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  1. Jay Rajgopal
  2. Service delivery
  3. Tuesday, March 14 2017, 05:23 PM

I was wondering if someone with experience on the subject could comment - even very generally - on daily arrival patterns of individuals (children) seeking routine immunizations (WHO-EPI vaccines) at health clinics in low and middle income countries? Are these pretty steady throughout the day or do there tend to be more arrivals at certain times of the day compared to others? Are there differences in these patterns depending on geographic location (urban, rural, etc.) and on time of the month/year? In adddition to anecdotal evidence, can anyone point me to any academic or other studies with data or findings that might provide information on this?

Thanks much for any pointers - I am working with some colleagues to try and mathematically model immunization processes at health clinics and an important step in this is to try and understand how daily demand arises over time.


Kshem Prasad Accepted Answer

I would like to invite all to also reflect on the other areas of curative services provided often by the same staff who is doing immunization. For a more efficient and people friendly service delivery, the health staff should not be stressed and loaded beyond what we would ourselves wish to have.

While we lack the skills and techniques to motivate the field staff in a sustainabnle manner, the managers should ensure that they do not add to their demotivation, specially in health centres scarce of HR.

  1. more than a month ago
  2. Service delivery
  3. # 1
Jay Rajgopal Accepted Answer

Thank you all (especially Mike Favin...) for your responses - these are quite illuminating. I have heard of the "morning crowd" phenomenon from other practitioners in the field, but did not realize the variety of reasons for this! It also appears that behavior varies by country and by geographic location (urban vs. rural).
Most analytical approaches will show that we can always plan better and will always provide higher service levels if demand is spread out uniformly over the day. I realize of course that this is easier said than done, but I am sure that any steps/procedures/inducements aimed at reducing "pockets" of crowding and uneven demand during the day will service (the same total) demand more effectively.



  1. more than a month ago
  2. Service delivery
  3. # 2
prabirkc Accepted Answer

Since small sub centres (in Indian villages) have no cold chain, they have weekly or even monthly days for immunization. If the staff are regular, patients line up before the health worker arrives- hoping to reduce the harrassment experienced.

In big hospitals unfortunately, a similar weekly schedule is followed with consequences that Mike Favin has described. That is reflected in James' experience too

Jay seems to have expected something like what happens in private urban clinics. Obviously parents prefer this- especially in cities when their preferred time is not that of normal hospital hours. In a small sub centre 11 am may be close to the time a worker returns home from the fields or finishes housework.

One issue with private clinics is that given small immunization numbers their cold chain may not be ideal and open vials may be common- so how do they give BCG or Measles for instance without raising costs?


  1. more than a month ago
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mfavin Accepted Answer

I’ve become more aware and concerned with this issue, which is usually manifested as morning-overcrowding in health facilities, over the last year or so. I’ve observed the situation in three different African countries, which I can describe briefly.

Overcrowding in one country (not Mozambique) was said to be due to mothers (and reportedly health workers also) believing that the vaccine becomes weaker after a couple of hours out of the refrigerator.

In another country, the issue seems to be that the health workers tell mothers to come early if they want to be sure they'll be served. A couple of people told me that health workers do this because they want to finish early and leave early. Facilities were also more crowded on Mondays (due to children who became ill over the weekend) and Fridays (people wanting care before the weekend and mothers bringing their babies for BCG on the only day when most facilities offered it).

There was massive morning overcrowding in health facilities in the third country. When I asked about the reason, people said that the mothers wanted to come early and finish early so they could get on with their other daily tasks. Another reason is that food supplements are available early on some days.

There are at least three serious, negative consequences to this morning over-crowding:

l. The dozens, even hundreds, of waiting caregivers and children stress the health workers, who feel pressure to work quickly and find it difficult to take any breaks.

2. The health worker has little opportunity to pass on key information (on the return date, side effects, etc.) to the caregiver, much less to invite questions or concerns from the caregiver.

3. Caregivers, mostly mothers with their young children, often have to wait in hot, crowded conditions without a place to sit for many of them.

In summary, the situation appears to be widespread, but the main reasons may vary from place to place. Thus, finding ways to reduce overcrowding should start with gaining an understanding of the causes in each setting.

Mike Favin

  1. more than a month ago
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  3. # 4
craig burgess Accepted Answer

Dear Jay,

This is an interesting question and I am not sure there is a straight forward answer. My colleague Mike Favin recently returned from Mozambique and there was some anecdotal that mothers prefered earlier mornings as there was a perception the vaccines may not be as 'potent' later on in the day if kept out of the cold chain. Note this is only a perception.

In Viet Nam my experience, like yours, in the highlands or areas with ethnic minorities working in agriculture made it hard for services to be utlized eary in the morning, and in some instances health workers had to visit the fields as mobile teams to reach the women. However in urban Hanoi, there was more of a need for early morning sessions before people started their city jobs - this varied by wealth levels though.

I think each context is so different it is hard to generalize, but you make a good point and also good topic for research - its about putting the customer first - what times of day suit? There may be need for afternoon or evening sessions, but of course then it comes down to staff incentives and availability.

Hope this helps.



  1. more than a month ago
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  3. # 5
James Cheyne Accepted Answer


Thank you for your question. It sounds like you may be onto some useful information that could influence clinic opening hours.

I regret that I have no data - only an observation. While taking part in a 30-cluster immunization coverage survey some years ago in a Mumbai slum I visited over 140 homes before finding the required seven eligible children. I had two surprises:

1. All seven children were fully immunized

2. All were immunized in private sector clinics

After further questioning I learned that the people from the slum can't afford to go to the free government clinic because it was only open during working hours and the slum dwellers couldn't afford to take the day off work.

Food for thought?

Thank you for your question!

  1. more than a month ago
  2. Service delivery
  3. # 6

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