New Delhi: Two in five infants nationwide did not receive complete immunisation, leaving them susceptible to disease. An intensified effort focussing on lagging districts is crucial to improve the lives of millions of children and, consequently, their ability to learn and earn as well as their peers and to contribute to the economy.

Mission Indradhanush, launched in December 2014, aimed to ensure 90% of infants would be vaccinated by 2020. Under Intensified Mission Indradhanush 2.0 (IMI 2.0), the second phase of the initiative launched on October 31, 2019, immunisation is set to be carried out in 271 districts across the country where fewer than 70% infants are currently vaccinated.

The scheme, which aims to achieve the target by March 2020, will especially focus on 652 blocks across 109 districts in Uttar Pradesh (UP) and Bihar--both among India’s worst performers on immunisation coverage.

To have received all basic vaccinations, a child must receive at least one dose of BCG vaccine, which protects against tuberculosis; three doses of DPT vaccine, which protects against diphtheria, pertussis (whooping cough) and tetanus; three doses of the polio vaccine; and one dose of the measles vaccine.

Immunisation has reduced deaths below the age of five, health ministry data show: In 1990, 3.3 million children below the age of five died. This fell to 1.2 million in 2015.

Nearly 47% of India’s poorest children are not fully immunised, 17 percentage points more than the richest children, according to national health data, leaving them prone to preventable disease and their households susceptible to catastrophic health expenditure, as IndiaSpend reported in September 2019.

This is critical in India where nearly 71% of families did not have a single member covered by health insurance by 2016, according to National Family Health Survey, 2015-16. This percentage is higher for the poorest families, with approximately 78% of families being uninsured. Indians are the sixth biggest out-of-pocket health spenders in the low-middle income group of 50 nations, we reported in May 2017. These costs push around 32-39 million Indians below the poverty line every year, according to various studies.

Immunisation campaigns for 30 years, yet low coverage

Government immunisation programmes have been carried out for 30 years, according to a January 2019 report of the Ministry of Health and Family Welfare (MoHFW). Yet, immunisation coverage grew at the rate of 1 percentage point per year, data show. India’s vaccination coverage grew from 35% in 1992-93 to 62% in 2015-16. Only 16 districts in India have a coverage of over 90%, the ministry said during the launch of IMI 2.0, citing an independent survey.

Due to initiatives such as Mission Indradhanush, the rate of growth rose to 6 percentage points over the past five years, the report said. This rate improved to 7 percentage points, the ministry claimed during the launch of IMI 2.0.

As of March 28, 2019, across 75 districts in UP, 17.5 million children and 4.9 million women were immunised under Mission Indradhanush, union health minister Harsh Vardhan told the Lok Sabha (lower house of Parliament) on July 26, 2019. In Bihar, 1.7 million children and 383,000 expectant mothers were immunised across 37 districts, he said.

Poor performance of Uttar Pradesh and Bihar

Two in five infants (aged 12-23 months) in Bihar and nearly every second infant in Uttar Pradesh did not receive complete immunisation, according to data from the National Family Health Survey, 2015-16 (NHFS-4), the latest available data.

Despite concerted efforts since 1989, when Universal Immunisation Programme was launched, UP and Bihar continue to perform poorly.

In 2005-06, more than three in four (77%) infants in UP were not fully immunised. This improved, as we said, to 48.9% by 2015-16. The issue persists across the state’s villages and urban centres: 46.4% of children in urban areas and 49.6% in rural areas were not fully immunised.

Similarly, in Bihar, 67.2% infants had not been fully immunised as of 2005-06. A decade later, this number improved to 38.3%: the proportion of those not fully immunised improved to 40.3% in urban areas and 38.1% in rural areas.

“It is not merely a matter of percentage; now it is seen where a majority of children have missed out on immunisation,” Ved Prakash, general manager, Immunisation and Children’s Health of National Health Mission, Uttar Pradesh, told IndiaSpend. “The number of such children is largest in Uttar Pradesh. This is the reason why the government has focused on UP in the second phase. At times, the data is encouraging but vis-a-vis the population, the number of children who have not been immunised is larger.”

UP has improved significantly, Ved Prakash said, citing data from the union health ministry’s Health Management Information System (HMIS): As of 2019, 87% infants had received full immunisation.

A World Health Organization monitoring report of October 2019 pegs this number at 83% after third-party evaluation, Prakash said. “Since 83% is still not satisfactory and far behind 90%, we need to do a lot more work on our campaign,” he added.

Migration could also be a reason for UP and Bihar’s poor coverage, Prakash said. “Mostly, children of migrant labourers miss out on immunisation.”

Intensified Mission Indradhanush 2.0

Under Mission Indradhanush, 33.9 million infants and 8.7 million expectant mothers were immunised across India’s 680 districts, the government said.

