dhis2-users team mailing list archive

[Knut Staring <knutst@xxxxxxxxx>]

The discussion below on denominators and coverage could be of interest to
many users of DHIS2, also outside of the vaccine domain.

Knut
---------- Forwarded message ----------
From: GREVENDONK, Jan Peter Kamiel <grevendonkj@xxxxxxx>
Date: Thu, Feb 12, 2015 at 2:13 PM
Subject: RE: Validating Denominators for Immunization Program
To: "Danovaro Alfaro, Maria Carolina" <danovaroc@xxxxxxx>, David Brown <
dbrown@xxxxxxxxxx>, "Singogo, Dr. Fwasa" <FSingogo@xxxxxxxx>, "
bidinitiative@xxxxxxxxxxxxxxxx" <bidinitiative@xxxxxxxxxxxxxxxx>


 Thanks for raising this important and timely discussion.



Fred started this discussion with stating that “Accurate coverage rates are
important for decision-making, planning and designing strategies to
increase reach.”



That is true, but as previous posters such as Carolina and David have
mentioned, accurate denominators and thus accurate coverage rates are
really hard to obtain, especially at subnational level. This problem is
worse in countries that already achieve high coverage.  I love this table
from one of David’s papers that shows what the impact of +/- 10%
denominator uncertainty is on coverage estimates: it clearly shows that for
countries with 80% + coverage, administrative coverage estimates are a
blunt measure that are more likely to mislead than to inform policies such
as district prioritization. Furthermore, I also think that there is no
really good way to improve denominators, and even if there were, that this
is most often something that goes beyond the responsibilities of
immunization program people. Even if you had a good way to estimate real
populations at district and health facility level, you would still often
need to use the “official” denominators instead.



 I therefore agree with Carolina: we should try to understand the
limitations of the data, and focus on what we can do, not on what we cannot
change.. Some concrete ideas:



·         Looking at *numerator trends* is often more informative than
calculating coverage: the reported numbers of doses is a harder number than
coverage: if that drops or stagnates then the program is probably in
trouble.

·         The *target for a health centre* could be to immunize 5% more
children than last year, instead of reaching 95% of an unknown population.

·         *Focus on reducing drop out*, as that is not dependent on
denominators

·         Calculate a “*BCG denominator*”: i.e. use an early dose like BCG
or DTP1 for which you have high confirmed coverage, and infer a denominator
from that

·         As Hassan said: look at past *consumption rates*, not (only)
target population for planning purposes

·         Validate the target population with the reported numbers of doses
administered during *campaigns*. (The latter is often a bit higher because
of doses given to people outside of the target range, but it can still give
an idea)

·         There are finally also experiments going on with the use of
*technology* to estimate demographic information, especially in Nigeria and
for the use of polio: this encompasses the use of GIS with feature
recognition, cell phone traffic picked up at local GSM antennas etc.



Hope to see more people weigh in on this denominator discussion!









Jan Grevendonk

Technical Officer, Strategic Information Group

Expanded Programme on Immunization (EPI)

Department of Immunization, Vaccines and Biologicals (IVB)

Family, Women's and Children's Health (FWC)

World Health Organization (WHO)

20 Avenue Appia, 1211 Geneva 27, Switzerland

O: +41 22 79 12589



*From:* bidinitiative@xxxxxxxxxxxxxxxx [mailto:
bidinitiative@xxxxxxxxxxxxxxxx] *On Behalf Of *Danovaro Alfaro, Maria
Carolina
*Sent:* 11 February 2015 19:04
*To:* David Brown; Singogo, Dr. Fwasa; bidinitiative@xxxxxxxxxxxxxxxx

*Subject:* RE: Validating Denominators for Immunization Program



Thank you for sharing. In Latin America we face the same question on what
to do about the denominators. For countries with good birth registration,
census projections are compared. Nevertheless, this is very difficult for
small populations such as those in sub-national levels.



We have advised countries to focus on their numerators to see if they
behave consistently overtime and monitor their drop-out rates. As the
denominator is a very difficult problem to solve, we have shifted the focus
to ensure adequate follow-up of each person using tickler files, or
follow-up books. We can do this more comfortably in countries with few
0-dose children. Honduras and Paraguay have created “inter-sectoral working
 groups” (see here: http://www2.paho.org/hq/dmdocuments/2010/SNE3201.pdf )
to review denominators; the experience has been mixed.



