B vaccine was also collected. Another question was on vitamin A fist dose.

Questionnaire for institutional survey

Through this questionnaire we collected information on the facilities of individual institutions. The services provided through each institution, number of beneficiaries in the last one-month, availability of drugs and other facilities were also assessed using this questionnaire. Access to the institution, water supply, electricity, and safety of the building was also collected through the questionnaire (See Annexure)

Focus group discussions

In addition to household surveys we conducted 8 focus group discussions four in the northern district of Kannur and four in the southern district of Kollam. FGDs were conducted separately for Junior Public Health Nurses, junior health inspectors and selected women in the age group of 15 to 50 years from the community. Some of the important information, which the questionnaire could not capture, could be obtained through these focus group discussions. Particularly the ‘why’ part of many questions could be collected using FGDs.

RESULTS AND DISCUSSION

Table 1. Number of households and institutions surveyed in the five selected districts.

Out of 5000 households surveyed 22 questionnaires were discarded (0.4%) and 4978 questionnaires were used for analysis (Table 1). For institutional survey our objective was to survey 70 subcentres. We could survey 70, and for CHCs and FRUs we planned to cover 5 each and we covered only 4 each. For sub centers, Mini PHCs and Block PHCs we covered the same number of institutions as we planned.

Antenatal Services

Results of the findings on antenatal services are given in table 2. This was analyzed from the information collected through the mother coverage form of household questionnaire.

Table 2. Percentage of Pregnant Women received TT vaccines and other services in 5 districts.

Tetanus Toxoid Coverage

Tetanus toxoid coverage was over 95% in both rural and urban antenatal women in our sample. Coverage of Tetanus toxoid has been high in Kerala in previous studies also. The objective of this vaccination in pregnant women is to prevent tetanus infection in the mother as well as to prevent neonatal tetanus in the newborn baby. Kerala has reported no neonatal tetanus in the last three years and is in the elimination stage. High coverage of this vaccine and nearly hundred percent institutional deliveries could be major reasons for the elimination of neonatal tetanus in the state. Surprisingly in Ernakulam district, one of the most advanced districts in Kerala both socially and economically, the TT coverage was found to be less than other districts.

Iron and Folic Acid consumption

Iron and Folic acid is distributed to antenatal mothers to prevent anemia in pregnancy. In spite of having a high consumption of iron and folic acid tablets there has been high prevalence of anemia among pregnant women in Kerala. We did not study the anemia prevalence in this study. However in the NFHS 2 it was reported that 22% of antenatal women were anemic ¹⁰. Although this is the lowest proportion of anemia in all the states of India this is a matter of concern. Iron and folic acid supplementation was over 90% in the year 1991-92 (NFHS 1) ¹¹. The coverage has increased from this figure to 94% in our study.

Ante - natal visits

The average number of antenatal visits in the sample was over 8. This is close the figure reported in NFHS 1 and 2. For a developing economy like Kerala do we need this many antenatal check-ups? Can we afford these many? This is the average number of antenatal visits followed in the developed countries. One recent study has shown that there is not much difference in the outcome of mortality and morbidity for the mother and baby when the number of visits was only four ¹². There was no significant difference in the average number of antenatal visits between rural and urban area. In terms of district wise analysis Ernakulam had the maximum visits and Kannur had the minimum number of visits. In spite of having the maximum number of antenatal visits in Ernakulam this district had the lowest proportion of TT vaccination. This needs further analysis. Antenatal visits are generally done by medical doctors in the state. NFHS 1 reported that most of these visits were to doctors. Only a small fraction of the visits were to health workers. This adds to the cost of health care in the state and for the individuals and households. Quality of antenatal visits is questionable since some of the outcomes of pregnancy and delivery are not commensurate with the number of antenatal visits. For example the proportion of low birth weight babies is still above 10 and the state has not achieved the target of LBW proportion even after the year 2000.

