Performance Audit Report

PAO-2017-04

SCHOOL-BASED
IMMUNIZATION PROGRAM

Delayed procurement of Td
vaccines and low parental
consent resulted in the non-
immunization of 1.065 million
or 64% of enrolled Grade 1
students and 0.998 million or
63% of enrolled Grade 7
students in 2016
Audit
November 2017
SCHOOL-BASED IMMUNIZATION PROGRAM

Highlights Delayed procurement of Td vaccines and low parental consent

resulted in the non-immunization of 1.065 million or 64% of enrolled
Why COA did this study Grade 1 students and 0.998 million or 63% of enrolled Grade 7
students in 2016
The Department of Health (DOH) launched
the School-based Immunization Program What COA Found
(SBIP) in 2013 to ensure prevention of
morbidity and mortality of school age The SBIP intends to provide all public school students enrolled in Grades 1 and 7
children due to vaccine-preventable nationwide with booster doses of routine vaccines to ensure that high level of protection is
diseases. Government funds amounting to maintained against measles, rubella, diphtheria and tetanus. Only students with parental
at least ₱330 million and ₱282 million were
consent are vaccinated. While the program aims to immunize all students in the said
allocated for the nationwide immunization
grade levels, achieving a 95% immunization target was already considered a success
campaign in 2015 and 2016, respectively.
DOH claims success at 95% immunization
following the principle of herd immunity.
coverage of public school students enrolled
in Grades 1 and 7. Thus, the need to For 2015 and 2016, the SBIP failed to achieve the immunization rate target in both
determine whether DOH is making progress Measles Rubella (MR) and Tetanus Diphtheria (Td) vaccines for Grades 1 and 7. While
in achieving its goals for the program. there was an increase of 12% in MR for Grade 1 from 60% in 2015 to 72% in 2016, the
rates for Grade 7 did not change at 72%. The Td vaccination rates of 73% and 72% in
In order to confirm the aforementioned 2015 for Grades 1 and 7, respectively, dropped to 36% and 37% in 2016.
assumptions, COA (1) identified the
program’s goals and objectives and the Figure1: Immunization Rates in 2015 and 2016
extent these goals can be measured; (2)
determined the fund allocation, extent of
utilization and whether these were enough to
procure the required type and quantity of
vaccines; and (3) determined the extent the
program achieved its immunization goals
and the extent of participation of partner
agencies in achieving these goals.

COA reviewed relevant guidelines, reports

and regulations to determine the program
goals, objectives and implementation
processes. To assess the extent of
program’s success, program implementation
for 2015 and 2016 was reviewed taking into The decline in immunization rates for Td was caused by lack of Td vaccines during the
consideration the principles of efficiency, campaign period in 2016. The gap of at least 20% between actual immunization rate and
economy and effectiveness. Areas that the target rate was mainly attributable to students not vaccinated in the absence of
were looked into included, among others, parental consent.
procurement of vaccines, inventory
management, participation of partner
Increasing awareness on the benefits of the program particularly for the parents and
agencies, fund utilization and reporting of
accomplishment. guardians will lower the number of students without consent. Apparently, the absence of
communication plan and lack of coordination efforts among partner agencies and
appropriate information materials to ensure high coverage impacted the attainment of the
What COA Recommends
target.
To increase the immunization coverage and
The timely procurement of vaccines aimed at ensuring their availability in time for the
attain the herd immunity target, DOH in
coordination with DepEd need to minimize
vaccination period was not achieved in 2016 for Td vaccines due to late initiation of
students without parental consent by procurement activity and failure to address the issues that caused delay in the
adopting and implementing, among others, procurement. In addition, no policy on maintenance of buffer stock was enforced to
an appropriate communication plan and answer for delay in the procurement of vaccines.
strengthening coordination efforts among
partner agencies. DOH needs to undertake The noted deficiencies in the reporting system for the Nationwide Accomplishment Report
its procurement plan as scheduled and (NAR) particularly on completeness of submission, accuracy of data reported and
address immediately any issue that may consistency in reporting impacted the efficiency and accuracy of data and information
hinder the availability of vaccines in time for needed for decision-making.
the vaccination period. There is also the
need to improve procurement planning and
inventory management, accomplishment
Control on the utilization of resources could not be maximized in the absence of separate
reporting and financial recording to promote inventory management and financial recording for the program. The challenges noted did
efficient, economical and effective program not contribute to the efficient, economical and effective implementation of the SBIP.
implementation and accountability of
program managers.
PAO-2017-04
 School-Based Immunization Program

Contents

Letter 1
Background 2
Supply of sufficient vaccines not ensured during the
vaccination month 4
Target immunization coverage not attained 8
Absence of communication plan for effective coordination
and information dissemination 11
No separate program budget and recording of expenditures
depriving Management with relevant information on the
efficient utilization of resources committed to the
program and the accountability of program managers 13
Deficiencies in reporting impacting on the efficiency,
accuracy and completeness of data in the Nationwide
Accomplishment Report 15
Poor inventory management as manifested in lack of
uniformity in computing the quantity of vaccines for
procurement, deficiency in maintenance of inventory
records and vaccine utilization not accounted and
reported 20
Conclusions 23
Recommendations 24
Agency Comments 25

Appendix I Accomplishment Forms 26

Appendix II Computation/Comparison 29

Appendix III Department of Health Management Comments 31

Appendix IV COA Contact and Staff Acknowledgements 33

Tables Table 1 : Funds allocated and actually obligated/expended for the

SBIP
Table 2 : Accomplishment Report on Td Vaccination by Region
Table 3 : Detailed Immunization Rates for 2015 and 2016
Table 4 : Percentage of Students Without Parental Consent on
Vaccination at NCR for 2016
Table 5 : Schedule of 2015 Sub-Allotments and Obligations for Other
Operating Expenses of DOH Regional Offices
Table 6 : Regional Office which Requested for Allotment for Other
Operating Expenses of SBIP
Table 7 : List of Schools where Number of Students Vaccinated
Exceeded the Number of Enrolled Students
Table 8 : List of Schools which Data were Taken-up Twice in the 2015
Nationwide Accomplishment Report
Table 9 : Comparison between the DepEd Masterlist and the Number
Enrolled Students in the Nationwide Accomplishment Report
Table 10 : Analysis of 2016 and 2017 procurement of vaccines
Table 11 : Analysis of utilization of available MR vaccines for 2016
Table 12 : Computation of Excess MR Vaccines in the NCRO

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 School-Based Immunization Program

Contents

Figures Figure 1 : Immunization Rates in 2015 and 2016

Figure 2 : Actual Vaccination of School Children under DOH SBIP
Figure 3 : Actual Procurement Timeline and Issuance of Td Vaccines
to DOH Regional Offices/Provincial/City Health Units
Figure 4 : Students Vaccinated with Td
Figure 5 : 95% Target vs. Actual Immunization Coverage
Figure 6 : Percentage of Total Students With and Without Consent on
Vaccination at NCR for 2016
Figure 7 : Flow of Accomplishing and Submission of the Report Forms
Figure 8 : Survey Results
Figure 9 : Flow of Receipt and Distribution of Vaccines
Figure 10 : Recording Form 1: Masterlist of Grade 1 Students
Figure 11 : Recording Form 2: Masterlist of Grade 7 Students
Figure 12 : Reporting Form: Regional/Provincial/City Consolidated
Accomplishment Form Report

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 School-Based Immunization Program

