Although vaccination cards or home-based records (HBR) are stored in a child’s home (as their name suggests), the health program often focuses on how health workers use these cards and not the role of parents and caregivers as their primary holders. Through Gates Foundation-funded work in Benin, DRC, Nepal, and Zimbabwe, JSI has been exploring how to improve the availability and use of HBRs for various users – health workers, community mobilizers, health administrators, and parents. We’ve learned that often parents are not aware of the importance of the vaccination cards or the need to preserve them. In some cases, parents never receive the card. But when the card’s purpose is explained to parents or caregivers, they protect them as a valuable record.
Improving access, use, and affordability of the cards is a priority for the health system. It is critical that health workers record vaccinations that the child has received and communicate and record return dates for subsequent services. Although health workers and programs assume that parents do not have their child’s card because it was lost or left at home, data shows that HBR stock-outs are common and frequently children do not receive cards in the first place. In Zimbabwe, we spoke to mothers who were sent to purchase a notebook when the facility had run out of cards. There were also issues around costs. In Kinshasa (DRC), mothers said they were charged for cards that the health facility was supposed to provide for free. In Benin, cards have been historically sold by facilities at a low cost, with these funds used to pay for reprinting; however, a newly introduced card is much more expensive and may be cost-prohibitive for many parents. In Kinshasa, health workers held cards at the facility as a way to track defaulters so parents were not able to take the cards home until their child was fully vaccinated. Each of these examples can result in parents not having cards and therefore lacking access to health information for their children.
Once a parent receives a card, they need to protect it and bring it when coming to the health facility. In Nepal, the 2011 DHS showed that while 91% of children had received a card, only 34% had the card on the day of survey. To better understand the issues, we conducted focus groups with caregivers and key informant interviews with health workers. We heard that often health workers did not request cards when parents came for services and parents were unaware of the card’s purpose. One mother said, “I thought the card is of no importance after immunizing the babies, so I lost it.”
In Nepal, the 2015 Immunization Law states that cards are required for school entry and, in a country where many individuals travel internationally for work or school, cards are also required as proof of vaccination at the border. Parents must be informed of their value when they receive it from the health worker and have that message reinforced on subsequent visits to ensure that they will protect their child’s card. As part of our work in Sindhuli district in Nepal, these messages were shared by health workers during vaccination sessions, in community mother’s meetings, and through PSAs on local radio stations. In a later assessment of these interventions, a mother explained that the card was important because “We can know which vaccines the baby received and which are left so we can confirm either our child is fully immunized or not.”
In Zimbabwe, we heard from parents who were told that they needed to keep the card safe as it may be required in the future and serves as the legal source of the child’s vaccination. In result, they made sure to bring it every time they visited the health facility. Other mothers who traveled with their husbands for work and visited multiple health facilities had their cards as proof of which vaccinations their child received and was due for next when visiting a new facility. Without the card, their children may have been revaccinated or never receive life-saving vaccines. A challenge, however, was that due dates for next vaccinations had not been systematically recorded. In several facilities, we trained health workers to record the due date information (in a new “return date” section) and communicate it to parents. Mothers shared that this helped them know when to return by looking at the dates themselves or asking a neighbor to read it for them if they are illiterate. One illiterate mother explained that even though she could not read the card herself, she could identify blank spaces on it indicating her child was not yet fully-immunized and she needed to continue coming to the facility.
In other countries, such as Madagascar, vaccination records are in an integrated Maternal and Child Health booklet that includes health messages to guide health workers and community mobilizers in counseling parents. This helps reinforce the importance of the card with parents and provides important information on vaccinations and other health services. It is important, however, that vaccination information is not overlooked in larger integrated booklets and that updating the other content in these books does not inadvertently cause delays in their printing or distribution and result in stock-outs.
It is the right of every parent to know which health services their child has received, which is particularly important for vaccinations and the immunization program. HBRs provide this documentation and serve as long-term records. Communicating the value of vaccination cards to parents is necessary to ensure its proper use, long-term retention, and for parents to demand access to these important documents.