It is not often that India comes in for flattering mention when health indices are discussed. But Mission Indradhanush (MI), a Central government initiative launched in 2014 with an aim to achieve full immunisation, has managed to get its share of attention and international adulation, including a reference in a 2017 report of the Johns Hopkins Bloomberg School of Public Health.
Launched in December 2014, Mission Indradhanush was designed as a booster vaccination programme in 201 districts with low immunisation coverage to ensure that all children under the age of two and pregnant women are fully immunised 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 Immunisation Programme against these seven diseases — the number has since risen to 12 with the inclusion of vaccines against measles rubella, rotavirus, Haemophilus influenzae type B, pneumococcus and polio. In a select few states and districts, vaccines are also provided against Japanese Encephalitis.
The importance the government is attaching to the programme was clear when in October, during the run-up to the Gujarat Assembly polls, Prime Minister Narendra Modi launched the upgraded version of the project — the Intensified Mission Indradhanush that aims to reach the last ‘unreached’ child. The intensified mission, for which 173 districts and 17 cities were chosen, aims to reach ‘full immunisation’ — or 90 per cent coverage — 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 44.96 lakh ‘unreached’ children — those who have never been vaccinated — and have fully vaccinated 11.93 lakh children. They have also reached 9.16 lakh pregnant women. The four phases of Mission Indradhanush, until July 2017, had reached 2.55 crore children and around 68.7 lakh pregnant women in 528 districts across the country.
According to the government’s Integrated Childhood and Immunisation Survey, the first two phases of Mission Indradhanush led to a 6.7 per cent annual increase in immunisation coverage as compared to the 1 per cent increase in the past.
What adds life to these numbers are photographs from December 2017 of the Intensified MI programme. These snapshots, on the official WhatsApp group set up to monitor the project, tell the tale of a mission whose success depends overwhelmingly on the dedication of workers on the ground — from Muslim religious leaders in Patna signing a vaccination pledge to health workers tracking a group of nomads in Sagar, and Assam’s boat clinics taking the precious vaccines to far-flung islands on the Brahmaputra.
Additional commissioner in the Union health ministry, Dr Veena Dewan, who recently travelled to Maharashtra to oversee the implementation of the programme there, says, “In Solapur and Ahmednagar, the workers on the sugarcane fields are mostly migrant labourers. It was important to reach their children, who get missed out easily since their families have no fixed addresses. That is why the district administration decided to hold supplementary vaccination sessions from evening till late into the night.”
The global plaudits that the Mission received has helped to keep the workers motivated. The Pneumonia and Diarrhoea Progress Report, 2017, brought out by the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health, noted: “The original aim of MI was to immunise all children under the age of 2 years against seven vaccine preventable diseases, a number that has expanded as new vaccines are added to UIP(Universal Immunisation Programme). With MI, India actualises its vision towards equitable immunisation and demonstrates its commitment to the nation’s health.”
However, it all started off as a routine review of the immunisation programme, with two officers discussing their own experiences — one on the difficulty of containing polio on the banks of Kosi in Bihar, where the shifting river made vaccination difficult, and another banking on his experience of working with a UN organisation in Chhattisgarh. Between Joint Secretary Rakesh Kumar and then additional secretary and National Health Mission Director
C K Mishra, the duo stumbled upon the shocking fact that India’s immunisation rate was crawling at a dismal 1per cent per year. At those rates, the country would take 25 years to reach 90 per cent coverage. The duo began brainstorming and drew on their own past to frame the first contours of what would go on to become Mission Indradhanush.
It took time for the political class to warm up to the idea and results of the first round of MI were not very encouraging. For the second round, the ministry drew up district micro plans and chief secretaries were made part of the monitoring mechanism. The results were dramatic: over 56 lakh of the 92 lakh targetted children were vaccinated.
“I do not think that a programme, even globally, has ever targetted such a large number of children in such diverse geographies. The only way ahead is to focus on districts. What is important is we do not need money to push these things; we need meticulous planning,” says Mishra, now secretary in the ministry of environment and forests.
MI happened with no additional resources from the Centre. When it was first mooted, states raised the demand for extra vaccines but deputy commissioner Dr Pradeep Halder, often hailed as the brainchild of the immunisation programme, argued that since vaccines 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 the states would have to fish out. They did that and out of this experience was born eVIN.
Developed indigenously, eVIN (Electronic Vaccine Intelligence Network) digitises vaccine stocks and monitors the temperature of the cold chain through a smartphone application. eVIN is presently being implemented across 12 states and aims to support the Universal Immunisation Programme by providing real-time information on vaccine stocks and storage temperatures across all cold chain points in the states. The technological innovation is implemented by the United Nations Development Programme and has been categorised as a global best practice. Teams from Philippines, Indonesia, Bangladesh and Thailand have already visited India to study eVIN and are preparing to roll it out in their own countries.
While they paint rosy pictures, officials have reasons to worry. Critics say the focus on MI is taking the emphasis away from routine immunisation. While MI is only meant to supplement routine immunisation, some states have started giving consolidated figures for routine immunisation and Mission Indradhanush 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 programme will suffer. We cannot let that happen,” said an official.