Abbreviations

AEFI Adverse Effect Following Immunization

APP Annual Procurement Plan
ARMM Autonomous Region in Muslim Mindanao
BAC Bids and Awards Committee
CAR Cordillera Autonomous Region
CARO Cordillera Autonomous Region Office
CHO/U City Health Office/Unit
COA Commission on Audit
DepEd Department of Education
DILG Department of Interior and Local Government
DM Department Memorandum
DO Department Order
DOH Department of Health
DPCB Disease Prevention and Control Bureau
EPI Expanded Program on Immunization
FHRP Family Health and Responsible Parenting
FT Fund Transfer
GVAP Global Vaccine Action Plan
HPCS Health Promotion and Communication Service
HPV Human Papillomavirus Vaccine
IEC Information, Education, and Communication
ISSAI International Standards of Supreme Audit Institutions
LCEs Local Chief Executives
LGUs Local Government Units
MCV Measles Containing Vaccine
MHU Municipal Health Unit
MOA Memorandum of Agreement
MR Measles-Rubella Vaccine
NAR Nationwide/National Accomplishment Report
NCR National Capital Region
NCRO National Capital Region Office
NTP Notice to Proceed
OIC Officer-In-Charge
PO Purchase Order
PHO Provincial Health Office
PPMP Project Procurement Management Plan
PR Purchase Request
PTA Parent-Teacher Association
RD Regional Director
RF Recording Form
RHU Rural Health Unit
RITM Research Institute for Tropical Medicine
ROs Regional Offices
SAAs Sub-Allotment Advices
SAOB Statement of Allotments, Obligations and Balances
SBIP School-Based Immunization Program
SOE Summary Of Expenses
Td Tetanus-diphtheria Vaccine
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 School-Based Immunization Program

Abbreviations

ToT Training of Trainors

TWG Technical Working Group
WMCHDD Women’s Men’s and Children’s Health Development
Division
WHO World Health Organization

Page iv PAO-2017-04
Republic of the Philippines
COMMISSION ON AUDIT
Commonwealth Avenue
Quezon City

November 23, 2017

DR. FRANCISCO T. DUQUE III

SECRETARY
Department of Health
Tayuman, Manila

Dear Secretary Duque:

In line with its vision to become an enabling partner of government in

ensuring a better life for every Filipino, the Commission on Audit (COA)
conducts performance audits to help government agencies better perform
their mandates and achieve program goals and objectives more
economically, efficiently and effectively.

Pursuant to Section 2 (2), Article IX-D of the 1987 Constitution which vests
COA the exclusive authority to define the scope of its audit and
examination, and establish the techniques and methods required therefor,
the COA Chairperson issued Office Order No. 2016-962 dated November
9, 2016, creating audit teams to conduct performance audits on selected
priority programs/projects of the government. COA has identified the
Department of Health (DOH) Immunization Project for Schools as one of
the priority programs to be audited.

The audit aimed to: (1) identify the program’s goals and objectives and the
extent these goals can be measured; (2) determine the fund allocation,
extent of utilization and whether vaccines procured were sufficient for the
target beneficiaries; and (3) determine the extent the program achieved its
immunization goals and how the identified partner agencies participated in
achieving these goals.

The School-Based Immunization Program (SBIP) was allotted at least

₱330 million and ₱282 million in 2015 and 2016, respectively, for the
immunization of Grades 1 and 7 students enrolled in public schools
nationwide against Measles, Rubella, Tetanus and Diphtheria diseases.
The audit covered the program implementation in 2015 and 2016.

We reviewed the applicable laws, rules, regulations and related guidelines

to SBIP implementation. We interviewed key officials and requested for
clarifications to better understand the process by which DOH plans,
implements and oversees the program. We also looked into the
documentation related to SBIP which included, among others,
procurement documents, records of receipts and issuances of vaccines,
financial records and accomplishment reports. Likewise, ocular
inspections were conducted to check inventory management and
reporting. Lastly, survey was conducted in sample schools in the National
Capital Region (NCR) to validate the program implementation and
reporting.

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 School-Based Immunization Program
We conducted the audit from January to June 2017 in accordance with the
Fundamental Principles of Performance Auditing as embodied in the
International Standards of Supreme Audit Institutions (ISSAI) 300. The
standard requires that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.

The Expanded Programme on Immunization (EPI) of the Department of

Background Health has focused on the provision of free vaccines for infants since
1975. However, the protection provided by some of these vaccines
decline over time and booster doses of appropriate vaccines are required
to ensure that high levels of protection are maintained.1

Protected from the threat of vaccine-preventable diseases, immunized

children have the opportunity to thrive and a better chance of realizing
their full potential. These advantages are further increased by vaccination
in adolescence and adulthood. As part of a comprehensive package of
interventions for disease prevention and control, vaccines and
immunization are an essential investment in a country’s—indeed, in the
worlds—future.2

In 2013, DOH, in collaboration with the Department of Education (DepEd)

and Department of Interior and Local Government (DILG) through their
various local health units, conducted the first national School-Based
Adolescent Immunization in public schools of priority provinces and
cities where high risk and vulnerability, based on behavior and potential for
outbreak in school and community were observed.3 The National
Epidemiology Center reported the increasing cases of measles, probable
diphtheria in 2010-2011and suspected pertussis in 2011-2012 among
adolescents, thus, Measles-Rubella (MR) and Tetanus-diphtheria (Td)
vaccines were introduced as an integral immunization strategy. The
program covered all 1st year to 4th year high school students (Grade 7-10)
in public school of the priority provinces and cities.4 During the same year,
Human Papillomavirus (HPV) vaccine was introduced as one component
in the comprehensive strategy for the prevention of cervical cancer. Grade
5 female learners within the age range of 10-14 years old in selected
public schools in Region VII and Cordillera Autonomous Region (CAR)
and a private school in Region VII were given the vaccine under SBIP.5
The Adolescent Immunization was expanded in 2014 to cover all thirteen
(13) years old in-school and out-of-school adolescents.6

The SBIP was expanded in 2015 to a nationwide and yearly immunization

of all school children enrolled in Grades 1, 4 and 7 with MCV/Td, HPV and
MR/Td vaccines, respectively.7 However, a department memorandum
issued at a later date specified that the program shall only include

1 DOH Department Memorandum No. 2015-0146 dated May 20, 2015, p. 1

2 World Health Organization (WHO) Global Vaccine Action Plan (GVAP) 2011-
2020, published 2013, p. 12
3 Supra Note 1, p. 1
4 DOH Department Memorandum No. 2013-0168 dated May 16, 2013, p. 2
5 DOH Department Memorandum No. 2013-0291 dated August 6, 2013, p. 3
6 DOH Department Memorandum No. 2014-228 dated July 22, 2014
7 Supra Note 1, p. 2

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 School-Based Immunization Program
Tetanus-diphtheria and Measles-Rubella vaccines for all Grade 1 and
Grade 7 students in public schools nationwide.8

Figure 2 : Actual vaccination of School Children under DOH SBIP

Source: Cembo Elementary School, Makati City

The SBIP’s goal is to reduce the morbidity and mortality among school
children, a strategy that supports the goal on elimination of Measles and
Maternal and Neonatal Tetanus.9 The performance indicator of most
vaccine-preventable disease to achieve the control, elimination and
eradication is to achieve at least 95% administrative coverage in any
vaccine delivery point, following the principle of herd or population
immunity.10

The Guidelines in the Implementation of SBIP as embodied in the DOH

Department Memorandum issued for the purpose provides that:11

1. All school children enrolled in Grade 1 and Grade 7 shall be

vaccinated with the appropriate vaccines as specified:

a. All eligible school children (male and female) shall be screened for
their measles vaccination history at the time of school entry and
vaccinated if evidences show either zero or only 1 dose to ensure
that these students receive at least 2 MCV by school entry.

b. Administered with one (1) dose of Tetanus-diphtheria (Td) vaccine.

c. All male and female students enrolled in Grade 7 regardless of age

shall be vaccinated with 1 dose each of Measles-Rubella and Td
vaccines on the same immunization session.