The focus group discussion supported many findings of our study from the households. They reported that the antenatal visits are regular and as per the instructions of the doctors. This could be the reason for a high number of antenatal visits in the state.  People select doctors according to their fame in the society. This was irrespective of whether the doctor works in the private sector or in the government sector. If the doctor was in the government sector they went to their private consultation. The number of antenatal visits was determined by doctors and not by the pregnant women. The doctor would be very unhappy if the visits are not regular. Therefore the women stick to the actual number of visits suggested by the doctor, which is around 8-10. For each visit the average expenditure would be around Rs 200 including the cost of medicines and the consultation fees to the doctor. Since the average number of children per couple in Kerala was only less than 2, each pregnancy was considered precious. This was another reason for regular antenatal visits. The use of technology like ultrasound scanning was also increasing recently. All the groups of male health workers, female health workers and community members were not aware of any sex selective abortion practices.

Institutional Delivery

One of the major reasons for a comparatively low rate of Infant mortality in Kerala is the high proportion of institutional delivery. In our study we found that 98.2 % of deliveries took place in institutions. Malappuram district only reported home delivery. All the other four districts reported 100% institutional delivery. Institutional delivery was reported to be 97% in the NFHS 2 study also. Malappuram district was reported to have the highest proportion of home deliveries in the Kerala districts in a study in 1993 also ¹³.  In spite of having near 100 per cent institutional delivery in the state the reported maternal mortality rate ranges from 87 to 132 maternal deaths for 100000 live births. These are all indirect estimates. The lowest figure of 87 was estimated by Srinivasan K etal in 1997 based on estimated regression equation obtained from regressing MMR with infant mortality rate of the countries. Since all the reported rates are higher than expected from the state of Kerala there is a need to study the actual MMR and the causes for it. Kerala’s infant mortality rate is comparable to that of many countries in the East Europe where the MMR is 10-20. In Sri Lanka the MMR was reported to be 60 ¹⁴.  Kerala should be able to reduce the MMR to this level at least. Since there is no district wise data available we do not know whether the there is a high MMR in districts like Malappuram where home deliveries are still taking place. Another concern is due to the high proportion of cesarean deliveries in the state and deaths due to anesthesia and cesarean operation itself.

            We also analyzed the place of delivery in the public sector in detail to find out the proportion of delivery at various levels of health care institutions. This was done because of reports of overcrowding at the tertiary level hospitals in the state even for normal deliveries. Deliveries in the lower level institutions have come down. In primary health centres, and sub centres there were hardly any deliveries. Most people went to a higher-level centre for delivery. Our findings confirm this. Among the total deliveries 52% of

Table 3. Percentage of deliveries conducted in various types of institutions.

deliveries were conducted in private sector institutions. This again varies with districts. The lowest proportion of 41% was in Kannur compared to the highest proportion of 67% in Ernakulam district. It is important to note that ‘out of pocket’ expenses for deliveries in public sector hospital were substantial. One study reported that the out of pocket expenses for a normal delivery in Kerala if one goes to a public sector hospital was Rs 2025 and for a private sector hospital was Rs 2870 ⁶. In addition in many centres clients will have to spend money for other things like purchasing coffee/tea for the labor room staff. Poor cleanliness, rude behaviour of staff long waiting time etc were reported as other reasons for not utilizing public sector hospitals in Kerala.  In districts where there was a medical college the proportion of deliveries in the medical college would be high. This was true for our study also. Alappuzha has a well-established medical college and 17% of deliveries took place in that medical college. Kannur district has also a medical college but it is in the very early stage to make an impact on service delivery.  No delivery took place in a sub centre in the entire sample. This should be a clear indication to stop supplying delivery kits to sub centres in the state. Except in Malappuram district there was no home delivery in the state. Even though there is an argument that the delivery kit supplied to the sub centres could be used for home deliveries in Kerala that is also not true except for a small proportion of home deliveries in Malappuram district. In Mini Primary health centres, block primary health centres, and community health centres no delivery was conducted in the southern three districts except one delivery in a mini PHC in Ernakulam district. Several studies reported that south Kerala is more advanced compared to north Kerala. As development increases people go for higher centres for delivery.  Deliveries in FRU were also very low. In the two northern districts that we studied deliveries were reported in Mini PHCs and Block PHCs. The only FRU in Kollam district where 26% of all deliveries took place in that district is an FRU that is located at the district head quarter. This is the major women and children hospital in Kollam district. All other FRUs we studied did not attract women for delivery. This is another issue that needs to be addressed.