When it became evident that this scheme would not achieve its goal of 90% coverage by 2020, the government launched the Intensified Mission Indradhanush in 2017 under which efforts were made to reach children who had not received immunisation fully or partially. Within a year, the scheme reached 50 million infants, the government said. As of 2017-18, India’s immunisation coverage rose to 86.7%, according to HMIS data.

IMI 2.0 will focus on, as we said, 271 districts nationwide--chosen based on current coverage, and prevalence of vaccine-preventable diseases. Under this scheme, 12 types of vaccines are included, of which 10 will be used throughout the country: immunisation against TB, pertussis, tetanus, polio, diphtheria, measles, rubella, hepatitis-B, meningitis and pneumonia caused by haemophilus influenza type B and rotavirus.

The other two--Japanese encephalitis vaccine and pneumococcal conjugate vaccine--will be administered in areas where these diseases are prevalent.

Lack of awareness, misinformation are key challenges

The biggest reason for low coverage is a lack of awareness about the benefits of immunisation, Ashwini Kumar Chaubey, Minister of State for Health and Family Welfare, told the Lok Sabha on June 21, 2019. Other reasons include side-effects immediately after vaccination (such as a fever), misinformation about vaccines, migration of families, refusal to get vaccinated and shortcomings in implementation of the scheme, he added.

Vinita (she uses only one name), 34, has been working as an auxiliary nurse midwife (ANM) in Sambhal block of UP’s Moradabad district for five years. She faces difficulty in explaining the benefits of immunisation, Vinita told IndiaSpend. “Women do not get their children vaccinated without permission from their mother-in-law or husband,” Vinita said. “We have to convince the entire family. Many people argue that since they themselves did not get vaccinated, there is no need to get their children or grandchildren immunised.”

“People agree to administer the BCG vaccine, but since other vaccines are stronger and may cause a fever, people think the vaccine causes ill health,” she added. “Still, people agree to one or two vaccines. When I visited one home for the fourth vaccine, the mother chased me out with a shoe.”

Fiza Parveen, 40, working as ANM in Moradabad’s Sirsi village since eight years, concurred, adding that her biggest challenge is convincing Muslims. “Less educated Muslims living in backward areas believe that if they get vaccinated, their children will not be able to bear progeny,” she told IndiaSpend. “They argue that religious scriptures do not say vaccination is required when children do not have a disease.”

There is a need to use new methods to spread awareness, Prakash of the National Health Mission told IndiaSpend. “We have started identifying areas where children do not get vaccinated and where families are prone to refuse vaccination. At the local level, we organise awareness meets in which we praise children who have received full immunisation.”

“This has been happening since a long time,” he added. “Now, we have trained ASHA (accredited social health activists) and anganwadi workers for social mobilisation. Along with this, street plays are performed in some districts, and information is written on walls, etc. We have also started using social media for spreading awareness.”

The focus of awareness campaigns has shifted to explaining the dangers of disease, Prakash said. It is necessary for information and awareness of new vaccines to reach people, he added. “It is important to tell people that there are new vaccines, not only for BCG but also for diarrhoea and pneumonia.”

Costs expected to rise

Between 2018 and 2022, India’s immunisation drive will cost Rs 52,220 crore ($7.3 billion), according to the comprehensive multi-year plan released by the MoHFW. This is 52% more than the Rs 34,336 crore ($4.8 billion) the country had spent between 2013 and 2017.

Between 2000 and 2018, the Global Alliance for Vaccines and Immunization (GAVI), a public-private collaboration of the Bill & Melinda Gates Foundation, the World Health Organization, UNICEF and the World Bank, provided $749.6 million (Rs 5,318 crore) to India to introduce new vaccines and strengthen India’s health system. GAVI is ending its financial support to India after 2020.

In 2017-18, India spent Rs 6,864 crore ($970 million) on its immunisation programme. Of this, the government spent 79% while the remaining 21% was funded by partners and donors, data show. GAVI contributed about 14%.

Compared to 2017, India’s immunisation programme is expected to cost 80% more by 2022, when the country would need to spend Rs 12,364 crore ($1.74 billion) on vaccines and shared personnel costs.

First published here on IndiaSpend Hindi.

(Tiwari is a principal correspondent with IndiaSpend.)

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Sadhika Tiwari

    Sadhika is a development journalist based in New Delhi. She has covered public health, gender issues and environment during her journalism career, which started with her internships during her undergraduate studies with organisations like NDTV 24x7, Asian Age, Gaon Connection and Economic Times. She has previously worked with GoNews, India's first app-based news channel as an anchor and senior correspondent where she also covered the 2019 general elections from the hinterlands of India. She holds an honours degree in Journalism Bachelors from Delhi University.