2. School-based vaccination shall be a FREE routine service to be

administered by the health center catchment and the schools;

8 DOH Department Memorandum No. 2015-0222 dated July 21, 2015

9 DOH EPI (http://doh.gov.ph/expanded-program-on-immunization)
10 Letter of OIC Director III, Family Health Office-Disease Prevention and Control

Bureau (DPCB), DOH dated June 1, 2017

11 DOH Department Memorandum 2015-0238 dated July 22, 2015, p. 1-2

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 School-Based Immunization Program
3. Only students with parental/guardian consent shall be vaccinated;

4. In case of zero or 1 dose or vaccination refusal, or no immunization

card presented, the student shall not be suspended, grounded, nor
reprimanded.

To affirm the partnership of concerned agencies in the implementation of

SBIP, a Memorandum of Agreement (MOA) was entered by the DOH,
DepEd and DILG on August 3, 2015 to define therein the roles and
responsibilities of each department. DepEd and DILG are tasked to issue
their own memorandum to ensure their respective department’s active
participation to the activity of the SBIP.12

The budget of SBIP was lumped in the DOH’s Family Health and
Responsible Parenting (FHRP) – Women’s Men’s and Children’s Health
Development Division (WMCHDD) in 201513 and the Expanded Program
on Immunization (EPI) in 2016.14 The funds allocated for the SBIP
vaccines identified in the Project Procurement Management Plan (PPMP),
Annual Procurement Program (APP) and the operating expenses for the
Regional Offices traced in the Sub-Allotment Advices (SAAs), Statement
of Allotment, Obligations and Balance (SAOB) and respective Summary of
Expenses amounted to ₱330.02 million in 2015 and ₱282.02 million in
2016. Amounts obligated reached ₱186.93 million in 2015 and ₱262.75
million in 2016.

Table 1: Funds allocated and actually obligated/expended for the SBIP

2015 2016
(In million pesos) (In million pesos)
Vaccines and 178.82 231.00
Logistics
Other Expenses 151.20 51.02
Total 330.02 282.02
Obligated 186.93 262.75
Unexpended 143.09 19.27

Supply of sufficient
vaccines not ensured
during the
vaccination month
The MOA between DOH, DepEd and DILG as well as all the DOH
Department Memoranda containing the guidelines in the implementation of
SBIP explicitly state that the immunization shall be done every August of
the year.15 All Grades 1 and 7 school children enrolled in public schools
shall be vaccinated with Measles-Rubella and Tetanus-diphtheria
vaccines.16

12 Memorandum of Agreement between DOH, DepEd and DILG entered on

August 3, 2015, p. 3
13 DOH Annual Procurement Plan FY 2015 – 4th Update, p.2,4-8
14 DOH Annual Procurement Plan FY 2016 - 2nd Update, Vaccines, p.1
15 Supra Note 12, p. 1
16 Ibid., p. 1

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 School-Based Immunization Program
Under the MOA, the DOH shall designate its Assistant Secretary from the
Office of Policy and Health Systems as its national focal person and the
Chairperson of the Technical Working Group (TWG) who will oversee the
entire program implementation to include the timely distribution of vaccines
to DOH regional offices, LGUs and schools.17

In line with the Republic Act No. 9184, the DOH prepared its Annual
Late initiation of Procurement Plan (APP) for FY 2016 which provides for the schedule for
procurement activities each procurement activity18 and the public bidding as the mode of
and delays in procurement for vaccines.19 Advertisement and posting of invitation to bid
procurement process should start in January 2016 with the Notice of Award and contract signing
in March 2016.20
not addressed
Records showed that the Bids and Awards Committee (BAC) received the
undated Purchase Request (PR) for Td vaccines on March 4, 2016. The
bidding process lasted for 78 days or until May 30, 2016 upon posting of
performance security by the supplier. The Purchase Order (PO) and
Notice To Proceed (NTP), which were released by the Accounting Division
on July 1, 2016 were issued to the supplier on July 25, 2016. Late
initiation of procurement process and replacement of the signatory in the
procurement document brought about by the new administration delayed
the procurement process by about four months. These conditions which
impeded the timely procurement of vaccines could have been avoided or
readily addressed by key officials of the program taking into consideration
that vaccines should be available in time for the vaccination period in
August.

NTP was issued to the supplier on July 25, 2016 and expected delivery
date of the first batch is within 60 days upon receipt of PO and NTP by the
supplier or until September 23, 2016 and 120 days for the second batch or
November 22, 2016. Actual deliveries were received at the Storage and
Distribution Department, Research Institute for Tropical Medicine (RITM)21
from September 27, 2016 to December 20, 2016 or way beyond the
scheduled immunization month of August 2016. Actual distribution of
vaccines to DOH Regional Offices and Health Units started in October 3,
2016 and lasted until Year 2017.

17 Ibid., p. 2
18 Republic Act 9184, Revised Implementing Rules and Regulations, Annex “C” –
Recommended Earliest Possible Time and Maximum Period Allowed for the
Procurement of Goods and Services
19 Supra Note 14, p.1
20 Ibid., p.1
21 RITM Vaccine Storage Facility

(http://ritm.gov.ph/about-us/our-facilities/vaccine-storage/)

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 School-Based Immunization Program

Figure 3: Actual Procurement Timeline and Issuance of Td Vaccines to DOH Regional Offices/Provincial/City
Health Units

It was noted that the Accounting Division waited for the submission by the
Procurement Service of the updated Tax Clearance Certificate causing
delay in the release of PO and NTP to supplier.

In anticipation that Td vaccines will not be available on time, the OIC-

Undersecretary of Health, Office for Technical Services, issued the
unnumbered memorandum on July 11, 2016 providing the following:

 Conduct inventory of Td vaccines in all health facilities; and

 Strategize administration of Td vaccine by prioritizing the public

school areas where Diphtheria and neonatal tetanus cases have
been reported for the past 2 years.22

These remedial measures would not result in the attainment of target

coverage rate considering that no policy on maintenance of buffer stock of
vaccine is enforced for the SBIP.

Due to insufficient number of vaccines during the immunization period,

64% of Grade 1 and
63% of Grade 7
students not
vaccinated with Td
vaccines in 2016
only health centers/facilities with Td vaccine in stock in August 2016 were
able to administer the vaccine on priority public schools. Nationwide, only
36% of students enrolled in Grade 1 and 37% in Grade 7 were vaccinated
with Td in 2016 leaving 64% of Grade 1 and 63% of Grade 7 not
vaccinated.
22 DOH Unnumbered Memorandum dated July 11, 2016, from OIC-Usec. Bayugo

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 School-Based Immunization Program

Figure 4: Students Vaccinated with Td

It should be noted that aside from all schools in Region 2, a number of

schools in different municipalities and cities of other regions were not able
to give Td vaccines to their students. It was only in Region VI and CAR
where rates are close to the target. The low regional immunization rates
are illustrated in Table 2.

Table 2: Accomplishment Report on Td Vaccinations by Region

Grade 1 Grade 7
Region
Enrolled Vaccinated % Enrolled Vaccinated %
NCR 171,926 95,622 55.62 176,103 104,240 59.19
CAR 31,174 28,237 90.58 28,969 26,381 91.07
I 88,629 58,361 65.85 90,113 58,114 64.49
II - - - - - -
III 197,234 5,317 02.70 189,254 1,429 00.76
IV-A 226,294 10,802 04.77 216,083 25,019 11.58
IV-B 72,495 57,172 78.86 62,318 35,553 57.05
V 139,249 3,574 02.57 126,242 4,407 03.49
VI 152,639 140,471 92.03 141,774 126,432 89.18
VII 15,016 1,762 11.73 89,500 20,097 22.45
VIII 63,399 4,724 07.45 66,660 5,920 08.88
IX 77,803 29,118 37.43 73,061 46,257 63.31
X 103,365 68,281 66.06 77,455 47,407 61.21
XI 100,222 12,011 11.98 90,538 24,791 27.38
XII 103,295 16,757 16.22 80,498 13,782 17.12
CARAGA 61,392 45,637 74.34 55,773 36,220 64.94
ARMM 59,141 19,677 33.27 24,095 13,540 56.19
Total 1,663,273 597,523 35.92 1,588,436 589,589 37.12

Management commented that the bidding process was done within the
prescribed period but the Purchase Order and Notice to Proceed was not
released until the copy of the renewed Certificate of Tax Clearance was
submitted because it was then nearing expiration and the DOH Accountant
did not want to certify the funds availability until the bid documents are
complete.

