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This paper presents findings from a study conducted in 2007 and 2008 in two states in India: Andhra Pradesh and Gujarat. The objectives of the study were to: (i) design effective and appropriate HPV vaccine delivery systems for 10-to 14-year-old girls; (ii) design a communication strategy for HPV vaccine delivery; and (iii) devise an HPV vaccine advocacy strategy.The study populations included girls, parents, and local-, district-, and national-level stakeholders. A mixture of group discussions, visual representation techniques, face-to-face interviews, desk and health facility record reviews, field observations, and consultative workshops were used to collect the data.Study findings showed that the policymakers, health care providers, parents, and adolescents were aware and concerned about cervical cancer; would welcome vaccination if safe, effective, affordable, and accessible. Health systems did not require large infrastructure investments to introduce HPV vaccine; basic cold chain and logistic equipment were available. New outreach systems for adolescent girls need to be tested through demonstration projects. No policies would compromise the introduction of HPV vaccination.An HPV vaccine program, requiring public education and provider training, could be delivered. Policymakers' safety and vaccine efficacy concerns can be addressed through targeted advocacy efforts. Three broad approaches were suggested: (i) merge HPV vaccination with already established immunization services; (ii) package HPV immunization with adolescent health services or as a part of a cancer control service; and (iii) deliver HPV vaccinations through either routine immunization services or a campaign using schools as sites for school-going girls and anganwadi or village health centers for non-school-going girls.

The immunization service delivery support (ISDS) model was initiated in Andhra Pradesh, India, in November 2003 with the aim of strengthening immunization services through supportive supervision. The ISDS model involves a well-established supervision system built upon the existing health infrastructure. The objectives of this approach are to: (1) identify areas of high performance and those that need improvement, (2) assist staff in identifying and correcting wrong practices, (3) improve staff skills, (4) motivate staff, and (5) initiate corrective actions at appropriate levels through information sharing. An evaluation of cost and effectiveness of ISDS in 16 districts that participated in the programme found that the incremental cost associated with three rounds of supportive supervision visits was approximately US$ 110 630 (US$ 36 877 per round). The performance of health centre and immunization sessions was evaluated using 43-and 28-point checklists, respectively, and demonstrated significant improvement during and following the twoyear implementation of ISDS. The average percentage change in health centre performance scores from baseline to the fourth round of evaluation was approximately 36%, and immunization session performance scores increased by an average of 9%. The incremental costs per additional per cent increase in average health centre performance score and per additional per cent increase in average immunization session performance score over the evaluation period were estimated to be US$ 3091 and US$ 12 760, respectively. The incremental cost-effectiveness ratios are relatively sensitive to personnel and travel costs. Integration of ISDS into the Andhra Pradesh immunization system is projected to result in a 39% potential cost savings per round of supervision visit. Diptheria, Pertussis and Tetanus) coverage nationally and at least 80% DPT3 coverage in every district by the year 2005, the "90/80 goal" adopted by the GAVI Alliance.2 Supportive supervision involves on-site training by supervisors, which promotes quality at all levels of the health system by strengthening relationships within the system, focuses on the identification and resolution of problems, and helps to optimize the allocation of resources. The approach also promotes continuous improvements to the quality of care by providing leadership and support and by promoting high standards, teamwork and better two-way communication.3 Different approaches to supportive supervision to strengthen health worker performance and health services have been developed and documented. For instance, an integrated health package to guide essential health service delivery was developed by the United Republic of Tanzania Ministry of Health following health sector reform in 1999. This included a plan to bring a team of supervisors to district health facilities to evaluate how services are being delivered, to provide feedback and to conduct on-site training.4 Since implementation, supervisory visits occur more frequently and have become an opport...

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