Assessment of Injection Practices in India (2002-2003): An IPEN Study

1. Assessment of Injection Practices in India (2002-2003) An IndiaCLEN Program Evaluation Network Study In Partnership with Ministry of Health and Family Welfare, GOI; World Bank & Clinical Epidemiology Unit All India Institute of Medical Sciences New Delhi Assessment of Injection Practices In India: An IPEN Study

2. Scheme of presentation • Objectives of the study & methodology • Magnitude of injections • Safety profile of injections • Sterilization & disposal • Summary & discussion points Assessment of Injection Practices In India: An IPEN Study

3. Assessment of Injection Practices in India Research Questions: What is the current frequency of injection use in India? 2. What proportion of injections in India are unsafe? 3. What proportion of injections are not required? What determines use of injections? Outcome of the Study What options are available for India to improve rationale and safe use of injections? Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

4. Phase I : Qualitative Study Phase II : Quantitative Study Assessment of Injection Practices in India (2002-2003): An IndiaCLEN Program Evaluation Network Study Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

5. Qualitative Study Health policy makers Health program managers Community Determinants of Injection Practices Professional bodies Industry Prescribers Providers Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

6. Central Coordinating Office Regional Coordinator Partner Medical College  Srinagar • • • Kangra • • Dehradun • • DELHI  • Dibrugarh • Agra Ballabhgarh • • Lucknow • Jodhpur • • Darbhanga • Imphal Bhopal Burdwan • • Surat • • Bilaspur Bhubaneshwar Nagpur • Mumbai Gulbarga • • Nalgonda (Hyderabad) • Tirupati • Chennai • Coimbatore • Thiruvananthapuram Assessment of Injection Practices in India (2002-2003): An IndiaCLEN Program Evaluation Network Study Study Centers(Qualitative Study) Assessment of Injection Practices In India: An IPEN Study

7. Data Collection * 22 Interviews were conducted to replace the interviews rejected at Regional Centers @ FGD with Informal Prescribers could not be conducted at one center due to their non-availability; an additional FGD with Injection Givers was conducted instead Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

8. Quantitative Study Community Interview of Clients Observation of Health facility Community & Health Facility survey for prevalence of injections & Injection practices Direct Observation of Injection practices Exit Interviews Prescribers Interview Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

9. Objectives of the study • To determine the magnitude of unsafe injections (both curative and preventive) • To achieve this we observed injection procedures at each of the three health facilities : • Govt. Health Facility • Private Health Facility • Immunization Clinic Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

10. Objectives of the study cont… • To determine the proportion of health care facilities (public / private / immunization clinics) where process of injections is unsafe • To determine the proportion of health care facilities where sharps waste management is inadequate To achieve these we observed three health facilities at each cluster : Govt. Health Facility Private Health Facility Immunization Clinic Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

11. Objectives of the study Contd… • To determine the proportion of prescriptions given at health facilities (public / private) that include injection(s) • To determine the proportion of patients with common conditions (fever, diarrhea and ARI) which are prescribed injections • To achieve this we did: • Govt. Health Facility - 5 Exit interviews Private Health Facility - 5 Exit interviews Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

12. Objectives of the study Contd… • To determine the frequency of injections in the community (injections / person / unit time) • To determine the indications of injections (curative / preventive) To achieve this we did: Community Survey - 10 Male Clients (per cluster) 10 Female Clients Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

13. Study Methodology • Population based Survey • Health facility based Survey Rapid population based cluster survey at household and health facilities Communities selected using “probability proportionate to size” (PPS) technique Census data base (1991) utilized for selecting the clusters (Growth rate of 2.28 is added to simulate current population) Separate group of clusters for Urban and Rural areas Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

14. Zone 1 Zone 5 Zone 2 Zone 7 Zone 3 Zone 6 Zone 9 Zone 8 Zone 4 Zone 10 Zone 11 Zone 12 Zone 13 Zone 14 Zone 15 Assessment of Injection Practices in India (2002-2003): An IndiaCLEN Program Evaluation Network Study Study Zones Assessment of Injection Practices In India: An IPEN Study