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 School-Based Immunization Program
Clarification if there is any existing policy on safety measures to ensure
that sufficient quantity of required vaccines is available when needed by
the program revealed that Management just make sure that vaccines for
SBIP are procured in time for the campaign in August. For vaccine in
routine program, a buffer stock is maintained all year round. In times of
stock outs of vaccines due to failure of bidding, the buffer stocks are used.

With vaccine as its basic component, no amount of preparation such as

orientation of vaccinators, availability of logistics, obtaining parental
consent and the like would ever make an immunization program
successful without it. Considering that Td vaccines were not procured and
delivered in time for the 2016 vaccinations, this situation may still occur in
the future resulting anew in lack of vaccines during vaccination period. In
the absence of policy requiring a buffer stock of vaccines for SBIP,
Management must ensure that vaccines are procured and distributed
before August by strengthening its monitoring on the actual procurement
and distribution of vaccines. Any delay and deviation from the procurement
schedule that may impact on timely distribution of vaccines must be readily
addressed.

Insufficient quantity of vaccines during vaccination period creates a

massive impact in the program implementation leaving significant number
of students susceptible to vaccine-preventable diseases until the next
immunization period while others are totally deprived of the health benefits
from immunization.

Target
immunization
coverage not
attained
Guidelines in the Implementation of School-Based Immunization under
Actual immunization DOH Department Memorandum No. 2015-0238 dated July 22, 2015
coverage at least provides that all eligible students enrolled in Grades 1 and 7 shall be
22% below the 95% administered with appropriate vaccines.23 DOH claimed that performance
target herd immunity indicator of most of the vaccine-preventable disease to achieve the
control, elimination and eradication is to attain at least 95% administrative
primarily due to coverage. It was added that this is an evidence based goal to attain herd
absence of parental immunity.
consent and lack of
Td vaccines in 2016 Herd immunity occurs when a significant proportion of the population (or
the herd) have been vaccinated, and this provides protection for
unprotected individuals. The larger the number of people who are
vaccinated in a population, the lower the likelihood that a susceptible
(unvaccinated) person will come into contact with the infection. It is more
difficult for diseases to spread between individuals if large numbers are
already immune, and the chain of infection is broken.24

The Nationwide Accomplishment Reports (NAR) for the 2015-2016

revealed that the SBIP failed to achieve the 95% target immunization rate.
For 2015, the immunization rates for MR and Td ranged from 60% to 73%

23Supra Note 11, p. 1

24Segen’s Medical Dictionary, 2012 Farlex, Inc.
(http://medical-dictionary.thefreedictionary.com./herd+immunity)

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 School-Based Immunization Program
or 22% to 35% below the target. There was an increase of 12% in the
immunization rate for MR in Grade 1 students while the rate for Grade 7
did not change at 72%. The Td vaccination rates fell from 73% in 2015 to
36% in 2016 for Grade 1 and from 72% to 37% for Grade 7. In effect,
Grade 1 students who were not vaccinated are susceptible to vaccine-
preventable diseases until they reach the next immunization in Grade 7
while the Grade 7 who missed the chance are deprived of the health
benefits of immunization.

Table 3: Detailed Immunization Rates for 2015 and 2016

Grade 1 Grade 7
2015
MR Td MR Td
Vaccinated 1,302,171 1,576,044 1,234,985 1,236,812
Not vaccinated 853,798 579,925 484,939 483,112
Total per masterlist 2,155,969 2,155,969 1,719,924 1,719,924
Immunization Rate 60% 73% 72% 72%

Grade 1 Grade 7
2016
MR Td MR Td
Vaccinated 1,197,182 597,523 1,146,504 589,589
Not vaccinated 466,091 1,065,750 441,932 998,847
Total per masterlist 1,663,273 1,663,273 1,588,436 1,588,436
Immunization Rate 72% 36% 72% 37%
sa

Figure 5: 95% Target vs Actual Immunization Coverage

Source: DOH

The low immunization rates were attributable mainly to the policy of “No
parent/guardian consent, no immunization”. In 2016, the lack of TD
vaccines contributed significantly to low immunization rates.

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 School-Based Immunization Program
The program implementation of nationwide coverage necessitated the
collaboration of DOH, DILG and DepEd. Funds allocated and obligated
for the procurement of vaccines and logistics, expenses related to
vaccinators such as training/orientation, honoraria and cost of transporting
them to and from their assigned schools, supplies and materials for
information dissemination and other program-related expenditures, when
summed up is material in amount that had to be paid out before and/or on
the day of immunization. All the preparation effort and expended funds go
to waste when vaccines, the main component of the program, are not
available. The vaccine administration, storage and transport,
immunization safety as well as the steps of addressing adverse events
following immunization are discussed in detail in the guideline but there
was not a single section pertaining to ways to increase parent/guardian
awareness and/or consent nor remedial courses of action in case of any
event that may lead to low immunization rate.

Management admitted that the approved consent for vaccination from the
students’ parent/guardian, a policy imposed by the DepEd, hinders
achieving the desired coverage. Other reasons such as absentees,
illness, hesitancy of mothers for fear of side effects or adverse events
following immunization (AEFI) contributed to low coverage.

Management further commented that they have no intention to vaccinate

anyone of the students who missed the Td vaccines because it will be too
costly on their part and will disrupt classes and school activities being
conducted. Besides, the vaccines are mere booster doses because the
children had been vaccinated when they were younger. The Management
also stated that they will wait for the disease to happen before they do the
catch up immunization.

Clarification on the 5% rate of students that could not be vaccinated given

the 95% target revealed that it is attributed to the drop-outs mainly
because of absenteeism and contra-indication of vaccination. For
students who were absent during the vaccination period, they could be
vaccinated at the nearest health centers to prevent disruption in schools.

It is apparent that DOH is not anticipating higher percentage of students

without parental consent to achieve the herd immunity at 95%.
Considering that the highest immunization rate achieved in 2015 and 2016
was only 73%, the percentage of children without consent nationwide
could be readily estimated to at least 20%. At the NCR, the percentage of
children without consent stood at 35% for both Grades 1 and 7 in 2016.

Table 4: Percentage of Students Without Parental Consent on Vaccination at

NCR for 2016
Grade 1 Grade 7 TOTAL
Enrolled 171,926 176,103 348,029
With Consent 113,845 112,995 226,840
Percentage of Students with Consent
66% 64% 65%
to Enrolled
Percentage w/o consent to enrolled 34% 36% 35%
Sour ce :

Page 10 PAO-2017-04
 School-Based Immunization Program

Figure 6: Percentage of Total Students With and Without Parental Consent

on Vaccination at NCR for 2016

Absence of
communication plan
for effective
coordination and
information
dissemination
The tripartite MOA entered into by the DOH, DepEd and DILG on August
Partner agencies not 3, 2015 provides the rationale for the institution of an immunization
able to participate as program, the immunization period and the roles of the participating
expected due to lack of agencies. The MOA states that DOH, as the overall lead agency, shall
coordination efforts on develop communications plan including risk communications in
coordination with DepEd and DILG, among others.25
their roles particularly
on communications A Communication Plan is a document that guides organizations and
and information project workers in managing and implementing communication efforts to
reach desired goals. It is like a road map that provides a common direction
dissemination involving for people working on a project so that limited resources are maximized
stakeholders of the and communication interventions are managed well.26
program
DOH DM No. 2015-0238 was issued on July 22, 2015 to provide
guidelines in the implementation of the School-Based Immunization
Program. While the memorandum was addressed to DOH officials it
includes the roles and functions of other agencies and partners such as
the DepEd, DILG, Local Government Units (LGUs), Parents-Teachers
Association and Private Sector/ Professional Organizations.27

