Project Assistance Completion Report -PACR 
Pan-American Health Organization PAHO, Grant 520G-00-01-00022-00 
May 2004 
I. BASIC ACTIVITY INFORMATION 
Date of Award: August 3, 2000 
Completion Date: September 30, 2003 
Implementing Agency: Pan American Health Organization PAHO 
Total Amount Authorized: US$ 600,000.00 
Total Amount Expended: US$ 583,766.00 
Counterpart Contribution 
Ministry of Health Contribution: US$ 2,852,000.00 
PAHO Contribution: US$ 133,544.00 
Others: US$ 2,007.00 
Counterpart Total = US$ 2,987,551.00 
II. INTRODUCTION 
In the mid-1980's the Ministry of Health (MOH) and international donors began a 
partnership to improve childhood immunization rates in Guatemala. During the 
meeting held in Canada in 1999, "XIII Reunion del Grupo Técnico Asesor de la 
OPS sobre Enfermedades Prevenibles por Vacunacion ", Haiti and Guatemala 
were pointed out as priority countries due to the large number of susceptible 
children that placed these two countries in high risk for serious measles outbreaks. 
Despite a positive trend in overall immunization rates, coverage for specific 
diseases was still under the minimum required to halt epidemic outbreaks. 
USAID provided PAHO with $600,000 to implement this activity, with the basic 
purpose of improving immunization rates throughout Guatemala, especially in 
communities with high risk of measles and other immune-preventable diseases. 
The main objectives included: 
a) Increase national immunization rates by at least 10-15% for each of the key 
antigens (DPT3, polio and measles) as measured by the MOH information 
system (SIGSA). 
b) Reduce the number of municipalities at high risk of measles and other diseases 
(DPT, polio and tetanus) through improved coverage rates as measured by the 
MOH information system (SIGSA). 
c) Provide technical assistance/training to local level health providers to improve 
the quality and use of an early warning system (epidemiological surveillance 
system) for vaccine preventable diseases. 
d) Improve the cold chain, including assistance to health areas and health districts 
to improve/maintain refrigerators and thermoses. 
e) Promote mothers' understanding of the importance of immunizations and 
improve their compliance with recommended immunization schedules through 
a two-pronged approach of better counseling services in health facilities and 
better information, education and communication (IEC) programs at the local 
level; this included a special effort to develop linguistically and culturally 
appropriate IEC materials. 
Substantial improvements in coverage rates for key diseases were achieved as 
shown in the following Accomplishments. 
III. MAJOR ACTIVITY ACOMPLISHMENTS 
By the completion date on September 30th 2003, progress was made toward the 
project purpose and objectives. The major accomplishments and performance 
indicators for each of the specific results were: 
a) Result No. 1: Immunization Coverage Increased Nationwide with Emphasis in 
High-Risk Areas 
The target was to increase coverage at least 10% over the 1999 baseline. There was 
a sustained increase in immunization rates for all vaccines from 2000 to 2003. The 
accumulated coverage, due to horizontal immunization services (permanent 
provision of vaccines), improved in health facilities. Baseline data for OPV3 and 
DPT3 in 1999 was 88% and rose to 94% in 2004. In 1999 the measles baseline was 
83% coverage and it reached 94% in 2000. MMR vaccine (mumps, measles, 
rubella) was introduced in 2000 (86%) instead of the prior vaccine for measles 
alone. It reached 94% coverage in 2003. Substantial improvements were achieved 
in selected geo graphic areas with high percentage of Mayan population such as 
Huehuetenango, Totonicapan, Quetzaltenango, Quiché, Sololá, Petén and Alta 
Verapaz . 
The percentage of municipalities with immunization coverage of 80% or less, was 
reduced from 10% (2000) to 6% (2003); for MMR the municipalities with 
coverage of 80% or less, were reduced from 22% to 9% in the same period. The 
abandon-rates between 2000 and 2003 for DPT3/Measles and BCG/Measles were 
reduced to 6% and 7% respectively. 
b) Result No. 2: Early Warning Systems (Epidemiological Surveillance) are 
Functioning in High-risk Areas 
There are important process indicators that need to be achieved for measles 
eradication and to maintain the polio eradication certification. The target was to 
achieve at least 80% satisfaction of surveillance indicators for suspected cases of 
measles (6 indicators) and acute flaccid palsy for polio (4 indicators). 
