© The Society of Public Health, 1991
Public Heahh (1991), 105, 229-238
P r i m a r y Health Care and I m m u n i s a t i o n in Iran K. Nasseri, 1. B. Sadrizadeh, 2 H. Malek-Afzali, 1,2 K. Mohammad, 1 M. Chamsa, 2 M-T. Cheraghchi-Bashi, 2 M. Haghgoo 3 and M. Azmoodeh 2
1School of Public Health, Medical Sciences University of Teheran; 2Ministry of Health and Medical Education, Teheran. /ran; 3World Health Organisation. Eastern Mediterranean Regional Office
The Primary Health Care (PHC) network o f Iran consists of a rural and an urban branch. While the rural branch presently covers a sizeable portion of the rural population, the urban PHC project is in its early stages of implementation. The Expanded Programme on Immunisation (EPI) in Iran, which started as an independent and vertical project in early 1983, is being gradually integrated into the PHC network as the latter expands. Results of the second PHC programme review of Iran shows that immunisation coverage of children has improved appreciably since the first PHC review, especially for BCG which stands at 56.3%. Complete immunisation at first birthday in the rural areas with the PHC services is 44.1%, whereas for urban areas other than Teheran it is 28.1%. While the high coverage in the rural areas is attributed to the 'active' approach and vigilance of the providers o f immunisation (i.e. the community health workers and the vaccinators of the mobile teams), the higher coverage in the capital city of Teheran is attributed to the involvement o f private paediatricians and the generally higher social, economic, and educational status as well as higher interest of mothers. It is noticed that the results of cluster sampling for determination of immunisation coverage in large metropolitan areas of the developing world must be interpreted with much care. The reason is that in these areas extreme fluctuations in the crude birth rate are common and therefore results tend to over-represent the attributes of the segment of population with lower birth rate. It is also argued that complete immunisation might not be the best indicator for assessing the progress of the immunisation efforts. These and other findings are discussed in detail. Introduction P r i m a r y H e a l t h C a r e ( P H C ) a n d the E x p a n d e d P r o g r a m m e on I m m u n i s a t i o n ( E P I ) a r e two o f the m a j o r p r o g r a m m e s d e v e l o p e d a n d a d v o c a t e d b y the W o r l d H e a l t h O r g a n i s a t i o n ( W H O ) to facilitate the a c h i e v e m e n t o f the g l o b a l g o a l o f ' H e a l t h F o r All'.~ B o t h n a t i o n a l a n d i n t e r n a t i o n a l c o m m i t m e n t to these p r o g r a m m e s a r e o v e r w h e l m i n g , especially in the d e v e l o p i n g countries. I r a n is n o e x c e p t i o n a n d is d e e p l y i n v o l v e d a n d c o m m i t t e d to b o t h p r o g r a m m e s . T h e a i m o f this p r e s e n t a t i o n is to p r o v i d e a g e n e r a l overview o f the P H C n e t w o r k o f Iran; to d e t e r m i n e the i m p a c t o f P H C services o n i m m u n i s a t i o n activities in a r e a s w h e r e the t w o services a r e i n t e g r a t e d , a n d finally r e p o r t the p r o g r e s s o f E P I since its i n c e p t i o n in Iran. T h e E P I in I r a n officially b e g a n in early 1983, with a w o r k s h o p o n ' h i g h level m a n a g e m e n t ' , which n o t o n l y served as a n i n t r o d u c t i o n to the p r o g r a m m e b u t also set a p r e c e d e n t for t r a i n i n g o f n a t i o n a l m a n a g e r s at v a r i o u s levels. T h e u l t i m a t e g o a l o f the p r o g r a m m e was set as ' c o m p l e t e i m m u n i s a t i o n at first b i r t h d a y o f 9 0 % o f the I r a n i a n * Present address: Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of California, 1100 Glendon Avenue, Suite 711, Los Angeles, CA 90024, USA.
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children by 1990'. 2 Complete immunisation was defined as a m i n i m u m of three D P T (diphtheria, pertussis, tetanus), three OPV (oral polio vaccine) (beginning no sooner t h a n eight weeks of age with a minimum o f four weeks interval), one B C G any time after birth, and one live attenuated measles vaccine after seven m o n t h s of age. F o r rapid achievement of this goal, it was decided that the p r o g r a m m e would be implemented as an independent and vertical project. However, different strategies for urban and rural areas were considered. In the urban areas the main aim o f the p r o g r a m m e was to strengthen the immunisation units within the already functional health centres. For the rural areas, mobile teams which would visit villages on fixed schedules were considered. The first official p r o g r a m m e review 3 was carried out in early 1984 and was relied u p o n as the baseline, against which future progress would be measured. With the expansion o f the P H C services to cover a sizeable p r o p o r t i o n of the rural population o f the country and the need for cost effectiveness, immunisation services are being integrated into the routine activities o f the P H C network. Iran's involvement with P H C dates back to the early 1960s when an experiment on the feasibility o f the then new idea was designed and successfully carried out in one o f the provinces--the West Azerbaijan. 4 U p o n the official endorsement of P H C as a m a j o r health care delivery strategy in the Internationar'Conference of Alma A t a in 1978, and later by W H O , ~the government of Iran adopted it as the principal policy for delivery o f health care throughout the country. Implementation of this decision, however, was interrupted soon after its adoption in 1978, due to the social unrest which resulted in the Islamic Revolution of 1979, and the significant changes that followed it. In late 1983, interest in P H C was revived within the Ministry of Health and an appreciable a m o u n t o f financial and other resources were allocated to the implementation of a partially modified version of the original policy. In brief, the P H C network of Iran consists of a rural and an urban branch. The rural branch starts with a series of 'health houses' in the villages, each o f which is responsible for 1500 1800 people. Each health house is staffed by one male and one female 'Behvarz' or community health worker. They are selected f r o m the same area and often the same villages in which they will be working after their training. They receive two years o f basic training in health topics and are mainly responsible for providing general preventive services, including immunisation, family planning, advice on breastfeeding and nutrition, and environmental sanitation for all the individuals in their coverage area. They are also expected to provide basic therapeutic measures for m i n o r illnesses and refer other cases to their immediate Rural Health Centre ( R H C ) for attention by a physician. Each R H C is responsible for four health houses or some 7,500 population and is staffed by one or two physicians and a number o f paramedics, who are expected to closely m o n i t o r and support the activities o f the health houses. The R H C s report to the District Health Centre ( D H C ) for their administrative needs and should maintain close relationships with hospitals and other health institutions for their referrals. This latter activity is p r o b a b l y the weakest link in the system and needs specific attention. The P H C network of the urban areas is still in the early stages of implementation. It aims to integrate the present therapy-oriented health centres into the public health-oriented P H C network. T h e s m a l l e s t functioning unit in the urban branch of P H C network is the U r b a n Health Centre which is similar to the R H C in staffing and the scope of services. Each urban health centre covers almost 12,500 people and follows the general guidelines of P H C for services provided. However, more emphasis is given to health education, nutrition, maternal and child health (MCH), and treatment o f endemic diseases. The urban health centre is, like the R H C , under the administrative supervision of the D H C and maintains close relationships with hospitals for its referrals.
