Systematic collection of samples of live-virus vaccines — poliomyelitis and measles — from district warehouses and health centers may be carried out in order to assess virus titers in a national or external control laboratory. If possible, these samples should include vaccine that has already been sent to field teams and returned for storage.
Another method is to obtain random samples from several district warehouses and health centers, as deemed appropriate. Assessments should always be carried out when the program director has any reason to doubt vaccine potency in the area or when the cold chain raises suspicion. A table showing the minimum number of doses needed for laboratory testing is printed in the WHO EPI operations manual.
A management information system may also be used for quality control. Monthly summary forms on the operation and maintenance of cold-chain equipment may be collected from all levels and analyzed to identify common equipment defects. Areas with frequent equipment failures may be marked for visits and vaccine samples collected for assessment.
Supervisors, the field development officer and higher-level managers should view quality control as an important component of every inspection visit. They should regard their supervisory trips to district and local health services as part of the quality-control system.
Problem-Solving in Immunization Programs
Given the conditions prevailing in developing countries, problems requiring innovative and energetic solutions are bound to arise every day. The question is how to leave room for individual creativity without leaving the worker helpless and unsure of how to proceed.
Operations manuals can provide guidelines for action. But they should also encourage personnel to solve individual problems using solutions related to local conditions. Very often, local personnel are more familiar with local resources and politics, and are therefore the best suited to solve a problem.
However, directives, manuals and orders often come down from above in absolute and unchangeable form. Central-level personnel believe they have studied the problem and possess far greater technical capacity and knowledge than the local auxiliary nurse, and for that reason they assume they have provided the best solutions for most conceivable problems.
Nevertheless, solutions tend to look different from the national capital, with its excellent transportation and communications, than from a remote health center located two hours’ walk from the road.
One of the reasons for the success of the smallpox eradication program was the decentralization of the decision-making process. Personnel at district and regional levels were freed from central-level directives, sometimes cast in bronze, in order to innovate and find the procedures that worked best in their areas.
Programs that for years had been sustained by constant reports of cases suddenly began reporting zero cases. Many factors contributed to the success of smallpox eradication, but decentralization and encouragement to solve problems locally certainly played a part.
However, local areas cannot be left entirely to their own discretion. Central directives on matters such as the number of vaccine doses to be administered, dosages, storage temperatures and intervals between doses must continue to be based on the best internationally accepted information. This can only be determined by highly competent planners. But once a minimum level of standards and practices has been established, it may turn out that local personnel know best how to carry them out.
The question is how to stimulate problem-solving capacities at the local level while still maintaining sufficient conformity to obtain a high-quality result and proper supervision and evaluation. Some calculation methods and standing orders are ways of proceeding in such cases, but they require further development and testing.
The intelligence and problem-solving capacities needed to develop successful immunization programs exist at local levels. Manuals should be prepared to make use of this resource, not to suppress it.
At present, problems exist at all levels of immunization programs. Areas such as logistics, communications, the cold chain, health education, information and supervision systems, vaccination sessions, community participation, program evaluation and training are full of systems and procedures that do not work as planned.
When problems cause program failure or produce inadequate services, personnel should feel free to try methods different from those that are “accepted.” The results can then be communicated to someone who can assess the measures taken and apply them more broadly if applicable.
The most important aspect of problem-solving is that it must be integrated into programs so that it becomes a viable part of operating procedures.
