3764 DS175.

83 May 3, 2013

An Evaluation of the Philippines' Expanded Program on Immunization using the Basic Needs and
Entitlements Approach
Despite the numerous advances that have been made in the past century in terms of vaccine research
and development, several children and infants continue to die from VCDs such as polio, measles, maternal and
neonatal tetanus, tuberculosis, hepatitis B, diphtheria, pertussis, to name a few. According to the World
Health Organization, the total number of annual deaths among children less than five years of age from
vaccine-preventable diseases (VCDs) comes up to a number of almost 12 million (8). Without immunization
programs worldwide, the death toll could be higher: 2.7 million are expected to die from measles, 1.2 million
from tetanus, 10,000 from diphtheria and 800,000 from polio. In fact, data from the National Statistics Office
and UNICEF showed that 35 out of 1,000 Filipino infants still die annually from VCDs (8). Moreover,
tuberculosis remains to be one of the top ten leading causes of mortality among all Filipinos. Also, an
estimated 9,000 Filipinos continue to die yearly from chronic Hepatitis B infections (3).
In light of this, the WHO established the Expanded Program on Immunization (EPI) in 1974 through a
World Health Assembly resolution that aimed to ensure that all children in all countries benefited from life-
saving vaccines (4). In the Philippines, the Department of Health launched the nationwide campaign of the
Expanded Program on Immunization in 1976 to guarantee all infants and children have access to routinely
recommended infant/childhood vaccines. Initially, six VCDs were included in the EPI: tuberculosis,
poliomyelitis, diphtheria, tetanus, pertussis and measles. The program has since expanded to cover vaccines
for hepatitis B, H. Influenzae Type B (HiB), German measles, and rotavirus (5).
The over-all goal of the program is to reduce the morbidity and mortality among children against the
most common VCDs. Specifically, it aims to immunize all infants/children against the most common VCDs (2).
In terms of the 5Ps (people, product, price, place, promotion), the EPI can be understood as the following:
1. People: The primary target groups include all infants (aged 0-12 months), and all women of childbearing
age (aged 15-49 years old). [The women of childbearing age are to receive five doses of tetanus toxoid for
lifetime protection against maternal tetanus as well as to prevent the occurrence of neonatal tetanus
among their infants (5)].
2. Product: As of 2012, the EPI covers Bacillus Calmette-Gurin vaccine (BCG) for tuberculosis, Diphtheria-
Pertussis-Tetanus Vaccine (DPT), Hepatitis B vaccine, HiB vaccine, measles vaccine, MMR vaccine, oral
polio vaccine (OPV), and the rotavirus vaccine (5).
3. Price: All immunization services given by the government are free of charge as prescribed by law (5).
4. Place: Immunization services are required to be given in all local government health facilities across the
country once a week (usually Wednesday, national immunization day) strictly by trained/skilled
government health workers such as doctors, nurses and midwives (5)
5. Promotion: DOH is required to make available appropriate information materials regarding
immunization and to have a system of its distribution to the public such as local immunization awareness
campaigns and immunization talks during community assemblies. Moreover, healthcare practitioners
who administer prenatal care are also required to educate pregnant mothers on the availability, nature
and importance of giving their infants basic immunization services (7).
In terms of the impact, there have been great successes made as seen in lower reported cases of VCDs as
well as increases in immunization coverage rates since the establishment of the EPI (10). One of the greatest
achievements was when the Philippines officially became polio-free since October 2000, and sustained its
polio-free status. Since 1980, deaths due to measles infections have gone down from almost 14,000 every
year to just an average of 4 deaths per year starting 2005 (10).
However, despite all the successes of the program, the Philippines still has a long way to go in terms of
achieving a fully immunized population. Except for polio, the Philippines immunization coverage rates for a
lot of VCDs are still mostly less than 90%: 84% (BCG), 80% (DTP), 76% (Hepatitis B), 14% (HiB), 87%
(Measles), 56% (Maternal Tetanus/Tetanus Toxoid). Vaccine supply shortages continue to come up especially
during and after disease outbreaks (2). Moreover, while the incidence of VCDs has lowered dramatically in
numerous provinces, there continue to be high-risk areas for certain VCDs such as tetanus (2). Also, the EPI
still does not cover several other VCDs such as flu vaccine for influenza, pneumococcal vaccine for Strep.
pneumoniae, meningococcal vaccine for N. meningitides, hepatitis A, and typhoid (8). These are just some of
the challenges still facing the EPI in the Philippines.
Given all of this, this paper will attempt to evaluate the EPI using two developmental frameworks: the
Basic Needs approach and the Entitlements approach. The program and how it tackles the problem of VCDs in
the country will be discussed in relation to each approach. Moreover, suggestions on how to improve the
program design will be given in accordance to each approach.