Primary Health Care and Immun&ation in Iran
231
Establishing a P H C network, which means a D H C and all the facilities that report to it in an area, starts with the health house or urban health centre and passes through a three-year cycle o f initiation, consolidation, and maintenance. There are 24 provinces in Iran and each year 24 new networks enter the initiation phase; 24 networks which were in the initiation phase in the previous year m o v e up to the consolidation phase; and another 24 which were in the consolidation phase enter the maintenance phase. Once a P H C network assumes the maintenance status, immunisation services in the area will be integrated into it. Methods In the a u t u m n o f 1987, the second PHC/EP1 p r o g r a m m e review of Iran was carried out by a team o f experts f r o m the G o v e r n m e n t o f Iran, W H O , and U N I C E F . Detailed information on this exercise is available elsewhere? Briefly, using the 1986 general census, the population o f the country was divided into four groups based on their area o f residence. The four groups thus formed were: a) residents o f the capital city of Teheran; b) residents of all other u r b a n areas; c) residents of rural areas with the P H C services either in consolidation or maintenance stages; and d) residents o f rural areas without the P H C services. Each group, except for the capital city of Teheran, was further sub-divided into three strata based on the infant mortality rate ( I M R ) recently measured in a country-wide survey. 6'v A total of 10 samples of 30 clusters each, one in the city of Teheran and one in each o f the nine strata thus formed, were drawn following the guidelines suggested by W H O . 8,9 In each o f the 300 clusters thus selected, a m i n i m u m o f seven children o f 12-23 months o f age (total o f 2,118 children) were identified and examined by local health workers. The local health workers who participated in this survey were selected from a m o n g those who had previously received intensive in-service training in EPI cluster survey methodology as part o f their EP1 training, and were closely supervised by a m e m b e r of the P H C p r o g r a m m e review team. Once a child was identified, his or her exact age was verified from the birth certificate or other reliable source such as the immunisation card. U p o n confirmation o f age eligibility, the immunisation status o f the child was recorded from the immunisation card and in its absence, by asking the mother. The child's arm was then examined for the B C G scar, and the mother was interviewed for particulars o f M C H services she had received during pregnancy and delivery o f that child. The completed forms were examined by the visiting m e m b e r o f the P H C p r o g r a m m e review team at the site for completeness and accuracy. All the forms were then brought back to Teheran for final analysis. Results Table I shows the distribution o f population by area o f residence and stratification by I M R . No attempt was made to stratify the population of Teheran. This Table reveals that a b o u t 55% of the population of Iran live in the urban areas and that a b o u t a third o f the rural population are covered by a P H C network. Table II shows complete immunisation at 12 months, as documented by the immunisation card, by area o f residence and I M R stratification. N o association was detected between the immunisation coverage and I M R stratification. Reasons for this observation might include one or m o r e of the following: a) possible error in determination o f I M R by using a one-year m e m o r y recall technique; b) choosing stratification points o f low discriminatory value, i.e. 30 and 35 per t,000 live births; and c) dominance o f other causes of infant mortality, such as diarrhoea, which are not prevented by immunisation. In fact, in a recent study, it was shown that almost 25% of all deaths a m o n g children under
232
K. Nasseri et al. Table I Population of Iran (in 1,000s) by area of residence and infant mortality rate (IMR) 1987. (Figures in brackets show percentage of the total population studied.) Infant mortality rate Residence
Low*
Medium*
High*
Total
Capital city of Teheran
6,022 (12.2) 9,992 (20.3) 2,100 (4.3) 7,371 (14.9) 25,485 (51.6)
--3,668 (7.4) 1,442 (2.9) 3,214 (6.5) 8,324 (16.9)
--7,268 (14.7) 2,230 (4.5) 6,022 (12.2) 15,520 (31.5)
6,022 (12.2) 20,928 (42.4) 5,772 (11.7) 16,607 (33.7) 49,329 (100.0)
Urban areas Rural, PHC + * Rural, P H C - * Total
* Low: IMR < 30; medium: IMR = 30-35; high: IMR > 35 per 1,000 live births t Rural, PHC+: rural areas with PHC services Rural, P H C - : rural areas without PHC services
Table II
Percentage of children with complete immunisation* at 12 months of age, by area of residence and infant mortality rate (IMR), 1987 Infant mortality rate
Residence
Lowt
Mediumt
Hight
Total (population-weighted average)
Capital city of Teheran U r b a n areas Rural, P H C + ¶ Rural, P H C - ¶ Total
34.9 26.2 48.8 31.8 31.7
-32.4 36.7 26.6 30.9
-28.6 44.5 31.3 31.0
34.9 28.1 44.1 30.6 31.6
Total:~
34.9 29.0 43.3 29.9 34.2
( ± 8.3) ( ± 4.4) (±5.6) (±5.5) (±2.9)
* Complete immunisationconsists of at least three DPT (diphtheria, pertussis, tetanus), three OPV (oral polio vaccine) (beginning no earlier than eight weeks and continued with at least four weeks interval), one BCG at any time after birth, and one live attenuated measles vaccine given not earlier than seven months of age. lmmunisations documented by 'probing mothers' memory' were not included among those completed at 12 months of age t See * footnote to Table I $ Pooled over the samples, with 95% confidence interval given in parentheses ¶ See I footnote to Table I
five years o f age in I r a n are c a u s e d by d i a r r h o e a . '° D u e to this o b s e r v a t i o n , I M R stratification was a b a n d o n e d a n d the three cluster samples in each o f the areas were p o o l e d together. However, T a b l e II presents a d r a m a t i c v a r i a t i o n in coverage o f c o m p l e t e i m m u n i s a t i o n by area of residence. It is best in those r u r a l areas with P H C services, followed by that o f the capital city o f T e h e r a n . O t h e r u r b a n areas have as low a coverage as the r u r a l areas w i t h o u t the P H C services.
