It is not common that India comes in for approving mention when health indications are in question. Mission Indradhanush (MI), a Central government initiative launched three years back in December 2014 with an aim to achieve full immunization, has managed to get its share of attention and international adulation. This is including a reference in a 2017 report of the Johns Hopkins Bloomberg School of Public Health.
Mission Indradhanush was designed as a booster vaccination program in 200-odd under-served districts with low immunization coverage, to ensure that all children under the age of two and pregnant women are fully immunized against seven life-threatening diseases – tuberculosis, poliomyelitis, hepatitis B, diphtheria, pertussis, tetanus and measles.
The word 'Indradhanush' was chosen to represent the seven vaccines that are currently included in the Universal Immunization Program against these seven diseases – the number has since risen to 12 with the inclusion of vaccines against measles, mumps and rubella (MMR), rotavirus, Haemophilus influenzae type B, pneumococcus and polio. In a select few states and districts, vaccines are also provided against Japanese Encephalitis.
The importance of the government is attaching to the program was clear when last year in October 2017, during the run-up to the Gujarat Assembly polls, Prime Minister Narendra Modi launched the upgraded version of the MI project – the Intensified Mission Indradhanush that aims to reach the last 'unreached' child. For the intensified MI, 1,743 districts and 17 cities were identified, aiming to reach 'full immunization' by December 2018. According to the National Family Health Survey 4, the vaccination coverage in the country is a mere 65 per cent.
In the three phases of the Intensified MI so far (usually held between the 7th and 14th of each month), health workers have covered approximately 4.5 million 'unreached' children – those who have never been vaccinated – and have fully vaccinated approximately 1.2 million children . They have also reached approximately 1 million pregnant women. The four phases of Mission Indradhanush, until July 2017, had reached approximately 26 million children and around 6.8 million pregnant women in 528 districts across the country.
According to the Government's Integrated Childhood and Immunization Survey, the first two phases of Mission Indradhanush led to a 6.7 per cent annual increase in immunization coverage as compared to the 1 per cent increase in the past. At those rates, the country would take a quarter of a century to reach the target of 90 per cent coverage.
MI happened with no additional resources from the Center. When it was first mooted, states raised the demand for extra vaccines but Dr. Pradeep Halder, often hailed as the brainchild of the immunization program, argued that since vaccinations are procured with the entire birth cohort in mind, those meant for children who are not covered “should be somewhere in the system”. About 10 per cent could be presumed wasted, but the rest of states would have to fish out. They did that and out of this experience was born ' eVIN '.
eVIN (Electronic Vaccine Intelligence Network) is an indigenously developed technology system in India that digitizes vaccine stocks and monitors the temperature of the cold chain through a smart phone application. The innovative eVIN is currently being implemented across twelve states in India. eVIN aims to support the Government of India's Universal Immunization Program by providing real-time information on vaccine stocks and flows, and storage temperatures across all cold chain points in these states. The technological innovation is already being implemented by the United Nations Development Program (UNDP) and has been categorized as a global best practice. Teams from Philippines, Indonesia, Bangladesh and Thailand are now preparing to roll it out in their own countries.
Future Challenges & Opportunities –
The picture is not all that rosy. Health officials have reasons to worry. There is fear that MI is taking the emphasis away from the routine immunisation (RI) project. While MI is only meant to supplement RI, some states have started reporting consolidated figures for RI and MI that not only takes away from a realistic assessment of MI but also raises fears of the booster shot replacing the primary. There are concerns that because of the emphasis on MI and now Intensified MI, states will push resources into this and the routine immunization program will suffer.
The first 2 phases of MI had led to an increase in immunization coverage by approximately 7 percent. Micro-planning needs to be strengthened so that all children and pregnant women, especially those in far-flung areas and high-risk habits are covered. The biggest challenge is the deadline India has set for itself, that is, of bringing down the target date (for 90% immunization coverage) from 2020 to December 2018. This means that the Intensified MI would have to reach out to the protests in the most remote locations in a limited timeframe. However, it is easier said than done. A major barrier in achieving this target is the deeply ingrained cultural issues and religious beliefs and general lack of formal health communication at the ground level (village households).
MI is a strategy to strengthen RI. MI must lead to capacity building of frontline health manpower for providing quality immunization services. Massive campaigns have been carried out for MI which has led to an increased awareness on immunization and encouraged inclusiveness. Most importantly, MI in areas which were previously left out of RI has led to these areas being integrated into RI micro-plans and taking immunization services closer to the people than ever before. An integrated RI plus MI (and now Intensified MI) has provided much needed impetus to the national immunization program.
Is achieving 100% target possible for India?
Achieving 100 percent immunization coverage requires persistent and sustained efforts because new cohorts of children who have to be immunized are added continuously. There is always a high probability that small proportion of children may not be covered since best possible efforts due to reasons like migration (for work), among other factors. Here, there can never be a target date for achieving 100 percent coverage. The aim should probably be to attain and sustain the immunization coverage across the country at 90-95 percent levels.
Vaccination is one of the surest methods of ensuring healthy children and ever a healthy nation. As per the direction of the Prime Minister of India, the goal of Intensified Mission Indradhanush is to increase the immunization coverage to 90 percent by the end of this year. This can be achieved only when we reach out to those 'unreached' children who are left out of routine immunization sessions.
A public health program, let alone child immunization program, even globally, has never targeted such a large population in such diverse geographies. The only way ahead is to focus on the most backward districts. What is significant is India does not need money to push these things forward but unwavering focus and meticulous planning and implementation.