All the best,

Carolina



*M. Carolina Danovaro, MD, MSc*

*Regional Immunization Advisor*

*Department of Family, Gender and Life Course/Comprehensive Family
Immunization Unit (FGL/IM)*

*Pan American Health Organization,*

*525 Twenty-third St, NW, Washington DC 20037 - USA*

*Tel.** 1-202-974-3856 <1-202-974-3856> E-mail: **danovarc@xxxxxxxx*
<danovarc@xxxxxxxx> *Web*: *www.paho.org/immunization
<http://www.paho.org/immunization> *

[image: Description: cid:image003.png@01CEAA51.3711F640]



*From:* bidinitiative@xxxxxxxxxxxxxxxx [
mailto:bidinitiative@xxxxxxxxxxxxxxxx <bidinitiative@xxxxxxxxxxxxxxxx>] *On
Behalf Of *David Brown
*Sent:* Monday, February 09, 2015 2:37 PM
*To:* Singogo, Dr. Fwasa; bidinitiative@xxxxxxxxxxxxxxxx
*Subject:* RE: Validating Denominators for Immunization Program





This is a topic of recent interest, and I look forward to learning of the
shared experiences. As the conversation evolves, I would also like to share
several recent documents that have been put together at the global level
that may be of interest to some.





·         Avoiding the Will O’ the Wisp: Challenges in Measuring High
Levels of Immunization Coverage with Precision
<http://www.scirp.org/Journal/PaperDownload.aspx?paperID=48503>



·         Proportionate Target Population Estimates Used by National
Immunization Programmes in Sub-Saharan Africa and Comparison with Values
from an External Source
<http://www.scirp.org/Journal/PaperDownload.aspx?paperID=49008>



·         A Comparison of National Immunization Programme Target Population
Estimates with Data from an Independent Source and Differences in Computed
Coverage Levels for the Third Dose of DTP Containing Vaccine
<http://www.scirp.org/Journal/PaperDownload.aspx?paperID=42546>



·         Raising Awareness Among Immunization Programme Managers to the
Potential Bias Resulting from the Application of Fixed Factors to Obtain
Target Population Size Estimates
<http://benthamopen.com/contents/pdf/TOPHJ/TOPHJ-5-15.pdf>



All the best,



David







*From:* bidinitiative@xxxxxxxxxxxxxxxx [
mailto:bidinitiative@xxxxxxxxxxxxxxxx <bidinitiative@xxxxxxxxxxxxxxxx>] *On
Behalf Of *Singogo, Dr. Fwasa
*Sent:* 09 February, 2015 10:11
*To:* bidinitiative@xxxxxxxxxxxxxxxx
*Subject:* Validating Denominators for Immunization Program



Dear Colleagues,



The Better Immunization Data Initiative is currently testing a number of
change management and product vision interventions at selected health
facilities in Livingstone District, Zambia to help overcome challenges in
abnormal immunization coverage.



Accurate coverage rates are important for decision-making, planning and
designing strategies to increase reach. A key challenge in calculating
coverage data is the uncertainty inherent in current methods for estimating
the size of target populations (Denominators), which are based on Central
Statistics Office (CSO) extrapolations from previous census. The
denominators obtained from these projections do not reflect the true
population on the ground for most districts because censuses are conducted
once every 10 years. The use of inaccurate denominators give rise to
coverage rates that exceed 100% - a mathematically unlikely outcome.

Consequently, it is imperative that denominators used in immunization
programs are accurate/correct at all levels to ensure accuracy in reporting
the services provided and the number of children reached.

As we continue to engage the District Health Office over the actual numbers
of children for immunisation, we would like to hear from others



1.    How you have managed to ensure that districts and or Health Centers
are using actual prevailing numbers of children (Denominator) in their
catchment area for immunisation

2.    What tools/processes can one use to validate the denominator for the
immunisation program for the Health Center and District

Sharing of your thoughts and experiences with us will be appreciated.



*Fred Shamakondo Njobvu*

Provincial Coordinator - Better Immunization Data (BID) Initiative

[image: Description:
http://www.charity.org/sites/default/files/images_logos/ca_path_logo_0.png]

P.O. Box 60045

Plot # 2898/207

Livingstone, Zambia

Mobile:  +260 977867860

Skype: fred.njobvu

Email: *fnjobvu@xxxxxxxx <fnjobvu@xxxxxxxx>*





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-- 
Knut Staring
Dept. of Informatics, University of Oslo
Norway: +4791880522
Skype: knutstar
http://dhis2.org