15. • Srinagar • • Amritsar Kangra ¨ Chandigarh • • Dehradun • Rohtak ¨ Ghaziabad • • Aligarh Jodhpur • • Gangtok • Jaipur ¨ Agra • Muzaffarpur • • Lucknow • Dibrugarh (2) • • ¨ Barmer Guwahati Ajmer • • • • • • Kohima Darbhanga Chittorgarh Shillong ¨ Udaipur Gaya • Patna • ¨ Gwalior Varanasi Imphal ¨ • Bhagalpur • • Rajkot Agartala • Bhuj • • • Ranchi Aizwal • ¨ Bhopal Burdwan ¨ Jabalpur • • Jamshedpur Jamnagar Kolkata (4) Baroda • ¨ Raipur • • • Cuttack • Bilaspur ¨ Nagpur Bhavanagar Bhubaneshwar Sambhalpur • Surat Berhampur • • Mumbai (2) • Pune Hyderabad (2) • Visakhapatnam • • ¨ Kakinada • Vijayawada Gulbarga • • Panaji • Bijapur Kurnool Belgaum • ¨ Manipal Bangalore • Chennai • Vellore • • Calicut • Coimbatore • Kannur • Madurai • • Thrissur Thirunelveli Kottayam ¨ Thiruvananthapuram Assessment of Injection Practices in India (2002-2003): An IndiaCLEN Program Evaluation Network Study Study Centers(n==84)(Quantitative Study) Medical Colleges 69 NGOs 9 Pub Health Inst 6 Assessment of Injection Practices In India: An IPEN Study

16. Quality Assurance Mechanisms * Facilitate common understanding of the objectives and data collection methods * Obtain group consensus in finalizing the interview schedules National Protocol Finalization Workshop (CCT+ZC+PI) Level: 1 * Ensure common understanding of the objectives and data collection methods * Provide hands on experience Zonal Workshops (CCT+ZC+Research Teams) Level: 2 * Check quality of work being done by each team in the field* Take corrective steps, if needed CCT Members’ Field Visits (Assigned Zones) Level: 3 * Scrutinize responses and appropriate coding on the schedules & ICR sheets Data Collection(Research Teams) Level: 4 * Checks for completeness * Checks for appropriate tick marks on the ICR sheets * Do consistency & range checks Data Management (CCO) Level: 5 Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

17. Magnitude of various types of injections in the country Assessment of Injection Practices In India: An IPEN Study

18. Magnitude of Injections in India - I * The No. of injections received in last three months **The no. of injections received in last two weeks Assessment of Injection Practices In India: An IPEN Study

19. Zone 1 7.1 6.5 5.0 Zone 5 6.4 Zone 2 Zone 7 3.5 Zone 3 Zone 6 Zone 9 3.1 3.8 Zone 8 Zone 4 6.0 2.4 Zone 10 Zone 11 8.0 5.2 Zone 12 9.9 Zone 13 7.2 Zone 14 Zone 15 9.8 4.3 Magnitude of Injections in India - II (based on two week recall) Zone wise estimation ALL INDIA : 5.8 Assessment of Injection Practices In India: An IPEN Study

20. Magnitude of Vaccine Injections in India-I * Of the no. of injections recd in last 3 months; how many were vaccine injections. Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

21. Magnitude of Vaccine & Curative Injections at different Health Facilities(as per reason given for last injection) Assessment of Injection Practices In India: An IPEN Study Assessment of Injection Practices In India: An IPEN Study

22. Magnitude of Plastic Syringe Use(as a Proportion of Last Injection Given) Assessment of Injection Practices In India: An IPEN Study

23. Areas of unsafety • Using equipment of doubtful sterility • Reusing unsterile injection equipment • Unsafe injection giving habits Assessment of Injection Practices In India: An IPEN Study