In the case of measles surveillance, five out of six indicators achieved or surpassed 
the standard of 80% satisfaction: 1) case notification, increased from 515 
suspicious cases in 2001 to 601 in 2003; 2) case investigation in 48 hours or less 
was accomplished in 98% of cases; 3) correct sampling process was achieved in 
99% of cases; 4) samples arriving to the laboratory before 5 days, increased 
significantly from 59% in 2001 to 78% in 2003, considering the complex transport 
and logistical aspects involved in this indicator 5) proportion of laboratory results 
provided in four days or less, increased from 87% to 93% in the same period; 6) 
notifying municipalities was 46% in 2001 and 52% in 2003, notifying units was 
36% in 2001 and 31% in 2003. Follow up of this indicator requires effective 
coordination and agreement on roles and responsibilities between the 
Epidemiology Department, National Immunization Program (PNI in Spanish) and 
SIGSA information system at the MOH central level, plus effective Health 
Area/district supervision. 
For acute flaccid palsy surveillance for polio, three out of four indicators achieved 
the expected level of satisfaction: 1) number of cases reported, increased from 65 
cases in 2000 to 101 cases in 2003, active surveillance and past year review 
supported this significant improvement; 2) case investigation in 48 hours or less 
was accomplished in 91% of cases; 3) correct sampling process increased from 
74% in 2000 to 91% in 2003. This level is well above the international requirement 
and reflects improved national capacity to detect wild poliovirus if at any time it 
would be introduced again to the country; 4) weekly reporting from notifying units 
was 53% in 2003, as well as the measles negative reporting indicator, which 
depends on coordination and role definition among several MOH central level 
offices. 
Overall, there has been progressive improvement in complex surveillance 
indicators, faster reporting processes, prompt case investigation and improved data 
quality. 
c) Result No. 3: Community Participation and Vaccine Acceptance are 
Increased. 
In the case of measles and MMR vaccines, coverage rates increased in 
municipalities with more than 75% of Mayan population. Coverage rose from 84% 
in 2000 to 92% in 2003. DPT had no significant variation, because in 2000 the 
coverage was already over 90%, achieving 91% in 2003. Information, education 
and communication (IEC) strategies were implemented to increase vaccine 
demand and acceptance. Mayan language materials were developed and 
community participation was actively promoted. The most significant achievement 
is related to equity, i.e. improved vaccine access for the underserved Mayan 
population in priority municipalities. 
d) Result No. 4: Immunization Cold Chain Functioning Properly 
The training target related to cold chain norms was achieved in 100%, 89% of 
trainees had 80 points or more in post-test evaluations. Seventy three (73%) of all 
health facilities updated their cold chain inventory every quarter. Monthly 
monitoring of vaccine loss was performed; the application of emergency plans was 
also constant. 
e) Result No. 5: National Immunization Program is Properly Managed 
Managerial capabilities have been transferred to national counterparts and now all 
management, technical and logistic aspects related to programming, surveillance 
and training are developed by PNI personnel. 
As a direct consequence of USAID support the PNI has management indicators to 
conduct a situation analysis to monitor program performance. Furthermore, on an 
annual basis, the PNI develops and distributes programmatic guidelines for the 
national and local levels; these standardized guidelines are shared with national 
and international institutions, public sector, NGOs and private sector 
organizations, promoting an integrated response for immunization interventions. 
To improve coordination and effectiveness of the PNI, an Executive Immunization 
Committee was created. Members include, but are not limited to: PNI, MOH 
monitoring unit (USME), Epidemiology Department, SIGSA, National Laboratory, 
pharmaceutical product control unit and surveillance unit, social communication 
limit, service provision units (UPSI-UPSII), INCAP and PAHO. SIGSA forms 
were revised to improve data quality and the arrival time of information from 
health facilities to the central level was substantially reduced. 
National Immunization Program personnel have the necessary skills to develop 
risk assessments, stratify intervention areas, use electronic tools and determine the 
most effective responses for national or local levels. Besides they have been 
enabled to apply improved investigation methodologies i.e. active search in 
epidemiologically silent areas/units, rapid assessments. MOH/PNI has been 
successfully represented at international meetings that monitor country and 
regional level commitments and targets related to immunization. 