Consequently, the DepEd attached the said DM to its own memorandum

issued on July 31, 2015 to all concerned Directors and Heads of Units
enjoining them to provide full support in the conduct of the activity. 28
There was no indication, however, that a copy of the said DM was
disseminated to other agencies/sectors. In August 2015, the

25 Supra Note 12, p. 2

26 Asian Institute of Journalism and Communication-A Guide on Communication
Planning, March 2012, Chapter 3, p. 14
27 Supra Note 11, p. 5-6
28 DepEd Memorandum No. 82, s. 2015 dated July 31, 2015 &

DepEd Memorandum No. 128, s. 2016 dated August 16, 2016

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 School-Based Immunization Program
immunization activity was delayed in the city and province of Iloilo due to
non-receipt of the DepEd memorandum.29

On the other hand, verification from DILG revealed that it did not issue any
memorandum/circular/similar documents to carry out the department’s role
in the implementation of the SBIP of MR-Td vaccines. As a result, DILG
was not able to perform its tasks, which included, among others the
following:

a. To issue a memorandum to all the local chief executives (LCEs)

for their active participation to the activity including the
organization of the vaccination team for deployment to school
and completion of the activity and ensure high immunization
coverage per grade level.30 At the NCR, the DOH Regional Office
constituted the vaccination teams.

b. Enjoin LGUs to prepare and submit reports to DOH.31 In 2016

campaign, no reports were received from 7,140 out of 38,803
schools involving 310,856 Grade 1 students and 1,020 out of
8,282 schools or 156,000 Grade 7 students. The absence of
reports impacts on the completeness and accuracy of data used
for the computation of immunization rates for which the
performance of the program is assessed.

Likewise, the DOH DM and the tripartite MOA did not specify which party
shall conduct the orientation of the vaccination teams and of beneficiaries’
parents/guardians. This activity should be part of communication efforts to
provide common direction to vaccination teams to facilitate the conduct of
vaccination including the reporting requirements. At the National Capital
Region, it was the DOH Regional Director that initiated the conduct of
orientation. It coordinated and invited representatives from the DepEd and
DILG through the Schools Division Superintendent and LCEs,
respectively. The DepEd and DILG mobilized parents of eligible students
for orientation on the disease, program and immunization activities32 while
school authorities had made the orientation as part of the agenda in the
PTA meeting held before the vaccination day.

Need to provide readily Streamers, standees, pamphlets and advisory sheets prepared for
information dissemination purposes were in English, thus, may not be
understandable understood or appreciated by some parents/guardians. Naturally,
information materials parents/guardians will not allow their children to be vaccinated if the
benefits that can be derived therefrom are not properly explained and
understood.

Management commented that the information dissemination materials are

translated to the local vernacular but no copies of any related materials
were presented to the audit team.

DOH commented that the EPI and the Health Promotion and Coordination
Service (HPCS) call for orientation meeting/workshop to reorient
stakeholders on the activity and provide any update. The HPCS with their

29 SunStar Iloilo, August 10, 2015 by Lydia C. Pendon

30 Supra Note 11, p. 6
31 Supra Note 12, p. 4
32 Ibid., p. 3-4

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 School-Based Immunization Program
original counterparts and DepEd has consultation workshop, develops
video presentation and prototype Information, Education, and
Communication (IEC) materials for reproduction at the regional levels.
The information and materials are disseminated to the
regional/provincial/city counterparts for distribution to the schools. Further,
the school/classroom clinic teachers disseminate the information for the
immunization activity to secure the consent of parents or guardians of the
students prior the vaccination.

The audit team took note of the efforts to disseminate information on the
immunization program. As the absence of parental consent is the main
cause for not attaining the immunization target rate, there is a felt need to
enhance the existing approach to address the issue.

The absence of communication plan was manifested in the deficiencies

noted. The plan would detail the active participation of partners and
stakeholders and effective information campaign to achieve the desired
goals. Considering that immunization coverage is below the target herd
immunity, effective communication plan is necessary for the SBIP to
address the causes hindering the attainment of the target.

No separate program
budget and
recording of
expenditures
depriving
Management with
relevant information
on the efficient
utilization of
resources committed
to the program and
the accountability of
program managers
The SBIP as a program should be provided with a budget necessary to
No separate program attain its objective. Management did not provide the audit team with the
budget for SBIP program budget for 2015 and 2016.

The team noted that SBIP was a sub-program of Family Health and
Responsible Parenting (FHRP)-WMCHDD in 2015. Its
appropriation/budget was lumped in the FHRP budget and could not be
separately identified. Since the Annual Procurement Program was also
presented by major program, the allocation for vaccines and logistics
(syringes and collector boxes) for SBIP/Adolescent Health was traced to
the Project Procurement Management Plan (PPMP). However, there was
one supplemental PPMP wherein charges for the SBIP could not be
derived. Budget for other related operating expenses were traced to the
Sub-Allotment Advises (SAAs)/Fund Transfer (FT) released to the regional
offices. Summary of Expenses (SOE) or Statement of Allotments,

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 School-Based Immunization Program
Obligations and Balances (SAOB) were submitted by the Regional Offices
but some without details or object of expenditures.

Table 5: Schedule of 2015 Sub-allotments and Obligations for Other

Operating Expenses of DOH Regional Offices

Amount Amount
Region Balance
Received Obligated
NCRO ₱10,000,000.00 ₱9,536,470.39 ₱463,529.61
CARO 5,200,000.00 5,125,500.00 74,500.00
RO I 5,200,000.00 5,199,932.97 67.03
RO II 5,500,000.00 5,235,990.00 264,010.00
RO III 6,500,000.00 6,500,000.00 0.00
RO IV-A 6,800,000.00 6,800,000.00 0.00
RO IV-B 5,200,000.00 5,200,000.00 0.00
RO V 7,900,000.00 7,000,000.00 900,000.00
RO VI 8,300,000.00 8,300,000.00 0.00
RO VII 12,000,000.00 11,932,734.19 67,265.81
RO VIII 7,500,000.00 4,455,390.45 3,044,609.55
RO IX 6,100,000.00 6,100,000.00 0.00
RO X 6,000,000.00 5,990,362.00 9,638.00
RO XI 9,900,000.00 9,900,000.00 0.00
RO XII 6,700,000.00 6,693,271.00 6,729.00
RO XIII 5,500,000.00 5,340,602.28 159,397.72
ARMM 5,700,000.00 5,700,000.00 0.00
doh

The SBIP was transferred to the EPI per DOH DM No. 2015-0226 dated
July 22, 2015.33 The items in the 2016 PPMP, however, were not
categorized per sub-program. The allocation for the SBIP was identified
using the type of vaccines used by the program namely Measles-Rubella
(MR) and Tetanus-diphtheria (Td) vaccines. The allocation for SBIP
logistics (syringes) could not be derived from the total allocation for EPI.
For the regional offices, except for the regions which requested for sub-
allotments under DOH DOs 2016-0196 dated July 25, 2016 and 2016-
0221 dated August 30, 2016, others regions used their regular
appropriations to defray the operating expenses for the SBIP.

Table 6: Regional Office which Requested for Allotment for Other

Operating Expenses of SBIP

Amount Amount
Region Balance
Received Obligated
CARO ₱3,887,072.00 ₱3,493,072.00 ₱394,000.00
RO IV-B 3,351,000.00 1,587,421.72 1,763,578.28
RO VII 3,000,000.00 0.00 3,000,000.00
Source: DOH

No separate accounting Details of expenses identifiable with SBIP were requested from the DOH
Regional Accountants, however, eight out of seventeen (17) regional
of expenditures of the offices did not submit summary of expenses for 2015 and 2016.
program
In the absence of information regarding the budget allocated to the SBIP
coupled with the absence of separate recording for program expenditures,
monitoring, control and accountability over the resources committed for
the program cannot be enforced.