24. Characteristics of unsafe Injection: All India Assessment of Injection Practices In India: An IPEN Study

25. Characteristics of unsafe Injection: Govt. Health Facility Assessment of Injection Practices In India: An IPEN Study

26. Characteristics of unsafe Injection: Private Health Facility Assessment of Injection Practices In India: An IPEN Study

27. Characteristics of unsafe Injection: Immunization Clinic Assessment of Injection Practices In India: An IPEN Study

28. Magnitude of Plastic Syringe Use(as a proportion of past injection given - health facility wise) Assessment of Injection Practices In India: An IPEN Study

29. Characteristics of unsafe injections: health facility wise Assessment of Injection Practices In India: An IPEN Study

30. Sterilization & Disposal profile Assessment of Injection Practices In India: An IPEN Study

31. Sterilization Equipments & Fuels at Health Facilities * Sterilizer / Pressure Cooker/ Autoclave** Kerosene /Gas / Wood / Oil / Electricity Assessment of Injection Practices In India: An IPEN Study

32. Definition: Acceptable terminal disposal of injection related waste If used plastic syringes were disposed using ONE of the following methods; • Buried in a pit. • Carried away by municipal/panchayat workers for proper disposal. • Sent to incinerator. Assessment of Injection Practices In India: An IPEN Study

33. Acceptable Terminal Disposal of injection related wastes at health facilities(as observed by investigators) Assessment of Injection Practices In India: An IPEN Study

34. Health facilities selling plastic injection waste to rag-pickers Assessment of Injection Practices In India: An IPEN Study

35. Summary & Points to Ponder Assessment of Injection Practices In India: An IPEN Study

36. Magnitude of Injections in India & Its Implications Yearly burden (Y Hutin) Assessment of Injection Practices In India: An IPEN Study

37. Summary & Points to Ponder - II • 60% of of injections administered at the country level are unsafe. • Safety of injections is poorest at immunization clinics. • Use of glass syringes increases unsafety by over 20% as compared to plastic syringes. • Use of glass syringe is maximum at immunization clinics Assessment of Injection Practices In India: An IPEN Study

38. Determinants of unnecessary injections(from qualitative data) • Prescribers / Injection givers : -‘Prescribing unnecessary injections is quite common’ - to satisfy patients - for quick relief - to make money - to maintain credibility & keep practice floating - influenced by the medical representatives - to clear stock of injectables lying in stores - patients demand for injections • Prescribers even give distilled water injections at times, to satisfy patients’ demand • More by the quacks & PPs and in home setting Assessment of Injection Practices In India: An IPEN Study

39. Summary & Points to Ponder - IV • 73% of all injections administered in the country use plastic syringes and/or needles • Rural areas 68% • Urban area 77% Assessment of Injection Practices In India: An IPEN Study

40. Summary & Points to Ponder - V Disposal of injection related waste • Acceptable waste disposal at health facilities level 65% • Acceptable terminal waste disposal 47% Assessment of Injection Practices In India: An IPEN Study

41. Magnitude of Injections In India@Location of Injection @ Estimate based on 3 month recall Assessment of Injection Practices In India: An IPEN Study

42. Points to Ponder - VII Issues related to unsafety can be categorized under: Assessment of Injection Practices In India: An IPEN Study

43. Thank you Assessment of Injection Practices In India: An IPEN Study

44. Timeline[Communication of Results] Assessment of Injection Practices In India: An IPEN Study

45. Acceptable method of waste disposal (as observed by Investigators) Assessment of Injection Practices In India: An IPEN Study

46. Terminal Disposal of wastes at health facilities Assessment of Injection Practices In India: An IPEN Study

47. Timeline[Communication of Results] Assessment of Injection Practices In India: An IPEN Study

48. Summary & Discussion Points -I

49. Summary & Discussion Points -II

50. Summary & Discussion Points -III