Primary Health Care and Immunisation in Iran Table III
233
Immunisation coverage at 12 months of age, by area of residence, 1987 City of Teheran
Urban areas
Rural (PHC+)
Rural (PHC-)
Total Iran
16,607
49,329
Population (in 1000s)
6,022
20,928
5,772
No. children examined
212
630
637
639
% Children with immunisation card
95.3
84.9
95.3
95.1
90.8
% with DPT I % with DPT III DPT drop out
91.5 79.2 13.4
79.5 58.4 26.5
92.5 69.9 24.4
87.8 50.1 43.0
85.3 59.5 30.2
% with OPV I % with OPV III OPV drop out
92.0 78.3 14.9
79.8 56.8 28.8
92.0 70.5 23.4
87.0 50.7 41.7
85.1 59.0 30.7
% with measles
63.2
49.2
67.8
55.2
55.1
% with BCG (injection) % with BCG (scar)
50.9 37.7
49.5 40.9
66.4 47.9
63.2 49.0
56.3 44.0
4.7 3.3
8.6 5.9
24.3 19.8
17.8 13.8
13.1 9.9
34.9
29.0
43.3
29.9
31.7
% of mothers with: TT immunisation I* TT immunisation II % with complete immunisation#
2,118
* Only those that are documented and dated # Complete immunisation: as defined in Table II
Further details of the immunisation coverage by residential areas are given in Table III. Data reported in this Table are limited to those immunisations that were given before the first birthday and that were recorded on the child's immunisation card. This Table not only confirms the overall results o f Table II, but also reveals that the coverage of various immunisations in rural areas with P H C services is generally better than the rest o f the country (with the exception of D P T and OPV coverage in the capital city o f Teheran). Table IV shows the sources of immunisation and utilisation of some M C H services by area o f residence. As can be seen, children in rural areas with a P H C service have the highest contact rate. Analysis of the source o f contact reveals that in the urban areas the major role is played by the health centres, whereas in the rural areas either the health houses or the mobile teams are more important. It has also been observed that while almost 25% of all immunisations in the city of Teheran are provided by private physicians, hospitals where over 74% o f urban children are born do not play an appreciable role in immunising them. The pattern o f breastfeeding identified in this Table is also interesting. With the exception of Teheran, close to 50% of the children in the rest of the country are breastfed beyond their first birthday. Overall, this Table shows that mothers in rural areas with P H C services receive much better M C H care, advice and attention in comparison to mothers in other rural and most urban areas.
K. Nasseri et al.
234 Table IV
Utilization of immunisation and maternal and child health services (%), by area of residence, Iran 1987 City of Teheran
Immunisation: average contact per child
Urban areas
Rural PHC +
Rural PHC-
Total Iran
7.6
6.8
8.3
7.6
7.3
Source: hospital health centre health house mobile teams private
6.2 69.1 NA NA 24.7
3.1 93.1 0.1 3.1 0.7
0.8 11.6 73.7 13.9 0.04
1.2 9.2 5.1 84.3 0.2
2.6 52.4 10.4 31.3 3.4
MCH Services: prenatal care
72.7
51.9
63.4
18.5
44.5
Delivery at: private hospital public hospital home
42.0 56.1 1.9
7.6 67.0 15.4
3.3 47.1 49.6
0.6 39.7 59.7
13.2 54.1 32.7
Child weighed at birth:
95.7
68.9
43.6
29.4
55.9
Child breast-fed: < 12 months > 12 months None
80.7 4.2 15.1
39.4 48.6 12.1
41.0 52.4 6.6
33.5 61.0 5.5
42.6 47.8 9.6
Advised on: breastfeeding weaning
41.0 39.1
39.2 29.0
53.4 36.6
25.0 14.2
36.3 26.1
Table V shows the progress of EPI in Iran between the first P H C programme review in 1984, 3 and the second one in 1987. Data used in this Table includes all immunisations up to the day o f study. The extent of progress is impressive especially for BCG vaccination, completion of immunisation before the first birthday, and Tetanus Toxoid (TT) immunisation o f mothers. Discussion
Although immunisation coverage of Iranian children has improved since the beginning o f EPI in 1983, it has not been uniform throughout the country and is far behind the original goal of 90% coverage of complete immunisation by 1990. 2 Coverage in the urban areas is less than that o f the rural areas. This result is not unprecedented globally and has previously been shown on various occasions for Iran. T M The main reaso~a for better coverage in the rural areas in general, and rural areas with P H C services in particular, lies in the nature o f the strategies adopted for delivery of immunisation. The 'active' strategy adopted for the rural areas requires that the provider, either the community health workers who actually live in their village of assignment, or members o f the mobile teams w h o ' regularly visit the villages, actively search for and immunise eligible children. Our data does
Primary Health Care and Immunisation in Iran Table V
235
Progress of expanded programme on immunisation in Iran between 1984 and 1987 1984"t
Number of surveys Number of children examined Population covered (l,000s)
19877
14 2,959 5,683
10 2,118 49,329
Percentage of children with: immunisation card
76
91
DPT I immunisation DPT III immunisation DPT drop out
89 73 18
94 75 20
OPV I immunisation OPV III immunisation OPV drop out
87 72 17
94 76 19
Measles immunisation
72
78
BCG immunisation (scar)
14
56
Complete immunisationtt < 12 months At the time of survey
46 61
32 54
Percentage of mothers with: TT I immunisation TT II immunisation
5 3
41 29
* From Reference 3 t Weighted average tt In 1984, complete immunisation excluded. BCG immunisation from the criteria, whereas in 1987, BCG immunisation was included as a part of the criteria for completion
not differentiate between vaccinations provided by the mobile teams or the community health workers in the PHC-covered areas. On the other hand, the 'passive' strategy adopted for the urban areas means that the child's immunisation is dependent on the mother's initiative and attention. As has been shown earlier in a different set of data, H and is repeated here, the main reasons for low coverage in the urban areas lie in the lack o f knowledge and improper attitude towards immunisation on the part o f mothers. In the urban areas, about half (54.1%) o f the incomplete immunisations have been attributed to the presence o f 'obstacles' which include: mother too busy (14.4%), child perceived ill by the mother and not brought for immunisation (17.0%), and child not immunised by the vaccinator due to illness (10.0%). Other major reasons for incomplete immunisation in the urban areas are: postponement for no apparent reason (11.2%), and lack of concrete knowledge a b o u t immunisation and its value (22.3%). Although the effectiveness o f ' a c t i v e ' follow-up and maintenance o f proper organisation in improving the immunisation coverage is well documented, ~3 the consistently lower coverage in the urban areas of the developing world has made it necessary for W H O to prepare special recommendations for improvement. 14,15 As for the source of immunisation, Table IV shows that about 25% o f the immunisations
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K. Nasseri et al.