33 DOH Department Memorandum 2015-0226 dated July 13, 2015

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 School-Based Immunization Program
Management commented that they have maintained subsidiary records for
expenditures under the SBIP but nothing had been presented and
submitted to the audit team up to the writing of this report.

Deficiencies in
reporting impacting
on the efficiency,
accuracy and
completeness of data
in the Nationwide
Accomplishment
Report
DOH DM No. 2015-0238 dated July 22, 2015 provides specific guidelines
for the recording and reporting of accomplishment reports. It prescribes
appropriate recording and reporting forms which shall be completed and
submitted from the service delivery point to the next higher administrative
level until the report reaches the DOH Central Office.34

Figure 7: Flow of Accomplishing and Submission of Report Forms

Source: DOH

Deficiency in the Review of the reporting process and the Report Forms used revealed
Report Forms deficiencies impacting on the efficiency of reporting and accuracy of
reported data.

a) Not all data required in the consolidated report can be readily

obtained in the Report Forms and completion of these data
involves extra time and effort

34 Supra Note 11, p. 3

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 School-Based Immunization Program
 The consolidated report requires the number of deferred
students per type of vaccine for Grade 1 but this is not found in
the Recording Form 1.(See Appendix I)

 The consolidated report for Grade 1 and 7 requires the number

of refusal per type of vaccine which is not captured
separately in Recording Forms 1 and 2.(See Appendix I)

b) No process to ensure accuracy of data reported by accounting for

the number of students in the masterlist against the students given
consent and those without parental consent. Similarly, the number
of students with consent was not tallied against students
vaccinated, deferred and refused. As a result, significant
differences were not investigated or corrected. These could be
attributed to different interpretation of data to be reported.(See
Appendix II-A)

c) On the submission of report, responsible officer in each level of

implementation (School/RHU/PHO/CHO) is required to submit the
report weekly to the next level while the DOH Regional Health
Office is required to submit to the DOH Central Office after two
weeks.35 The absence of a definite period or fixed date within
which reports should be submitted by the Regional Office caused
the delay in the consolidation of data for the nationwide
accomplishment report.

The DOH NCR conducted a Training of Trainors (TOT): Orientation of

Vaccination Teams on Adolescent Immunization with DepEd Schools
Division and LGU health staff January 21-22, 2015.36 The orientation
aims to discuss the guidelines and plans for the scale up and
implementation of the School-Based Adolescent Immunization Activity in
NCR. On reporting of accomplishments, it was agreed during the training
that DepEd Division shall provide school accomplishments to DepEd
Regional Division and City Health Office, DepEd Regional Office to
consolidate and furnish copy to DOH-NCRO.

The agreed reporting arrangement was, however, different from the

manner of reporting provided in the DOH DM where school nurse shall
submit accomplished Recording Form 1 or 2 to municipal/city health unit
to provincial/regional health office to DOH Central Office.37

Such difference in understanding among reporting units as to where the

reports are to be submitted for consolidation impacts on the timely
consolidation of data for the nationwide accomplishment report.

Management commented that submission of the accomplishment reports

has been agreed during consultation workshops. Schools that conducted
the immunization are requested to submit the report to the next
administrative level and constantly be followed-up if delays exist. All
LGUs shall also submit their report to the next administrative level.

35 Ibid.
36 DOH NCRO Personnel Order No. 2014-0978 and 2014-978A dated November
17, 2014 and January 6, 2015, respectively.
37 Supra Note 11, p. 3

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 School-Based Immunization Program
Analysis of the Nationwide Accomplishment Reports for years 2015 and
2016 and the Accomplishment Reports prepared and submitted by the
NCRO disclosed not only incomplete submission of reports but also
included errors and inconsistencies in the reports that impact on the
accuracy of actual immunization coverage:

Incomplete, late a) The Nationwide Accomplishment Report as of June 16, 2017 for
submission of reports immunization year 2016 had undergone several revisions to
include reports submitted late. As of cut-off date, reports from
and errors/ 7,140 out of 38,803 or 18.40% of schools for Grade 1 and 1,020
inconsistencies of data out of 8,282 or 12.32% of schools for Grade 7 remain unsubmitted
in the reports and therefore not included in the analysis of accomplishment.
Similarly, schools which lacked data on enrolment and vaccinated
students were not included in the computation of the overall
immunization rate.

b) The errors and/or inconsistencies in the reports were noted in the

following instances:

 The reported accomplishment (number of students vaccinated)

is greater than the total enrolled students in a number of
schools.

Table 7: List of Schools where Number of Students Vaccinated Exceeded the Number of Enrolled Students

Vaccinated Difference
Region Name of School Enrolled
MR/MCV Td MR/MCV Td
2015, Grade 1
NCR A. Fernando ES 210 373 373 (163) (163)
NCR A. Mariano ES 179 264 264 (85) (85)
NCR Antonio Serapio ES 71 190 190 (119) (119)
NCR Gen. T. 1 ES 358 460 460 (102) (102)
NCR Malinta ES 164 572 572 (408) (408)
NCR Paltok ES 122 130 130 (8) (8)
NCR Paso de Blas ES 91 118 118 (27) (27)
NCR Punturin ES 163 164 164 (1) (1)
NCR Silvestre Lazaro ES 378 390 390 (12) (12)
III not provided 17,666 21,117 18,110 (3,451) (444)
III not provided 6,640 7,060 (420)
2016, Grade 1
NCR MUZON ES 91 94 (3)
VIII not provided 4,029 4,378 (349)
2016, Grade 7
VIII no data 5,869 6,001 0 (132)
VIII no data 6,964 26 (6,964) (26)
TOTAL 36,031 48,181 20,891 (12,241) (1,398)
doh

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 School-Based Immunization Program
 Double Reporting in the 2015 Nationwide Accomplishment
Report

Table 8: List of Schools which Data were Taken-up Twice in the 2015
Nationwide Accomplishment Report

Grade Vaccinated
City Name of school Enrolled
Level MR TD
Caloocan Llano High School 7 510 340 336
Caloocan Bagumbong HS 7 1,017 523 523
Caloocan Caloocan National
Science and
Technical High
School 7 136 109 109
Kalayaan High
Caloocan School 7 1,447 1,121 1,115
Taguig Bagumbayan
National High
School 7 1,028 444 443
ource: DOH

 The number of enrolled students in the DOH Nationwide

Accomplishment Report vary from the number of students per
masterlist of DepEd.

Table 9: Comparison between the DepEd Masterlist and the Number of

Enrolled Students in the Nationwide Accomplishment Report

Grade 2015
Level Per DepEd Per DOH Net Difference
1 2,110,567 2,155,969 (45,402)
7 1,713,333 1,719,924 (6,591)

Grade 2016
Level Per DepEd Per DOH Net Difference
1 1,964,338 1,663,273 301,065
7 1,782,780 1,588,436 194,344
Source: DOH

 Schools listed in the DOH Accomplishment Report not in the

DepEd Masterlist and vice-versa.(Appendix II-B)

 Errors in total enrolment and vaccinated students upon

recomputation of accomplishment reports in the NCR.

 The accomplishment reports in the NCR contain relevant

information such as number of students ‘with and without
parental consent which were not required in the prescribed
format. These information were included in the consolidation
but served no purpose because other reporting units were not
required to provide these information.

Analysis of the results of survey conducted with the Division

Superintendents, School Nurses/Clinic Teachers, LGU/City Health
Officers and Health Workers in the National Capital Region also revealed
different practices in the reporting of accomplishment reports. The DM
provides that deferred students willing to be vaccinated shall be referred

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 School-Based Immunization Program
to the health center for vaccination and reported in the health center
accomplishment report.38 Contrary to the prescribed reporting process,
59% of 41 Grade 1 school nurse respondents and 35% of 20 Grade 7
school nurse respondents claimed that they included the deferred
students vaccinated in the health centers in their report. In addition, 55%
of the 38 health center nurses did not include in their report the deferred
students vaccinated in the health centers. These deviations impact on the
completeness and accuracy of the consolidated report and the data for
the computation of the overall immunization rates.