We did not try to collect information on maternal mortality. However it is important to note here that the reported maternal mortality ratio in the state is much higher than what is expected from the state. The entire available maternal mortality figure in Kerala is based on indirect estimates. The lowest figure of 87 per 100000 live births is also higher than that of Sri Lanka’s figure of 60/100000 and that of the most advanced countries 10-20 per 100000 live births. In spite of having near cent percent institutional delivery why should Kerala have such high maternal mortality? This needs further investigation.

 A lot of information could be collected through the FGDs on delivery practices. Most women like the doctor who checks up her during the antenatal visits to conduct the delivery also. Since more hospital beds are available in private hospitals they go to the private doctors/hospital for ante- natal visits also. However there are some women who go to antenatal visits to the government sector and for delivery to the private sector. This is mainly due to lack of cleanliness, rude behavior of staff in labor room, and lack of facilities in the government hospital. They will have to purchase many items from outside and pay money to the staff in the labor room. In one of the groups it was reported that the labor room staff asked to bring coffee for all the staff in a Pepsi bottle. She reported that even if they asked to bring coffee in a bucket they would have brought because her daughter was in labor room with labor pains. In exact words of the woman who reported this “ Makal prasavavamuriyil kidakkumbol pepsi bottle alla buckettil kappi vangan paranjaalum vangendi varum”. Regarding the increased proportion of cesarean section the group felt that cesarean is safe and there is no labor pain for the mother. Most often the decisions are made by the doctor to go for a cesarean or not. The choice for the mother in this is limited. All the groups agreed that the cost of cesarean section delivery will be higher that of normal delivery. However if there were a need of cesarean delivery they would not have any other choice. A few women also reported that cesarean has become so casual and even for getting good birth star for the baby some women go for cesarean delivery. High rate of cesarean section delivery was reported from the state in earlier studies also ^15-17. The fees for cesarean delivery depend on the hospital. They said there was no standard rate for either normal delivery or cesarean section. The doctor of the hospital management in the case of private hospital decided this. In a government hospital the amount of expenses would be certainly high for a cesarean section compared to normal delivery.  The cesarean section rates in the state are going up. In urban areas it was around 35% and in rural areas around 30% ¹⁶. This is much higher than the 10 – 15% cesarean section deliveries recommended by the World health organization. The average cost of cesarean section delivery in the state was around Rs 3800. This is not very much as one would expect. However the total unnecessary expenditure for cesarean section delivery is enormous. This was estimated to be more than the total plan allocation for the entire state of Kerala for a year. However either the doctors or the community feel that the cesarean rates are high. From the personal discussions with obstetricians and primary health center doctors they did not believe that mortality and morbidity due to cesarean section are higher compared to normal delivery. They were not aware of the literature on this issue. 

Table 4. Maternal mortality ratio in Kerala from various sources, around 1992.

Source: Shenoy, T.S., K.T. Shenoy and C G Chandrika Devi, Challenges in Safe Motherhood Initiative in Kerala, India, Medical College, Thiruvananthapuram, January 1999 ¹⁹.

Note: 1. The estimate given here is based on estimated regression equation obtained from regressing MMR and with infant mortality rate of the countries.