in the capital city of Teheran are provided by private physicians, although this might not be valid. The reason for this lies in a technical question about the sampling methodology used. All the sampling procedures for this study followed the general guidelines advocated by W H O ~'9 which ensured that samples are drawn with 'probability proportionate to size' (PPS). However, it has recently 16 been shown that in a large and heterogeneous metropolitan area like the city o f Teheran where birth rate varies greatly from one part to another, the PPS sampling tends to over-represent the segment with lower birth rate. Since low birth rate is, generally, an attribute o f the 'higher socio--economic' classes who also tend to utilise the services of private health care providers more often, the results of such sampling tends to be biased towards the behaviour o f these groups and over-state the share of private physicians. The extent of this bias is not determined yet, but the DPT, OPV and BCG coverages stated in Table III might provide some clue to its magnitude. Private paediatricians are very particular about D P T and OPV immunisation of children under their care and meticulously follow the proper schedule. Part o f the reason for this is the fact that they are dealing with the higher socio-economic strata which is more highly educated, more interested in the well-being of their children, and is also more affluent. Thus, part of the high coverage o f these immunisations in Teheran and also the corresponding small drop-out rate should be attributed to them. On the other hand, no BCG vaccines are provided to the private sector in Iran and thus there is no coverage difference between Teheran and other urban areas for BCG. The low coverage o f maternal T T immunisation in the urban areas in general and the city of Teheran in particular, is because neonatal tetanus is not a major public health problem in the urban areas of Iran, 17 and most obstetricians and gynaecologists are reluctant to recommend or inject anything into a pregnant woman. On the other hand, the difference between rural areas with and without P H C services is explained by the fact that female community health workers in the PHC-covered areas can more easily inject the rural women, who are culturally reluctant to expose themselves to the male vaccinators o f the mobile teams. Table IV reveals that, with the exception o f Teheran, almost 50% o f all children have been breastfed beyond their first birthday. Although there is a tendency to explain the low breastfeeding rate in Teheran on mothers' finding employment outside the home, recent data 18 put more emphasis on the type of work women engage in, rather than the fact that they find employment. No reliable data on the impact of the type o f work on maternal behaviour of the Iranian female is available, but we do know that all rural women work and it seems that the agricultural nature of their work does not interfere with regular breastfeeding o f their children. Since the beginning of the EPI in Iran, complete immunisation (i.e. a minimum of three DPT, three OPV, one BCG, and one measles vaccination at first birthday) has been considered the single most important indicator o f progress. This, in fact, is not a good measure because it misrepresents the true immunisation status o f a given community by introducing organisational concerns which are not directly relevant to the overall immunity levels. Figure 1 shows that although children o f Teheran have high coverage for almost all vaccines, they are forced to a lower position only because o f their B C G immunisation coverage. It also shows that over 90% of children have had at least one contact with the immunisation services, as evidenced by possession of an immunisation card. Thus it is concluded that: a) using the coverage of complete immunisation does not convey the true and exact status of the immunisation in a community, and b) that the immunisation services and outlets are adequately expanded and well accepted by the Iranian people. The main problem with immunisation in Iran, however, is more with the attitude of mothers
,oo[
Primary Health Care and Immunisation in Iran
237
8o~ 60-
40-
20-
Comp, Immun.
1Teheran
Imrnun. Card
~
DPT III
Urban areas
[~
OPV III
Rural, PHC+
Measles
~
BCG
Rural, PHC
Figure 1 Possession of immunisation card, and coverage of single and complete immunisation at 12 months of age by area of residence, 1987
than availability of the services, as is shown by the drop-out rate. To improve immunisation coverage, it is crucial to reduce the drop-out rate, which is still close to 20%. Our previous work has shown that most o f the reasons stated for not completing the immunisation schedule are nothing more than excuses," and to reduce that is clearly a task for health education. Another important a p p r o a c h is provision o f all immunisations, including BCG, at every health facility, even hospitals and maternity wards, to the extent that every encounter of a child with a health facility can be used for up-dating his or her immunisation status. Active participation o f hospitals and maternity wards in the immunisation services is a promising approach, which not only helps children to receive their first immunisation but also provides an opportune time for educating mothers a b o u t immunisation.
Acknowledgements Authors wish to express their thanks to Dr A.A. Khan, Representative of the World Health Organisation, and Mr Hosseiny, UNICEF Program Manager, for their support and participation in this PHC programme review while on duty in Iran. Authors also wish to acknowledge their indebtedness to all their colleagues, both international and national, especially the local health workers who sincerely helped with both planning and data collection.
References 1. World Health Organisation (1978). Primary health care. Report of the International Conference on Primary Health Care, Alma Ata, USSR. (Health For All Series, no. 1). 2. Rezaii, P. & Hanna, I. (1985). Report on Expanded Programme on Immunization in Iran. Intercountry Meeting on EPI in Tunis. Teheran, Iran: Ministry of Health. Unpublished document. 3. Expanded Programme on Immunization (1985). Programme review in Iran. Weekly Epidemiological Record, 60, 110-112.
