Several types of healthcare units operate in India at varying scales and offering various services. We conducted contextual inquiries to assess stakeholder needs.

Understanding context of immunization:
Below are the observation exercises conducted at four kinds of clinics:
- Private clinic
- Trust funded multi-facility hospital
- BMC run Primary Health Centre (our focus) (add mumbaiphc.jpg here)
- Government funded multi-facility hospital and medical college.

Findings at private clinic
• Volume received: 
At the most 10 to 15 parent-child pairs daily.

• Demographic: 
Upper-middle income families.

• Experts available:
Pediatrician, gynecologist (Timings differ, see patients with prior appointments).

• Services provided at the clinic: 
Pre and post natal care of pregnant women, delivery of babies and immunization of young children, blood tests.

• Immunizations administered: 
All the vaccines recommended in UIP programme as well as those by the Indian Academy of Pediatrics. No vaccines/services are provided for free.

• Immunization Protocol: 
Seek prior appointment before visiting the clinic for immunization- health-check up and immunization by the doctor, entry of immunization data in the card by the doctor.

• Observations:
At a private clinic with upper-middle income demographic, parents visited for immunization of their children with prior appointments or seek on-the-spot appointments after arrival at the clinic. They came and waited in the seating area, until the nurse calls out their name. The clinic is air-conditioned and although not very big, there is sufficient seating space and the ambience in pleasant. Once their turn comes, they meet with the doctor, in the doctor’s cabin. This cabin ensures privacy and personal attention to the parents without any distractions while discussing with the doctor.

The doctor himself checked the baby and weighed it before immunization, giving parents the necessary instructions. He noted down the immunization details for the dose administered as well as plotted baby’s growth progress on the growth chart. This private hospital provides parents with a laminated hard stock paper immunization card that doubles up as a file to hold papers related to baby’s healthcare needs. There is no clinic side copy of this data in the immunization file. When I asked a parent waiting his daughter’s turn to be immunized he said, he had never thought of backing up the immunization data himself. When I asked him what would happen in event of loss of this file, he was stumped for answers. He however made a note of creating an excel sheet at home to back up this immunization data. When asked how the parents remember date of next visit - he said he used cell phone reminders.

Findings at Trust funded multi-facility hospital
• Volume received:
Massive, thrice a week on days of routine immunization or well-baby clinics.

• Demographic:
Lower and middle-middle income families.

• Experts available:
Pediatrician, gynecologist, Family planning counsellors.

• Services provided at the clinic:
Pre and post natal care of pregnant women, delivery of babies and immunization of young children, blood tests, family planning advice and free contraceptives.

• Immunizations administered: 
All the vaccines recommended in UIP programme for free. Additional recommended vaccines are provided against purchase by parents.

• Immunization Protocol:
Queue up way before clinic opening time- get queuing token number for waiting in the seating area-babies are weighed according to token number - waiting again in the weighed baby queue for turn of immunization-after immunization collect immunization card submitted to the health worker/nurse for recording details- deposit clinic side.

Findings at BMC run Primary Health Centre (our focus)
• Volume received:
Substantial, twice a week on days of routine immunization between 10 am to 12 pm

• Demographic:
Low and lower-middle income families.

• Experts available:
1 doctor and health workers.

• Services provided at the clinic: 
Immunization only.

• Immunizations administered:
Free compulsory vaccines recommended in UIP programme only.

Immunization Protocol:
- Queue up - way before clinic opening time - Deposit card at the reception window - weigh the baby - card remains at the reception - Baby is taken to the nurse for immunization with a chit made by health worker at reception desk regarding immunization to be administered - Immunization takes place - Collect the card without fail, from reception window on your way out - Health worker at the reception window will remind about date of next visit.


Findings at Government funded multi-facility hospital and medical college.
• Volume received:
Massive, daily, Monday to Saturday.

• Demographic: Low income families.

• Experts available:
A team of 2 doctors who are also professors in the medical college, a team of senior medical students and nurses apart from senior doctors who are available in case of serious cases

• Services provided at the clinic: 
Pre and post natal care of pregnant mothers, delivery of babies and immunization of young children, also facilities for children with terminal illnesses such as AIDS and Cancer

• Immunizations administered:
Free compulsory vaccines recommended in UIP programme only.

• Immunization Protocol:
Get child’s case files from the reception - queue up for child’s health check-up - team of pediatricians will check the child for illness etc and prescribe medicines- they will check home-based immunization card for the previous immunization and note current immunization to be administered onto another prescription- queue up for weighing the baby- when turn comes undress the baby, baby is weighed, dress the baby- queue up outside immunization room- enter room handover card to 2 nurses one reading from the card other making entries- she will note down details of immunization in the home based card as well as make a copy of the same details in the clinic side register- baby is immunized by third nurse- mother is given relevant instructions and asked to sit outside holding the baby and send her companion into the immunization room- mother’s companion comes in- nurses tell him/her about date of next visit and any other instructions regarding immunization or care of the baby.

Observations at three types of facilities mentioned above have been clubbed together here as they were found to be identical:

Facilities where vaccines available under UIP programme are given for free receive substantial to massive parent turnout during routine immunizations. The ratio of health care workers to number of children immunized is skewed hence giving personal attention to queries of each parent is very difficult.

Parents' lack of awareness:
It was observed that often young and first-time mothers visit the hospital for vaccination of the baby, without having any detailed knowledge about vaccination and or its significance. Young mothers also showed less confidence in holding the baby, carrying it from one point to the other in the immunization process. Most women visit vaccination centre with a responsible family member such as husband, mother-in-law, elder sister, for company.

Thus even if a mothers holds the child while it receives immunization, the health-care workers prefer giving further instructions to the accompanying individual. Thus the mother isn’t fully involved in the vaccination process.

Repetition of instructions: 
Health-workers were found repeating these instructions for each and every mother.
• How to hold the baby as depending on the site of immunization, the way the baby is to be held changes.

• What clothing is appropriate for baby depending on the season? 
• Not to breast-feed the child for the next 10 minutes after polio drops had been administered. In their experience this had caused children to vomit.

• To press the cotton wad at the site of immunization and not to not let go of the baby for a while as the wound of immunization continues to bleed for a bit, if not pressed shut with a piece of cotton.

• After immunizations, the babies were likely to get fever and health-workers told each mother that she should give her child medicine for fever thrice a day.

• Parents were also encouraged to get rid of old stock of fever medicine at home and use fresh one. As fever medicine was not covered by immunization program (though it is one of the side-effects seen in some babies) parents were less likely to throw out dated medicines for fear of ‘wasting’ them.

BMC run Primary Health Centre (our focus). Image credits: Shishir Bhagade