IV. LESSONS LEARNED 
ƒ It's not necessary to change the MOH reporting system to achieve significant 
improvements in the quality of information and thereby have a positive effect on 
coverage rates. The existing system, functioning at an optimum level, provides 
reliable information about coverage rates at the national, area and municipal levels, 
per vaccine type, number of doses and monthly coverage. This monthly reporting 
analysis with feedback to health facilities need to be continued and strengthened. 
ƒ Surveillance systems for Measles and Polio are strong within the MOH, and meet 
international and national standards. MOH personnel exercise a leading role that 
needs to be recognized and encouraged. The political priority given to these 
interventions needs to be reflected in adequate resource allocation. Active case￾study research and negative-case notification are important strategies that improve 
surveillance data; these need to be continued. When it comes to surveillance, clear 
roles for laboratory, program and implementing units, are key to achieve expected 
results. 
ƒ Administrative load and management style prevalent in the MOH make it difficult 
to further improve a single program's performance such as PNI. Frequent and long 
meetings, no delegation of authority, personnel rotation, lack of follow up to 
previous agreements, absence of induction to post mechanisms, etc. are limitations. 
One managerial best practice to be continued is the provision of annual 
standardized guidelines for health area and municipal levels. Also the use and 
analysis of management indicators at the program level needs to be continued. 
ƒ Although the "salas situacionales" (health information situation rooms) are 
developed, their analysis focuses on the latest data. No trend analysis or 
managerial aspects are discussed. There is no follow up of previous agreements. 
This weakness is not only associated with immunization but all other aspects 
analyzed in the "salas situacionales"; follow up to previously determined actions 
needs to be assured. 
ƒ Stratification of municipalities and communities based on coverage and 
demographic criteria is an effective tool to improve coverage rates and equity. 
National guidelines that were developed to characterize and rank municipalities 
should continue to be applied and improved. 
ƒ Efficient management and logistic control of existing cold chain at the local level 
remains a challenge; its follow up depends on constant supervision to ensure 
compliance with programmatic and normative guidelines. 
ƒ Coordination within MOH units and between institutions (INE, SIGSA, 
Epidemiology, PNI) needs to be continued and strengthened. In terms of 
notification units and surveillance, the commitment of other actors such as the 
Epidemiology Department, is key to success. 
ƒ Interventions need to be supported by BCC (behavior change communication) and 
promotion activities adapted to local conditions and needs. Cultural considerations 
and language constraints are key elements for a successful BCC and promotion 
strategy. Adequate technical support, resources and monitoring need to be 
continued for this component. Community participation must be continuously 
encouraged and improved, not only for vaccination activities but for surveillance 
and situational analysis. 
ƒ A common weakness throughout the MOH is the quality and coverage of 
supervision; it focuses on crisis actions, Technical aspects are not adequately 
covered, mentoring is absent and coordination with service providers is not 
systematized. This needs a more holistic approach and integral improvement 
within the MOH. 
V. FINANCIAL CLOSEOUT AND AUDITS 
De-obligation of unspent funds: notification was received from PAHO that 
US$16,233.96 were not spent. 
Counterpart Contribution: PAHO and the MOH fully complied with 
counterpart obligations. 
Audits: According to Standard Provisions of PIO Grant Agreements, the Grantee 
is audited according to PAHO audit regulations and procedures. 
VI. SOURCES OF INFORMATION 
PAHO Grant No. 520-0428.00.01 
PAHO Grant amendments 
PAHO Grant final report. 
PAHO final financial report 
PAHO grant counterpart reports 
VII. KEY CONTACTS 
Pedro Luis Castellanos, PAHO Country Representative 
Irene Leal, PAHO Project Officer 
Patricia Juárez, PAHO Financial Officer 
7a Ave. 12-23, Zona 9 
Edificio ETISA 3er. nivel 
Ciudad de Guatemala, 01009 
Telephone: (502) 2332-2032 
Fax: (502) 2334-3804 
Lucrecia Peinado, USAID/G-CAP Project Officer 
la Calle 7-66, Zona 9 Edificio Plaza Uno 
Ciudad de Guatemala, 01009 
Telephone: (502) 2332-0202 
Fax: (502) 2331-1472