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4. King, M. H. (1983). An Iranian Experiment in Primary Health Care: the West Azerbaijan Project. Oxford: Oxford University Press. 5. Iran/WHO/UNICEF (1988). Second Primary Health Care Programme Review in Iran, September~October 1987. World Health Organisation: Regional Office for the Eastern Mediterranean. Unpublished document. 6. Malek-Afzali, H. & Rezaii, P. (1986). A survey on the mortality rates of the rural population of Iran. Daroo-va-Darman, 3(28), 5-8. 7. Malek-Afzali, H. (1987). A survey on the mortality and fertility rate of the urban population of Iran. Daroo-va-Darman, 4(38), 7-11. 8. World Health Organisation (1979). Training Module for Mid-level Managers: Evaluate Vaccination Coverage. Expanded Programme on Immunization, Geneva. 9. Henderson, R. H. & Sundaresan, T. (1982). Cluster sampling to assess immunization coverage: a review of experience with simplified sampling methods. Bulletin of the Worm Health Organization, 60, 253-260. 10. Matek-Afzali, H. (1987). Diarrhoea morbidity and mortality in Iran. Daroo-va-Darman, 4(47). 11. Nasseri, K., Latifi, M., Azordegan, F., Shafii, F. & All-e-Agha, R. (1990). Determinants of partial participation in the immunization programmes in Iran. Social Sciences and Medicine, 30, 379-383. 12. Nasseri, K. & Rezaii, P. (1987). Immunization coverage in the Islamic Republic of Iran. Eastern Mediterranean Region (EMRO) Health Services Journal, 1(2), 27 31. 13. DeQuadl:os, C.A. (1980). More effective immunization. Proceedings of the Royal Society of London, Series B, 209, 111-118. 14. Henderson, R.H. (1987). Improvement of Immunization on Services in Urban Areas. Paper presented at a workshop for managers of the Expanded Programme on Immunization, Manila, August 1986 (WPR/EPI/86. 14). Reviewed by Heggenhougen K and Clements J: Acceptability of Childhood Immunization. EPC Publication Number 14. 15. La Force, F. M., Henderson, R. H. & Keja, J. (1987). The expanded programme on immunization. Worm Health Forum, 8, 208-215. 16. Khoshgam, M. (1988). Time Trend of Immunization Coverage in Teheran 1979-85. A thesis submitted in partial fulfillment of the requirements of the degree of Master of Science of Public Health (MSPH) in Biostatistics at the School of Public Health, Medical Sciences University of Teheran. 17. Expanded Programme on Immunization (1987). Neonatal tetanus mortality survey in Iran. Weekly Epidemiological Records, 62, 38-39. 18. Kurinij, N., Shiono, P. H., Ezrine, S. F. & Rhoads, G. G. (1988). Does maternal employment affect breast fe~ding? American Journal of Public Health, 79, 1247-1250.
Public Heahh (1991), 105, 229-238
P r i m a r y Health Care and I m m u n i s a t i o n in Iran K. Nasseri, 1. B. Sadrizadeh, 2 H. Malek-Afzali, 1,2 K. Mohammad, 1 M. Chamsa, 2 M-T. Cheraghchi-Bashi, 2 M. Haghgoo 3 and M. Azmoodeh 2
1School of Public Health, Medical Sciences University of Teheran; 2Ministry of Health and Medical Education, Teheran. /ran; 3World Health Organisation. Eastern Mediterranean Regional Office
The Primary Health Care (PHC) network o f Iran consists of a rural and an urban branch. While the rural branch presently covers a sizeable portion of the rural population, the urban PHC project is in its early stages of implementation. The Expanded Programme on Immunisation (EPI) in Iran, which started as an independent and vertical project in early 1983, is being gradually integrated into the PHC network as the latter expands. Results of the second PHC programme review of Iran shows that immunisation coverage of children has improved appreciably since the first PHC review, especially for BCG which stands at 56.3%. Complete immunisation at first birthday in the rural areas with the PHC services is 44.1%, whereas for urban areas other than Teheran it is 28.1%. While the high coverage in the rural areas is attributed to the 'active' approach and vigilance of the providers o f immunisation (i.e. the community health workers and the vaccinators of the mobile teams), the higher coverage in the capital city of Teheran is attributed to the involvement o f private paediatricians and the generally higher social, economic, and educational status as well as higher interest of mothers. It is noticed that the results of cluster sampling for determination of immunisation coverage in large metropolitan areas of the developing world must be interpreted with much care. The reason is that in these areas extreme fluctuations in the crude birth rate are common and therefore results tend to over-represent the attributes of the segment of population with lower birth rate. It is also argued that complete immunisation might not be the best indicator for assessing the progress of the immunisation efforts. These and other findings are discussed in detail. Introduction P r i m a r y H e a l t h C a r e ( P H C ) a n d the E x p a n d e d P r o g r a m m e on I m m u n i s a t i o n ( E P I ) a r e two o f the m a j o r p r o g r a m m e s d e v e l o p e d a n d a d v o c a t e d b y the W o r l d H e a l t h O r g a n i s a t i o n ( W H O ) to facilitate the a c h i e v e m e n t o f the g l o b a l g o a l o f ' H e a l t h F o r All'.~ B o t h n a t i o n a l a n d i n t e r n a t i o n a l c o m m i t m e n t to these p r o g r a m m e s a r e o v e r w h e l m i n g , especially in the d e v e l o p i n g countries. I r a n is n o e x c e p t i o n a n d is d e e p l y i n v o l v e d a n d c o m m i t t e d to b o t h p r o g r a m m e s . T h e a i m o f this p r e s e n t a t i o n is to p r o v i d e a g e n e r a l overview o f the P H C n e t w o r k o f Iran; to d e t e r m i n e the i m p a c t o f P H C services o n i m m u n i s a t i o n activities in a r e a s w h e r e the t w o services a r e i n t e g r a t e d , a n d finally r e p o r t the p r o g r e s s o f E P I since its i n c e p t i o n in Iran. T h e E P I in I r a n officially b e g a n in early 1983, with a w o r k s h o p o n ' h i g h level m a n a g e m e n t ' , which n o t o n l y served as a n i n t r o d u c t i o n to the p r o g r a m m e b u t also set a p r e c e d e n t for t r a i n i n g o f n a t i o n a l m a n a g e r s at v a r i o u s levels. T h e u l t i m a t e g o a l o f the p r o g r a m m e was set as ' c o m p l e t e i m m u n i s a t i o n at first b i r t h d a y o f 9 0 % o f the I r a n i a n * Present address: Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of California, 1100 Glendon Avenue, Suite 711, Los Angeles, CA 90024, USA.