To start off, the Basic Needs approach argues that there is a minimum set of basic needs that must be
guaranteed in order for human life to be sustained. The Basic Needs approach acknowledges that because
income is not the only means of acquiring basic needs, emphasis should be shifted away from a focus on
increasing peoples income towards ensuring that peoples basic needs are met. Moreover, the Basic Needs
approach also highlights the fact that people desire income, not for incomes sake, but in order to acquire
basic needs. In light of this, the Basic Needs approach endeavors to view poverty in terms of a severe basic
needs deprivation, rather than merely income deprivation. Given this, the corresponding solutions prescribed
by the Basic Needs approach to addressing poverty largely involve increasing the supply and equitable
distribution of basic needs as well as generating remunerative and socially satisfying employment. It is
believed that an increased supply coupled with higher employment levels will allow individuals to adequately
meet their basic needs.
In evaluating the EPI, the Basic Needs approach would therefore argue that the lower incidence of VCDs in
the country over the years could be largely attributed to the DOHs efforts to ensure a steady and equitable
supply of vaccines to the different regions in the country. This was made possible by establishing a functional
system of vaccine procurement and dissemination from the national to regional levels as well as partnering
with international aid agencies such as UNICEF and USAID that provide vaccines for free (5). Likewise, the
Basic Need approach would probably view the remaining gap in immunization coverage rates as strictly a
quantity problem. Therefore, it would primarily look towards increasing the national supply of vaccines to
close the gap in immunization coverage rates. In order to do this, the program might look into more efficient
procurement methods to acquire these vaccines at cheaper prices, which would then equate to a larger
volume for the same rate. Another tactic would be to bolster ongoing collaboration with international aid
agencies as well as looking for more partners such as the Bill and Melinda Gates Foundation to obtain
additional vaccines for free. Also, it would advise the EPI to further strengthen its national distribution
system of these vaccines. These efforts would not only increase immunization coverage rates especially in the
high-risk areas, but also contribute to preventing any further shortages in vaccines from happening. With
regards to the VCDs not covered in the EPI, the Basic Needs approach would advise including them in the EPI
as soon as possible, followed by securing a stable supply of these new vaccines and introducing them into the
national distribution system.
On the other hand, the Entitlements approach focuses on the ability of individuals to establish command
or ownership over certain goods or services, specifically ones basic needs. The approach argues that there
are several ways for an individual to acquire basic needs. Moreover, the approach contends that increasing
the supply of basic needs and ensuring their equitable distribution does not automatically lead to peoples
basic needs being fulfilled. Therefore, the Entitlements approach would rather view poverty instead as severe
entitlements failure, or the inability to access basic needs. In light of this, the corresponding solutions offered
by the Entitlements approach to the problem of poverty revolve around making sure that people have the
ability to access their basic needs. Specifically, the approach looks at five distinct parameters the
availability, accessibility, security, acceptability, and quality of the vaccines provided by the EPI. To extend
this further, the Entitlements approach views the remaining gaps in immunization coverage rates as being
affected by the interplay of the five aforementioned parameters.
AVAILABILITY (9)
In terms of comprehensiveness, the vaccine supply is relatively sufficient for the routine immunizations
that are conducted in government health facilities in the country. In order to ensure adequate vaccine supply,
an inventory of vaccines is done every month on the barangay level, quarterly on the district level, and
biannually on the city/provincial level to check supplies. Likewise, resupplying of the vaccines is done on the
same schedule after the inventory check is done. The program design can be improved to prevent shortages
from occurring by increasing vaccine supplies in BHCs, strengthening distribution systems down to the
barangay level specifically, and reducing procurement and dissemination waiting times of the vaccines.
In terms of appropriateness, the kinds of vaccines included in the EPI as well as the introduction of new
vaccines are based on epidemiological data regarding current trends in disease and mortality rates. The
vaccines also come in packaging that is easy to understand so as to facilitate ease in immunization. The
program ensures the appropriateness of vaccines through constant disease surveillance and monitoring on
the national, regional and local levels so as to be updated with the health trends. Given that several other
VCDs arent included in the EPI yet, program design can be improved by making sure that their incidence
rates are also being carefully monitored, and not just the incidence rates of the VCDs included in the EPI. Once
the incidence rates of these other VCDs become epidemiologically significant, it would then be easier to push
for their inclusion in the EPI as well.
ACCESSIBILITY (9)
In terms of non-discrimination, the EPI provides vaccines only to those who belong to its target groups,
which indirectly excludes a large portion of the population. In order to address this issue, the government can
explore the possibility of widening their target groups in the future so that more people can benefit from the
EPI. In terms of economic accessibility, the vaccines included under the EPI are given free of charge. In terms
of physical accessibility, the vaccines are usually administered in barangay health centers (BHCs), which
make it easier for community members to avail of them given their proximity to the BHCs. The BHCs also
undertake outreach services to catch-up on children who have missed on some doses or are in hard to reach
areas. Further intensifying these efforts can help improve immunization coverage rates among high-risk
areas, which are often hard to reach. In terms of information accessibility, community members are made
aware of the availability and benefits of vaccines regularly through consultations in the BHCs, pre-natal and
post-natal check-ups, community assemblies and home visits.