Figure 8: Survey Results

School Nurse - Grade 1 School Nurse - Grade 7

(41 respondents) (20 respondents)

Say deferred students recorded in Nurse Report

Say recorded in RHU Report, Say recorded in both

Local Health Worker

(38 respondents)

Say that they include name of students vaccinated in the

center in Health Center Report

Source: DOH

During the exit conference, Management commented that they will review
the reporting forms for possible amendment. Accomplishment Reports will
likewise be reviewed to ensure the reliability of data captured. It was
explained that the mismatch of the list and the accomplishment reports
can be attributed to the under reporting in the service delivery points
because of the set deadline for submission of reports to the next higher
administrative level.

38 Supra Note 11, p. 2

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 School-Based Immunization Program

Poor inventory
management as
manifested in lack of
uniformity in
computing the
quantity of vaccines
for procurement,
deficiency in
maintenance of
inventory records and
vaccine utilization not
accounted and
reported
The procured vaccines are delivered by the suppliers to the DOH Central
Office Warehouse at the RITM before these vaccines are distributed to
the Regional and City Health Offices where Vaccinators Teams will
withdraw the stocks needed by the program.

Figure 9: Flow of Receipt and Distribution of Vaccines

Lack of consistency in The standing policy in determining the quantity of vaccines to be procured
is to compute for the total number of enrolled Grades 1 and 7 students of
the computation of the preceding school year based on the accomplishment reports of
vaccines to be regional offices, plus 10% buffer. The data on enrolment, however, may
procured impact on the computation since it is being based on the National
Accomplishment Report from the preceding school year which may not be
reliable unless 100% submission of report by all regions is ensured.
Existing balances at the RITM were not considered in the estimation of
vaccines to be procured. The lack of uniformity in the process of
estimation of quantity of vaccines to be procured was noted in the
procurement for 2016 and 2017. The number of Td doses expected to be

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 School-Based Immunization Program
available in 2017 was already more than double the requirement for
students in Grades 1 and 7.

Table 10: Analysis of 2016 and 2017 procurement of vaccines

MR Td Total
Particulars
Grade 1 Grade 7 Grade 1 Grade 7 MR Td
2016
Enrolled per 2015
2,155,969 1,719,924 2,155,969 1,719,924
Accomplishment Report
10% Allowance 215,597 171,992 215,597 171,992
Total 2,371,566 1,891,916 2,371,566 1,891,916 4,263,482 4,263,482
No of doses to be procured
4,000,000 5,000,000
per 2016 PPMP
Available doses for use in 2016
from existing stocks in RITM 0 898,940
(stocks in vial x 10 doses)
No. of doses expected to be
4,000,000 5,898,940
available for use in 2016
Percentage of stocks at RITM
to total requirement as buffer 0% 21%
stock
2017
Enrolled per 2016
1,663,273 1,588,436 1,663,273 1,588,436
Accomplishment Report
10% Allowance 166,327 158,844 166,327 158,844
Total 1,829,600 1,747,280 1,829,600 1,747,280 3,576,880 3,576,880
No of doses to be procured
5,000,000 7,000,000
per 2017 PPMP
Available doses for use in
2017from existing stocks in 299,400 3,576,382*
RITM
No. of doses expected to be
5,299,400 10,576,382
available for use in 2017
Percentage of stocks at RITM
to total requirement as buffer 8% 100%
stock
*Remaining Stocks as of December 31, 2016 plus undelivered units of vaccines

The team accepted the Management comment that it is not possible for
them to base the quantity to be procured on the actual number of enrolled
during the year because the procurement takes some time. APP showed
that procurement process is scheduled as early as January and it is
known that school enrollment is being done from April to May that
masterlist can only be finalized by June or July.

The team conducted ocular inspection of the vaccines at the DOH Central
Stock cards for Warehouse at the Research Institute of Tropical Medicine (RITM) last
vaccines not properly March 17, 2017 and noted that the MR and Td vaccines for the program
maintained are in good condition and the expiration dates have not elapsed. It was
noted that stock cards maintained for each type of vaccine do not indicate
to which programs they pertain to. For issuances, the requisitioning unit or
the receiving office was recorded in the stock card without specifying the
purpose or specific program for which the vaccines were issued/shipped.

Analysis of utilization of available MR vaccines for 2016 based on the

reported number of students vaccinated with 25% allowance for wastage
revealed that about 875,000 doses or 22% of the procured MR vaccines
was not utilized.

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 School-Based Immunization Program

Vaccine utilization not Table 11: Analysis of utilization of available MR vaccines for 2016

accounted and No. of doses of MR vaccines available for 4,000,000

reported 2016 vaccination period
Administered No. of doses 3,124,915
( No. of students vaccinated divided by 0.75)
or 2,343,686/0.75
Excess doses of MR vaccines 875,085
Percent of excess to No. of doses
available for 2016 21.88 %
Source: DOH

The balance of MR vaccines will further increase if the existing stocks

from 2015 balances at the Regional Offices and Health Centers are
added. As noted in the DOH NCR stock cards, there are 11,793 vials of
MR at the beginning of 2016 in addition to the receipt of 34,000 vials
before the vaccination campaign in August 2016. Out of the total balance
of 45,793 vials, 45,753 vials were issued to the City Health Offices for the
year’s vaccination requirement. Analysis showed that about 67,753 doses
or 14.81% of the total doses issued could be considered excess based on
the number of students vaccinated in 2016.

Table 12: Computation of Excess MR Vaccines in the NCRO

Total doses distributed to NCR City Health 457,530

Offices (1 vial = 10 doses)
Estimated number of students that can be
vaccinated (75% on multi-vial vaccines) 343,148
Students vaccinated
Grade 1 98,858
Grade 7 107,688
Total 206,546
Administered No. of doses 275,395
(No. of students vaccinated divided by 0.75)
or 206,546/0.75
Excess doses of MR vaccines 67,753
Percent of excess to No. of doses available 14.81%
for 2016
Source: DOH

If catchment vaccination will be undertaken by the health centers on the

identified deferred and refused students totaling 22,568 at NCR, at least
45,000 doses of MR vaccines for the program are still unutilized at the
health centers.

Ocular inspection and verification of stock cards and other related

documents at the City Health Offices of Makati City disclosed the
following:

a. One stock card is maintained for each type of vaccine intended for
different programs, thus, whether there are vaccines for SBIP
cannot be verified;

b. Entries in the stock cards are erroneous or incomplete. Not all

Receipts are recorded, only issues or reductions, and there are no
running balances to reconcile with the actual stock on hand.

c. Not all receipts and issuances are documented. No formal request

and approval is required for issuances. In one LGU, recipients are

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simply required to sign opposite the quantity deducted in the stock
card.

d. The Health Nurses in charge of the vaccine inventory was not able
to provide the accounting/report for the utilization of vaccines
under the SBIP due to lack of guidelines.

Taking into consideration that excess doses of vaccines at the Health

Offices/Units and stocks the Regional Health Offices exist, the SBIP need
to monitor and account for these vaccines to effectively manage the
procurement and inventory needed during the vaccination campaign. The
current system of inventory management and reporting does not promote
accountability of DOH officials over program resources and effective
procurement planning.

Conclusions The school-based immunization program was launched to provide booster

vaccines to school-age children to ensure that high levels of protection are
maintained because the protection provided by some of the vaccines given
to infants decline over time.39 The SBIP aimed at 95% immunization
coverage following the principle of herd immunity that at this level of
immune individuals in a population, a disease may no longer persist.