230
K. Nasseri et al.
children by 1990'. 2 Complete immunisation was defined as a m i n i m u m of three D P T (diphtheria, pertussis, tetanus), three OPV (oral polio vaccine) (beginning no sooner t h a n eight weeks of age with a minimum o f four weeks interval), one B C G any time after birth, and one live attenuated measles vaccine after seven m o n t h s of age. F o r rapid achievement of this goal, it was decided that the p r o g r a m m e would be implemented as an independent and vertical project. However, different strategies for urban and rural areas were considered. In the urban areas the main aim o f the p r o g r a m m e was to strengthen the immunisation units within the already functional health centres. For the rural areas, mobile teams which would visit villages on fixed schedules were considered. The first official p r o g r a m m e review 3 was carried out in early 1984 and was relied u p o n as the baseline, against which future progress would be measured. With the expansion o f the P H C services to cover a sizeable p r o p o r t i o n of the rural population o f the country and the need for cost effectiveness, immunisation services are being integrated into the routine activities o f the P H C network. Iran's involvement with P H C dates back to the early 1960s when an experiment on the feasibility o f the then new idea was designed and successfully carried out in one o f the provinces--the West Azerbaijan. 4 U p o n the official endorsement of P H C as a m a j o r health care delivery strategy in the Internationar'Conference of Alma A t a in 1978, and later by W H O , ~the government of Iran adopted it as the principal policy for delivery o f health care throughout the country. Implementation of this decision, however, was interrupted soon after its adoption in 1978, due to the social unrest which resulted in the Islamic Revolution of 1979, and the significant changes that followed it. In late 1983, interest in P H C was revived within the Ministry of Health and an appreciable a m o u n t o f financial and other resources were allocated to the implementation of a partially modified version of the original policy. In brief, the P H C network of Iran consists of a rural and an urban branch. The rural branch starts with a series of 'health houses' in the villages, each o f which is responsible for 1500 1800 people. Each health house is staffed by one male and one female 'Behvarz' or community health worker. They are selected f r o m the same area and often the same villages in which they will be working after their training. They receive two years o f basic training in health topics and are mainly responsible for providing general preventive services, including immunisation, family planning, advice on breastfeeding and nutrition, and environmental sanitation for all the individuals in their coverage area. They are also expected to provide basic therapeutic measures for m i n o r illnesses and refer other cases to their immediate Rural Health Centre ( R H C ) for attention by a physician. Each R H C is responsible for four health houses or some 7,500 population and is staffed by one or two physicians and a number o f paramedics, who are expected to closely m o n i t o r and support the activities o f the health houses. The R H C s report to the District Health Centre ( D H C ) for their administrative needs and should maintain close relationships with hospitals and other health institutions for their referrals. This latter activity is p r o b a b l y the weakest link in the system and needs specific attention. The P H C network of the urban areas is still in the early stages of implementation. It aims to integrate the present therapy-oriented health centres into the public health-oriented P H C network. T h e s m a l l e s t functioning unit in the urban branch of P H C network is the U r b a n Health Centre which is similar to the R H C in staffing and the scope of services. Each urban health centre covers almost 12,500 people and follows the general guidelines of P H C for services provided. However, more emphasis is given to health education, nutrition, maternal and child health (MCH), and treatment o f endemic diseases. The urban health centre is, like the R H C , under the administrative supervision of the D H C and maintains close relationships with hospitals for its referrals.
Primary Health Care and Immun&ation in Iran
231
Establishing a P H C network, which means a D H C and all the facilities that report to it in an area, starts with the health house or urban health centre and passes through a three-year cycle o f initiation, consolidation, and maintenance. There are 24 provinces in Iran and each year 24 new networks enter the initiation phase; 24 networks which were in the initiation phase in the previous year m o v e up to the consolidation phase; and another 24 which were in the consolidation phase enter the maintenance phase. Once a P H C network assumes the maintenance status, immunisation services in the area will be integrated into it. Methods In the a u t u m n o f 1987, the second PHC/EP1 p r o g r a m m e review of Iran was carried out by a team o f experts f r o m the G o v e r n m e n t o f Iran, W H O , and U N I C E F . Detailed information on this exercise is available elsewhere? Briefly, using the 1986 general census, the population o f the country was divided into four groups based on their area o f residence. The four groups thus formed were: a) residents o f the capital city of Teheran; b) residents of all other u r b a n areas; c) residents of rural areas with the P H C services either in consolidation or maintenance stages; and d) residents o f rural areas without the P H C services. Each group, except for the capital city of Teheran, was further sub-divided into three strata based on the infant mortality rate ( I M R ) recently measured in a country-wide survey. 6'v A total of 10 samples of 30 clusters each, one in the city of Teheran and one in each o f the nine strata thus formed, were drawn following the guidelines suggested by W H O . 8,9 In each o f the 300 clusters thus selected, a m i n i m u m o f seven children o f 12-23 months o f age (total o f 2,118 children) were identified and examined by local health workers. The local health workers who participated in this survey were selected from a m o n g those who had previously received intensive in-service training in EPI cluster survey methodology as part o f their EP1 training, and were closely supervised by a m e m b e r of the P H C p r o g r a m m e review team. Once a child was identified, his or her exact age was verified from the birth certificate or other reliable source such as the immunisation card. U p o n confirmation o f age eligibility, the immunisation status o f the child was recorded from the immunisation card and in its absence, by asking the mother. The child's arm was then examined for the B C G scar, and the mother was interviewed for particulars o f M C H services she had received during pregnancy and delivery o f that child. The completed forms were examined by the visiting m e m b e r o f the P H C p r o g r a m m e review team at the site for completeness and accuracy. All the forms were then brought back to Teheran for final analysis. Results Table I shows the distribution o f population by area o f residence and stratification by I M R . No attempt was made to stratify the population of Teheran. This Table reveals that a b o u t 55% of the population of Iran live in the urban areas and that a b o u t a third o f the rural population are covered by a P H C network. Table II shows complete immunisation at 12 months, as documented by the immunisation card, by area o f residence and I M R stratification. N o association was detected between the immunisation coverage and I M R stratification. Reasons for this observation might include one or m o r e of the following: a) possible error in determination o f I M R by using a one-year m e m o r y recall technique; b) choosing stratification points o f low discriminatory value, i.e. 30 and 35 per t,000 live births; and c) dominance o f other causes of infant mortality, such as diarrhoea, which are not prevented by immunisation. In fact, in a recent study, it was shown that almost 25% of all deaths a m o n g children under
232
K. Nasseri et al. Table I Population of Iran (in 1,000s) by area of residence and infant mortality rate (IMR) 1987. (Figures in brackets show percentage of the total population studied.) Infant mortality rate Residence
Low*
Medium*
High*
Total
Capital city of Teheran
6,022 (12.2) 9,992 (20.3) 2,100 (4.3) 7,371 (14.9) 25,485 (51.6)
--3,668 (7.4) 1,442 (2.9) 3,214 (6.5) 8,324 (16.9)
--7,268 (14.7) 2,230 (4.5) 6,022 (12.2) 15,520 (31.5)
6,022 (12.2) 20,928 (42.4) 5,772 (11.7) 16,607 (33.7) 49,329 (100.0)
Urban areas Rural, PHC + * Rural, P H C - * Total
* Low: IMR < 30; medium: IMR = 30-35; high: IMR > 35 per 1,000 live births t Rural, PHC+: rural areas with PHC services Rural, P H C - : rural areas without PHC services
Table II
Percentage of children with complete immunisation* at 12 months of age, by area of residence and infant mortality rate (IMR), 1987 Infant mortality rate
Residence
Lowt
Mediumt
Hight
Total (population-weighted average)
Capital city of Teheran U r b a n areas Rural, P H C + ¶ Rural, P H C - ¶ Total
34.9 26.2 48.8 31.8 31.7
-32.4 36.7 26.6 30.9
-28.6 44.5 31.3 31.0
34.9 28.1 44.1 30.6 31.6
Total:~
34.9 29.0 43.3 29.9 34.2
( ± 8.3) ( ± 4.4) (±5.6) (±5.5) (±2.9)
* Complete immunisationconsists of at least three DPT (diphtheria, pertussis, tetanus), three OPV (oral polio vaccine) (beginning no earlier than eight weeks and continued with at least four weeks interval), one BCG at any time after birth, and one live attenuated measles vaccine given not earlier than seven months of age. lmmunisations documented by 'probing mothers' memory' were not included among those completed at 12 months of age t See * footnote to Table I $ Pooled over the samples, with 95% confidence interval given in parentheses ¶ See I footnote to Table I
five years o f age in I r a n are c a u s e d by d i a r r h o e a . '° D u e to this o b s e r v a t i o n , I M R stratification was a b a n d o n e d a n d the three cluster samples in each o f the areas were p o o l e d together. However, T a b l e II presents a d r a m a t i c v a r i a t i o n in coverage o f c o m p l e t e i m m u n i s a t i o n by area of residence. It is best in those r u r a l areas with P H C services, followed by that o f the capital city o f T e h e r a n . O t h e r u r b a n areas have as low a coverage as the r u r a l areas w i t h o u t the P H C services.