SECURITY (9)
In terms of physical security, the vaccines have been pre-tested and FDA-approved which means they can
be safely used. Most of the time, peoples safety isnt endangered in the process of going to the BHCs to avail
of the vaccines. However, conflict-stricken areas can make it difficult for people to be physical secure as going
to the BHCs for immunizations might expose them to danger. This might necessitate that the DOH closely
collaborates with the military in ensuring that people still get access to vaccines in conflict areas. In terms of
economic security, the only real threat to this lies on the supply side. In the event that the costs of procuring
these vaccines suddenly shoot up, the government might be placed in a situation wherein it can no longer
fully subsidize the provision of vaccines. This is where efforts to collaborate with international aid agencies
and NGOs that essentially donate vaccines to the government have been crucial in ensuring economic
security. With regards to social security, these same international aid agencies and NGOs, along with the DOH,
represent the formal institutions that make sure people are able to continually access these vaccines through
the EPI. In term if environmental security, disasters can be a threat to peoples sustained access to
immunizations because they can prevent them from getting to the BHCs or halt immunization operations
entirely in times of crisis. Once again, close collaboration with the military and humanitarian aid agencies will
be crucial in ensuring that people can still get access to vaccines during disasters.
ACCEPTABILITY (9)
Immunizations are often culturally accepted given the high awareness of the severe complications
secondary to VCDs. However, it cannot be denied that there are still some pockets of resistance that exist in
certain indigenous tribes, which can contribute to the remaining gaps in immunization coverage rates.
Oftentimes, these challenges can be overcome through intensive and persistent health education of the
benefits of immunization. Moreover, the EPI makes a conscious effort to acquire the support of the LGU in
order to push for the immunization of all community members. Since a lot of high-risk areas often have large
communities of indigenous people in them, the program design of the EPI can be improved by having a
person from the indigenous tribes be the one to do the health education campaigns on immunization. This
move would make it more palatable for the indigenous people to actually consider being immunized.
QUALITY (9)
Quality of the vaccines is ensured by FDA approval and testing as well as adherence to cold chain
management protocols for the safe storage of vaccines. Moreover, educating health professionals such as
doctors, nurses and midwives on the correct and proper procedure of giving injections makes sure that
quality of the vaccines isnt compromised during immunizations. Strict compliance with proper waste
disposal techniques minimizes the inadvertent transmission of diseases during immunizations.
All in all, it can be seen that using two different developmental frameworks yield largely different analyses
and recommendations regarding what to do with the program design of the EPI. This is significant to note
because the government would be taking markedly different steps in improving the program design as well
as assessing the EPI if it chooses to take on one developmental approach over the other. But at the same time,
each approach has its own advantages and disadvantages. Therefore, it is important to be aware of the
developmental lens one adopts in evaluating health interventions.
Sources:
1. Immunization. World Health Organization Representative Office: Philippines. 2013.
http://www.wpro.who.int/philippines/areas/immunization/en/index.html
2. Expanded Program on Immunization. Department of Health. 2012.
http://www.doh.gov.ph/node/198.html
3. Immunizing against Measles and Rubella. World Health Organization Representative Office:
Philippines. 2013.
http://www.wpro.who.int/philippines/areas/immunization/story_ligtas_tigdas/en/index.html
4. Immunization Service Delivery. World Health Organization. 2013.
http://www.who.int/immunization_delivery/en/
5. Childhood Immunization Schedule. Philippine Foundation for Vaccination. 2013.
http://www.pidsphil.org/pdf/Journal_01242011/jo36_ja07.pdf
6. Policies on the National Implementation of the Expanded Program on Immunization. Department of
Health. April 2003.
7. Republic Act No. 10152 AN ACT PROVIDING FOR MANDATORY BASIC IMMUNIZATION SERVICES
FOR INFANTS AND CHILDREN, REPEALING FOR THE PURPOSE PRESIDENTIAL DECREE NO. 996, AS
AMENDED. Republic of the Philippines. Official Gazette. 2013.
http://www.gov.ph/2011/06/21/republic-act-no-10152/
8. Vaccine Advocacy: Mission NOT Impossible. Philippine Foundation for Vaccination. 2013.
http://www.philvaccine.org/news/vaccineadvocacymissionnotimpossible
9. Tang, Annabelle. Phone Interview. April 2013
10. WHO Vaccine Preventable Diseases Monitoring System: 2012 Global Summary. World Health
Organization. 2013.
http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileselect.cfm