The timely procurement of vaccines aimed at ensuring their availability in

time for the scheduled vaccination month was not achieved in 2016 for Td
vaccines. In addition to late initiation of procurement activity, delay in the
procurement process was not readily addressed resulting in late deliveries
and distribution of vaccines to DOH regional offices and health centers.
Consistency in the methodology used in estimating the procurement of
vaccines was not observed. There was also no policy requiring the
maintenance of buffer stock to answer for the absence or delay in the
procurement and distribution of vaccines. The lack of Td vaccines had
resulted in the low immunization rates of 36% for Grade 1 and 37% for
Grade 7 in 2016 or about 50% decline from 73% for Grade 1 and 72% for
Grade 7 in 2015.

The immunization rates for MR had increased from 60% in 2015 to 72% in
2016 for Grade 1 while the rates remained at around 72% in the same
period for Grade 7. As these rates are way below the target immunization
coverage of 95%, Grade 1 students not vaccinated are left vulnerable to
vaccine-preventable diseases while waiting for the next immunization in
Grade 7 while those not vaccinated in Grade 7 are totally deprived of the
immunization benefits from the program.

Contributing mainly to low immunization coverage was the policy of “No

parent/guardian consent, no immunization.” Apparently, information
dissemination efforts and materials were not adequate and appropriate in
the absence of communication plan. Increasing awareness on the
benefits of the program particularly for the parents and guardians will
lower the percentage of children without consent. This percentage must
be reduced to 5% or less for the program to achieve the desired herd
immunity at 95%. There was lack of coordination among partner agencies
in the program. One of the partner agencies was not able to issue
memorandum to local chief executives for their active participation in the
vaccination activity, including the organization of the vaccination team,

39Supra Note 11, p. 1

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ensuring high immunization coverage per grade level and enjoining LGUs
to prepare and submit reports to DOH.

The noted deficiencies in the current reporting system for the nationwide
accomplishment report impact on the accuracy and completeness of data
and information where the immunization coverage is derived. Inventory
management and reporting of vaccines utilization for the SBIP was not
segregated from other immunization programs of DOH. Issuances of
vaccines were not validated against Vaccines Utilization Report and as
such, excess issuances may not be accounted as utilized for the intended
beneficiaries of the program nor considered in procurement planning.

Finally, it was noted that the SBIP budget was lumped with the budget of
the major programs of the DOH and expenditures were not recorded
separately depriving Management with relevant information on the
efficiency and economical utilization of resources and the accountability of
program managers.

The challenges noted in the implementation impact on the efficient,

economic and effective implementation of the SBIP. The gaps between the
actual immunization coverage and the herd immunity of 95% signified that
the program has yet to achieve the desired objective of the program.

Recommendations In view of the opportunities for improvement noted in the review of SBIP, it
is recommended that DOH through the EPI addresses the implementation
gaps that prevent the attainment of the immunization coverage target.

To ensure that sufficient quantity of required vaccines is available during

the once a year immunization activity, DOH needs to undertake its
procurement plan as scheduled and address immediately any issue that
may affect the timely delivery and distribution of procured vaccines to
health centers. Consider maintaining a buffer stock to answer for
unavoidable delays in procurement and adopt a consistent methodology in
determining the quantity of vaccines to be procured.

To increase the immunization coverage and attain the herd immunity

target, DOH in coordination with DepEd need to minimize the students
without parental consent by adopting and implementing an appropriate
communication plan and strengthening coordination efforts among partner
agencies particularly aimed at ensuring high immunization coverage.

The accomplishment reporting system need to be enhanced to capture

relevant, complete and accurate nationwide accomplishment report from
which immunization rate is derived and enrolment data for use in the
estimation of vaccines to be procured are obtained. Inventory
management also need improvement particularly in the maintenance of
accurate and separate information and reporting of vaccine utilization for
the SBIP to aid Management in procurement planning and decision-
making.

Lastly, DOH should provide a separate budget for the requirement of the
SBIP from which program expenditures must be accounted for to gauge
the efficient and economical utilization of resources and establish
accountability of program managers.

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Appendix I:
Accomplishment
Forms40

Figure 10: Recording Form 1: Masterlist of Grade 1 Students

40 Supra Note 11, Annexes

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Figure 11: Recording Form 2: Masterlist of Grade 7 Students

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Figure 12: Reporting Form: Regional/Provincial/City Consolidated Accomplishment Form Report

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Appendix II:
Computation/
Comparison

A. Analysis of Related Data Reported in the Accomplishment Report in

Sample Cities at NCR

NCR Accomplishment Report 2015 – Measles Rubella

Grade 1 Makati City Manila Quezon City

Students Enrolled 7,324 29,136 40,353 a

With Consent 7,030 22,085 26,744 b

Without Consent 0 7,059 10,442 c
Total 7,030 29,144 37,186 d
Difference 294 -8 3,167 (a-d)

Vaccinated MR 7,030 22,033 26,628

Deferred 23 41 359
Refusal 271 4 13,721
Total 7,324 22,078 40,708 e
Difference -294 7 -13,964 (b-e)

NCR Accomplishment Report 2016 – Tetanus Diphtheria

Grade 7 Manila Taguig Caloocan City

Students Enrolled 24,294 11,220 22,977 a

With Consent 23,200 6,376 14,447 b

Disapproved Consent 1,015 0 5,288 c
Total 24,215 6,376 19,735 d
Difference 79 4,844 3,242 (a-d)

Vaccinated Td 22,640 6,368 14,425

Deferred 584 1 2,797
Refusal 0 0 472
Total 23,224 6,369 17,694 e
Difference -24 7 -3,247 (b-e)

Comparison of data revealed the following:

i. Total number of students enrolled not reconciled/tallied with the

number of students with and without parental consent.

ii. Total number of students with consent not tallied/reconciled with

the number of students vaccinated, deferred and refused.

Significant differences not investigated or corrected. These could be

attributed to different interpretation of data to be reported.

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B. Analysis of Reported Schools in the DOH Accomplishment Report and
DepEd Masterlist in Sample Cities at NCR

Grade City/ Per DepEd Per DOH

Year Name of School
Level Municipality Masterlist NAR
2015 1 Caloocan City Tala Elementary School 427 None
2015 1 Taguig Taguig Integrated School 715 None
2015 7 Pasig City Santolan HS 677 None
2015 7 Marikina Marikina Heights NHS 341 None
Valenzuela
2016 1 Luis Francisco ES 289 None
City
2016 1 Taguig Paulina Manalo ES 138 None
2016 7 Pasig City Sta. Lucia HS 1,280 None
2016 7 Paranaque La Huerta National High School 1,028 None
TOTAL 4,895

2015 1 Caloocan City Malaria ES None 426

2015 1 Paranaque FEES - Marcelo Green None 442
2015 7 Paranaque PHNS- San Antonio None 1,184
2015 7 Las Pinas Las Pinas NHS Almanza None 837
2016 1 Manila Benigno Aquino None 623
Valenzuela
2016 1 Antonio Serapio ES None 424
City
2016 7 Manila Earist None 700
2016 7 Muntinlupa MNHS Annex None 734
TOTAL 5,370

Comparison of gathered data showed that there are schools listed in the
DOH Accomplishment Report that were not in the DepEd Masterlist and
vice-versa.

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Appendix III:
DOH Management
Comments

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Appendix IV: COA

Contact and Staff
Acknowledgments
Assistant Commissioner Alexander B. Juliano, (02) 952-5700 local 2022 or
COA Contact abjuliano@coa.gov.ph

In addition to the contact named above, Emelita R. Quirante (Director IV),

Staff Michael L. Racelis (Director III), Cecilia G. Rañeses (Team Supervisor),
Acknowledgments supervised the audit and the development of the report. Eleanor B. Pilapil (Team
Leader), Cherrie Lou C. Arguilla, Leonardo A. Bautista, Czyrhinne R. Castillo and
Krisshia D. Genio (All Team Members) made key contributions to this report with
the assistance of Priscilla DG. Rivera.

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