Primary Health Care and Immunisation in Iran Table III
233
Immunisation coverage at 12 months of age, by area of residence, 1987 City of Teheran
Urban areas
Rural (PHC+)
Rural (PHC-)
Total Iran
16,607
49,329
Population (in 1000s)
6,022
20,928
5,772
No. children examined
212
630
637
639
% Children with immunisation card
95.3
84.9
95.3
95.1
90.8
% with DPT I % with DPT III DPT drop out
91.5 79.2 13.4
79.5 58.4 26.5
92.5 69.9 24.4
87.8 50.1 43.0
85.3 59.5 30.2
% with OPV I % with OPV III OPV drop out
92.0 78.3 14.9
79.8 56.8 28.8
92.0 70.5 23.4
87.0 50.7 41.7
85.1 59.0 30.7
% with measles
63.2
49.2
67.8
55.2
55.1
% with BCG (injection) % with BCG (scar)
50.9 37.7
49.5 40.9
66.4 47.9
63.2 49.0
56.3 44.0
4.7 3.3
8.6 5.9
24.3 19.8
17.8 13.8
13.1 9.9
34.9
29.0
43.3
29.9
31.7
% of mothers with: TT immunisation I* TT immunisation II % with complete immunisation#
2,118
* Only those that are documented and dated # Complete immunisation: as defined in Table II
Further details of the immunisation coverage by residential areas are given in Table III. Data reported in this Table are limited to those immunisations that were given before the first birthday and that were recorded on the child's immunisation card. This Table not only confirms the overall results o f Table II, but also reveals that the coverage of various immunisations in rural areas with P H C services is generally better than the rest o f the country (with the exception of D P T and OPV coverage in the capital city o f Teheran). Table IV shows the sources of immunisation and utilisation of some M C H services by area o f residence. As can be seen, children in rural areas with a P H C service have the highest contact rate. Analysis of the source o f contact reveals that in the urban areas the major role is played by the health centres, whereas in the rural areas either the health houses or the mobile teams are more important. It has also been observed that while almost 25% of all immunisations in the city of Teheran are provided by private physicians, hospitals where over 74% o f urban children are born do not play an appreciable role in immunising them. The pattern o f breastfeeding identified in this Table is also interesting. With the exception of Teheran, close to 50% of the children in the rest of the country are breastfed beyond their first birthday. Overall, this Table shows that mothers in rural areas with P H C services receive much better M C H care, advice and attention in comparison to mothers in other rural and most urban areas.
K. Nasseri et al.
234 Table IV
Utilization of immunisation and maternal and child health services (%), by area of residence, Iran 1987 City of Teheran
Immunisation: average contact per child
Urban areas
Rural PHC +
Rural PHC-
Total Iran
7.6
6.8
8.3
7.6
7.3
Source: hospital health centre health house mobile teams private
6.2 69.1 NA NA 24.7
3.1 93.1 0.1 3.1 0.7
0.8 11.6 73.7 13.9 0.04
1.2 9.2 5.1 84.3 0.2
2.6 52.4 10.4 31.3 3.4
MCH Services: prenatal care
72.7
51.9
63.4
18.5
44.5
Delivery at: private hospital public hospital home
42.0 56.1 1.9
7.6 67.0 15.4
3.3 47.1 49.6
0.6 39.7 59.7
13.2 54.1 32.7
Child weighed at birth:
95.7
68.9
43.6
29.4
55.9
Child breast-fed: < 12 months > 12 months None
80.7 4.2 15.1
39.4 48.6 12.1
41.0 52.4 6.6
33.5 61.0 5.5
42.6 47.8 9.6
Advised on: breastfeeding weaning
41.0 39.1
39.2 29.0
53.4 36.6
25.0 14.2
36.3 26.1
Table V shows the progress of EPI in Iran between the first P H C programme review in 1984, 3 and the second one in 1987. Data used in this Table includes all immunisations up to the day o f study. The extent of progress is impressive especially for BCG vaccination, completion of immunisation before the first birthday, and Tetanus Toxoid (TT) immunisation o f mothers. Discussion
Although immunisation coverage of Iranian children has improved since the beginning o f EPI in 1983, it has not been uniform throughout the country and is far behind the original goal of 90% coverage of complete immunisation by 1990. 2 Coverage in the urban areas is less than that o f the rural areas. This result is not unprecedented globally and has previously been shown on various occasions for Iran. T M The main reaso~a for better coverage in the rural areas in general, and rural areas with P H C services in particular, lies in the nature o f the strategies adopted for delivery of immunisation. The 'active' strategy adopted for the rural areas requires that the provider, either the community health workers who actually live in their village of assignment, or members o f the mobile teams w h o ' regularly visit the villages, actively search for and immunise eligible children. Our data does
Primary Health Care and Immunisation in Iran Table V
235
Progress of expanded programme on immunisation in Iran between 1984 and 1987 1984"t
Number of surveys Number of children examined Population covered (l,000s)
19877
14 2,959 5,683
10 2,118 49,329
Percentage of children with: immunisation card
76
91
DPT I immunisation DPT III immunisation DPT drop out
89 73 18
94 75 20
OPV I immunisation OPV III immunisation OPV drop out
87 72 17
94 76 19
Measles immunisation
72
78
BCG immunisation (scar)
14
56
Complete immunisationtt < 12 months At the time of survey
46 61
32 54
Percentage of mothers with: TT I immunisation TT II immunisation
5 3
41 29
* From Reference 3 t Weighted average tt In 1984, complete immunisation excluded. BCG immunisation from the criteria, whereas in 1987, BCG immunisation was included as a part of the criteria for completion
not differentiate between vaccinations provided by the mobile teams or the community health workers in the PHC-covered areas. On the other hand, the 'passive' strategy adopted for the urban areas means that the child's immunisation is dependent on the mother's initiative and attention. As has been shown earlier in a different set of data, H and is repeated here, the main reasons for low coverage in the urban areas lie in the lack o f knowledge and improper attitude towards immunisation on the part o f mothers. In the urban areas, about half (54.1%) o f the incomplete immunisations have been attributed to the presence o f 'obstacles' which include: mother too busy (14.4%), child perceived ill by the mother and not brought for immunisation (17.0%), and child not immunised by the vaccinator due to illness (10.0%). Other major reasons for incomplete immunisation in the urban areas are: postponement for no apparent reason (11.2%), and lack of concrete knowledge a b o u t immunisation and its value (22.3%). Although the effectiveness o f ' a c t i v e ' follow-up and maintenance o f proper organisation in improving the immunisation coverage is well documented, ~3 the consistently lower coverage in the urban areas of the developing world has made it necessary for W H O to prepare special recommendations for improvement. 14,15 As for the source of immunisation, Table IV shows that about 25% o f the immunisations
