Evaluation of Immunization Services for Children of Migrant Workers Along Thailand-Myanmar Border: Compliance with Global Vaccine Action Plan (2011-2020)

"[C]hallenges such as increased workload of local public health officers, language barriers, lack of vaccination record, and high turn-over rate of the volunteers should be considered when implementing such a program."

Immunisation is recognised as a core component of the human right to health. However, accessibility to the Expanded Program on Immunization (EPI) can be a challenge among migrant children. In the Tak province, along the Thailand-Myanmar border, vaccination coverage among migrant children was estimated to be only 56.7% in 2013. This study aims to assess the vaccination coverage of migrant children in this area under a mobile immunisation programme, initiated by the Thai government in 2014. Moreover, the researchers investigate satisfaction with immunisation services among different stakeholders and offer recommendations based on their experiences.

There are approximately 300,000 Myanmar migrants living and working in the Tak province, about 90% of whom are illegal migrants that do not have access to health services. To put in place the EPI in an attempt to reach them (and others), the Tak Provincial Health Office has worked closely with non-governmental organisations (NGOs) in the area; in remote areas where accessibility is difficult, community health volunteers have been trained to administer vaccines to migrant children under their coverage areas.

A cross-sectional, mixed-methods study was conducted in 5 districts along the Thailand-Myanmar border during July-December 2018. For the quantitative study, trained data collectors (interviewers) visited every household with children aged 12-60 months in 75 out of 172 randomly selected clusters (villages) and obtained vaccination records from the children's immunisation cards (if available) or other reliable records. For the qualitative aspect of the study, participants were purposively selected to participate in focus group discussions (FGDs) that included mothers/guardians, vaccine providers, and local health vaccine policymakers.

The mothers/guardians of 1,707 migrant children participated in the survey, which indicated that, overall, there was an increasing trend of vaccination coverage for all the recommended vaccines during 2014-2017, although this did not reach the EPI target of 90%. The highest vaccination coverage was observed for Bacillus Calmette-Guérin (BCG) vaccine, with 83.2% coverage in 2017. However, among the children of migrant workers in remote areas, overall vaccination coverage was only 18.3% in 2014 and increased to 39.5% in 2017.

Qualitative findings:

• The majority of those who received the vaccines were satisfied with the immunisation programme for migrant children. They appreciated that health officials came to offer the vaccines near their workplaces, because traveling to health facilities was the main challenge for them to receive vaccines for their children. They reported that health officials always informed them about the types and numbers of vaccines that were given. Although the migrants perceived the importance of immunisation, they did not remember what type of disease could be prevented by the vaccines.
• Community health volunteers, who play a major role in providing mobile vaccination services to migrants, said they felt proud of their responsibilities, though they had to work elsewhere to earn money. They suggested that training courses on immunisation should be conducted every year for new volunteers.
• The Thai health workers, who usually provide vaccination delivery services to migrant students in migrant learning centres, were less satisfied with the programme, citing the increased workload. They suggested that there should be migrant health volunteers in each community who could coordinate with the health workers to remind and motivate their fellow migrants to attend the next vaccination appointment. Moreover, they indicated that interpreters should be provided in migrant communities to assist their work.
• Local health vaccine policymakers said the main challenge for providing the immunisation service was the lack of communication among health authorities between Myanmar and Thailand. "To address this situation, a coordinating platform and structure between Thailand and Myanmar health officials, as well as related NGOs, should be established. Regular meetings should be conducted among healthcare workers in villages along the border on both sides to share and learn practical experiences together."

Based on the findings, recommendations include:

• Community health volunteers could be the contact persons who help to establish communication pathways between migrants and public health officers. In this study, about half of the migrants were illiterate and could not read the vaccination records of their children. Without a language barrier, community health volunteers should be able to find migrant children who did not receive vaccination in their community. In addition, the volunteers could provide health education and set up appointments for the next vaccination.
• Vaccination cards among the migrant population should be well designed. Because these people may move around between Thailand and Myanmar, the international vaccination card with different languages (Thai, Myanmar, and Karen) would be helpful to track a child's vaccination records. In this study, about 20% of the migrant children who were approached did not have a vaccination card because it was either lost or damaged. The vaccination card must be durable enough for migrants to carry it with them.

The researchers hope that findings from this study provide insights for EPI planning and implementation among this hard-to-reach population.