2. The estimate is based on indirect method based on procedure given in Bhat et al. 1994¹⁸.

3. The estimate for Kerala is based on five teaching hospitals attached to medical colleges of Kerala covering the period 1993-97. The estimate for India is based selected hospital in the urban area in most of the states.

Post natal care

Most mothers start breast-feeding as early as possible. In case of cesarean section mother and baby are separated for about 4-6 hours and there is problem in initiating breast-feeding. Some of the women said that breast milk is not sufficient in some women. This is the reason for artificial feeding.

Abortion services

Abortion services are available in many government and private hospitals. However they reported that nowhere it was free. 

Low Birth weight

Another information collected through the mother coverage form was on birth weight of babies.  Low birth weight proportion in our sample was 13.3. It was slightly higher in the rural area compared to the urban area. Government of India set certain targets in the health sector to be achieved by the year 2000. The state of Kerala achieved most indicators viz. infant mortality rate of less than 60, life expectancy of 64 years for males and females, crude birth rate of 21 for 1000 population etc. For Low birth weight the target was to reduce to less than 10%. Most studies on low birth weight in Kerala 10^{, 11, 20} reported that proportion of low birth weight in Kerala is over 10%. Our figure of 13.3% is lower than the figure reported in NFHS 2. In Urban Kerala the rate has come down to less than 10%. When we look at the figures for the districts there is a lot of variation ranging from as low as 6.4% in Kannur to as high as 26.7 % in Ernakulam. Although the sample size for estimating low birth weight proportion in the state is adequate it may not be enough for the district wise analysis. The low birth weight proportion seems to be decreasing over the years. In the NFHS 1 the low birth weight proportion in Kerala was 18% and it has come down in the NFHS 2 to 15%. 

Immunization Services

Immunization coverage was collected through a questionnaire addressed to mothers of children of 1 to 2 years. The results of this are given in Table 5.

Table 5. Percentage of children (12-23 months) received vaccines and other services in 5 districts.

Overall the immunization coverage in the state seems to be reasonably good. DPT 3 coverage was 84%. This was slightly less than the target of 85%. In rural area it was only 83%. The drop in DPT coverage in the state was mainly due to the low coverage of this vaccine in Malappuram district, where the coverage was only 44%.  It is important to see the variation of immunization coverage between the different districts of the state. Malappuram district is continuing to be lagging behind other districts in immunization coverage. This district reported a case of acute poliomyelitis in the year 2000 ²¹. If we need to eradicate polio from Kerala we need to concentrate on districts like Malappuram where the routine immunization coverage is lower than many backward Indian districts. There may be isolated pockets in many other districts in the state. Identification of low coverage areas and action plan to improve coverage in those areas would be the key in achieving polio eradication and elimination of other vaccine preventable diseases in the state. DPT 3 and Polio 3 coverage was over 90% in 4 districts studied. Measles coverage was also above 90% in three districts. Malappuram did not improve the vaccination coverage from the year 1993 when the polio 3 and DPT 3 coverage was around 45% ¹³.

The zero dose of polio vaccine is recommended in all institutional deliveries. However there was a mismatch between the proportion of institutional delivery and the proportion of children received zero dose of polio vaccine. This could be due to lack of awareness regarding the need for this polio dose or lack of availability of polio vaccine in all hospitals where deliveries are taking place in Kerala.

Source of Immunization

Source of various vaccines is given in the table 6. Except in Ernakulam district where around 40% of vaccines are taken from the private sector in all the other districts only around 20% vaccines were taken from the private sector. This has been shown in many previous studies also. This is probably due to the better quality of immunization services provided in the public sector particularly after the Universal Immunization program that was started in the year 1985. This again shows that people would certainly use the government services if good quality services were provided. Sub centres provide immunization services to around a quarter of the children. This proportion has to be increased substantially. For immunization there is no need to go to a primary health center except when the PHC is nearer than a sub center.

Table 6. Source of immunization in the selected districts.