236
K. Nasseri et al.
in the capital city of Teheran are provided by private physicians, although this might not be valid. The reason for this lies in a technical question about the sampling methodology used. All the sampling procedures for this study followed the general guidelines advocated by W H O ~'9 which ensured that samples are drawn with 'probability proportionate to size' (PPS). However, it has recently 16 been shown that in a large and heterogeneous metropolitan area like the city o f Teheran where birth rate varies greatly from one part to another, the PPS sampling tends to over-represent the segment with lower birth rate. Since low birth rate is, generally, an attribute o f the 'higher socio--economic' classes who also tend to utilise the services of private health care providers more often, the results of such sampling tends to be biased towards the behaviour o f these groups and over-state the share of private physicians. The extent of this bias is not determined yet, but the DPT, OPV and BCG coverages stated in Table III might provide some clue to its magnitude. Private paediatricians are very particular about D P T and OPV immunisation of children under their care and meticulously follow the proper schedule. Part o f the reason for this is the fact that they are dealing with the higher socio-economic strata which is more highly educated, more interested in the well-being of their children, and is also more affluent. Thus, part of the high coverage o f these immunisations in Teheran and also the corresponding small drop-out rate should be attributed to them. On the other hand, no BCG vaccines are provided to the private sector in Iran and thus there is no coverage difference between Teheran and other urban areas for BCG. The low coverage o f maternal T T immunisation in the urban areas in general and the city of Teheran in particular, is because neonatal tetanus is not a major public health problem in the urban areas of Iran, 17 and most obstetricians and gynaecologists are reluctant to recommend or inject anything into a pregnant woman. On the other hand, the difference between rural areas with and without P H C services is explained by the fact that female community health workers in the PHC-covered areas can more easily inject the rural women, who are culturally reluctant to expose themselves to the male vaccinators o f the mobile teams. Table IV reveals that, with the exception o f Teheran, almost 50% o f all children have been breastfed beyond their first birthday. Although there is a tendency to explain the low breastfeeding rate in Teheran on mothers' finding employment outside the home, recent data 18 put more emphasis on the type of work women engage in, rather than the fact that they find employment. No reliable data on the impact of the type o f work on maternal behaviour of the Iranian female is available, but we do know that all rural women work and it seems that the agricultural nature of their work does not interfere with regular breastfeeding o f their children. Since the beginning of the EPI in Iran, complete immunisation (i.e. a minimum of three DPT, three OPV, one BCG, and one measles vaccination at first birthday) has been considered the single most important indicator o f progress. This, in fact, is not a good measure because it misrepresents the true immunisation status o f a given community by introducing organisational concerns which are not directly relevant to the overall immunity levels. Figure 1 shows that although children o f Teheran have high coverage for almost all vaccines, they are forced to a lower position only because o f their B C G immunisation coverage. It also shows that over 90% of children have had at least one contact with the immunisation services, as evidenced by possession of an immunisation card. Thus it is concluded that: a) using the coverage of complete immunisation does not convey the true and exact status of the immunisation in a community, and b) that the immunisation services and outlets are adequately expanded and well accepted by the Iranian people. The main problem with immunisation in Iran, however, is more with the attitude of mothers
,oo[
Primary Health Care and Immunisation in Iran
237
8o~ 60-
40-
20-
Comp, Immun.
1Teheran
Imrnun. Card
~
DPT III
Urban areas
[~
OPV III
Rural, PHC+
Measles
~
BCG
Rural, PHC
Figure 1 Possession of immunisation card, and coverage of single and complete immunisation at 12 months of age by area of residence, 1987
than availability of the services, as is shown by the drop-out rate. To improve immunisation coverage, it is crucial to reduce the drop-out rate, which is still close to 20%. Our previous work has shown that most o f the reasons stated for not completing the immunisation schedule are nothing more than excuses," and to reduce that is clearly a task for health education. Another important a p p r o a c h is provision o f all immunisations, including BCG, at every health facility, even hospitals and maternity wards, to the extent that every encounter of a child with a health facility can be used for up-dating his or her immunisation status. Active participation o f hospitals and maternity wards in the immunisation services is a promising approach, which not only helps children to receive their first immunisation but also provides an opportune time for educating mothers a b o u t immunisation.
Acknowledgements Authors wish to express their thanks to Dr A.A. Khan, Representative of the World Health Organisation, and Mr Hosseiny, UNICEF Program Manager, for their support and participation in this PHC programme review while on duty in Iran. Authors also wish to acknowledge their indebtedness to all their colleagues, both international and national, especially the local health workers who sincerely helped with both planning and data collection.
References 1. World Health Organisation (1978). Primary health care. Report of the International Conference on Primary Health Care, Alma Ata, USSR. (Health For All Series, no. 1). 2. Rezaii, P. & Hanna, I. (1985). Report on Expanded Programme on Immunization in Iran. Intercountry Meeting on EPI in Tunis. Teheran, Iran: Ministry of Health. Unpublished document. 3. Expanded Programme on Immunization (1985). Programme review in Iran. Weekly Epidemiological Record, 60, 110-112.
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