Improving Vaccination Coverage in India: Lessons BMJ: First Published As 10.1136/Bmj.K4782 on 7 December 2018
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MAKING MULTISECTORAL COLLABORATION WORK Improving vaccination coverage in India: lessons BMJ: first published as 10.1136/bmj.k4782 on 7 December 2018. Downloaded from from Intensified Mission Indradhanush, a cross-sectoral systems strengthening strategy Vandana Gurnani and colleagues report an analysis from the Intensified Mission Indradhanush strategy in India, showing that cross-sectoral participation can contribute to improved vaccination coverage of children at high risk ndia’s immunisation programme and Family Welfare launched Mission 17 urban areas, and an additional 52 is the largest in the world, with Indradhanush (MI) in 2014, to target districts in the northeastern states (fig 1). annual cohorts of around 26.7 mil- underserved, vulnerable, resistant, and All children aged up to 5 years and preg- lion infants and 30 million pregnant inaccessible populations.8 The programme nant women were targeted, with a focus women.1 Despite steady progress, ran between April 2015 and July 2017, on ensuring full vaccination for children Iroutine childhood vaccination coverage vaccinating around 25.5 million children under 2 years. Vaccines included in the has been slow to rise. An estimated 38% of and 6.9 million pregnant women. This routine immunisation schedule were children failed to receive all basic vaccines contributed to an increase of 6.7% in full given—namely, tetanus toxoid for pregnant in the first year of life in 2016.2-4 The fac- immunisation coverage (7.9% in rural areas women based on their vaccination status; tors limiting vaccination coverage include and 3.1% in urban areas) after the first and for infants, Bacillus Calmette–Guerin, large mobile and isolated populations that two phases.9 In October 2017, the prime oral polio vaccine and hepatitis B at birth are difficult to reach, and low demand from minister of India launched Intensified or first contact after birth, three doses of underinformed and misinformed popula- Mission Indradhanush (IMI)—an ambitious pentavalent, oral polio vaccine and inject- tions who fear side effects and are influ- plan to accelerate progress. It aimed to able polio vaccine between 6 and 14 weeks, enced by anti-vaccination messages.5-7 reach 90% full immunisation coverage in measles or combined measles and rubella Owing to low childhood vaccination districts and urban areas with persistently vaccine at 9 and 18 months, and DPT and 10 http://www.bmj.com/ coverage, India’s Ministry of Health low levels. IMI was built on MI, using oral polio vaccine boosters at 18 months. additional strategies to reach populations Three doses of rotavirus, pneumococ- KEY MESSAGES at high risk, by involving sectors other than cal conjugate, and Japanese encephalitis health (table 1). vaccines were also given between 6 and • The Intensified Mission Indradhanush This case study was led and coordinated 14 weeks in areas where these had been strategy showed that cross-sectoral by the Ministry of Health and Family added to the routine schedule. A chain of participation can increase vaccination Welfare. The primary objective was support was established from the national rates in children at high risk to record the lessons learnt from IMI. level through states to districts. Senior staff on 2 October 2021 by guest. Protected copyright. • Strengthening of the system and Emphasis was put on understanding provided regular reviews of progress and practice changes could make it more how cross-sectoral and multistakeholder received updates on progress.10 effective engagement work to strengthen access to • Sustained high level political support, vaccine services and improve their quality. Implementation advocacy, and supervision across sec- A modified multistakeholder review A seven step process was developed to tors, together with flexibility to re- process was used, which included in-depth support district and subdistrict planning allocate financial resources and staff interviews of stakeholders at all levels and and implementation of IMI, with staff at 10 were essential for success a synthesis meeting (see suppl 1 on bmj. all levels receiving training (fig 2). Door- • Districts must strengthen staff capac- com). to-door headcount surveys and due listing ity to list household beneficiaries, of beneficiaries were conducted by facil- add additional vaccination sites, and Intensified Mission Indradhanush: programme ity staff (auxiliary nurse midwives), com- invest in the transportation required description munity based workers (accredited social for both Programme focus health activists), and non-health workers (Anganwadi workers), and validated by • Better communication and counsel- IMI targeted areas with higher rates of ling skills tailored to local beliefs are unimmunised children and immunisa- supervisors for completeness and qual- needed to deal with barriers to seek- tion dropouts. Updated data were used to ity. Session micro-planning identified new ing vaccinations select districts and urban areas in which sites for conducting vaccination sessions at least 13 000 children were estimated to if needed, organised mobile teams for Districts and primary care facilities • have missed diphtheria, tetanus, pertus- remote areas, and ensured that supplies work must more effectively with sis 3 (DPT3)/pentavalent 3 in the previous were available. If too few staff were avail- non-health stakeholders by involving year, or DPT3/pentavalent 3 coverage was able at health subcentres, additional staff them early in logistics planning, com- estimated to be 70%.11 These criteria were were hired or brought in from other areas. munication, and messaging strategies < used to select the weakest 121 d istricts, Vaccine supplies were tracked using the the bmj | BMJ 2018;363:k4782 | doi: 10.1136/bmj.k4782 1 MAKING MULTISECTORAL COLLABORATION WORK Table 1 | Comparison of the programme used by Mission Indradhanush (MI) and Intensified Mission Indradhanush (IMI) BMJ: first published as 10.1136/bmj.k4782 on 7 December 2018. Downloaded from Mission Indradhanush (MI): April 2015 to July 2017 Intensified Mission Indradhanush (IMI): October 2017 to January 2018 Objective Fully immunise 90% of infants by 2020 Fully immunise 90% of infants by 2018 Leadership Central health minister and secretary of Health and Prime minister, central health minister and cabinet secretary, monitored under the Family Welfare, monitored under the proactive proactive governance and timely implementation system governance and timely implementation system Implementation Ministry of Health and Ministry of Women and Child Ministry of Health with support from 12 non-health ministries, including Ministry of Development Women and Child Development Selection criteria Districts with lowest coverage and state priority: lowest Districts and areas which continued to underperform after the first mission< ( 70% coverage (n=201), intermediate coverage (n=296), and coverage) and >13 000 missed/partially immunised children other districts (n=31) Target areas 528 districts across 35 states 173 districts (including 52 districts from northeastern states) and 17 urban areas across 24 states Period Four phases, each consisting of four monthly rounds, One phase with four monthly rounds, each round lasting for 1 week with each round lasting for 1 week Programme approach • Improved microplanning, monitoring, social MI approach plus: mobilisation and strengthened vaccination systems • Rigorous head counts (validated by supervisors) for tracking and updating due lists (especially in areas with inadequate staff numbers) to identify children aged ≤2 years and pregnant women for vaccination • A ll vaccines under routine immunisation offered for • More intensive planning and monitoring in hard to reach urban areas children aged ≤2 years and pregnant women • Involving non-health sectors to deal with social barriers and gaps in knowledge in communities—and to create a vaccination “movement” • Additional financial support based on need, and flexibility in use of the fund Electronic Vaccine Intelligence Network Involvement of stakeholders in non-health based staff, such as accredited social and cold chain tracking programme, and sectors health activists and Anganwadi workers, distributed using the alternate vaccine IMI was an effort to shift routine immunisa- were available for health education and delivery mechanism.12 To facilitate local tion into a Jan Andolan, meaning “peoples’ coordination with other local participants. implementation, flexible vaccination funds movement” in Hindi. It aimed to mobilise These included non-health government were used for personnel costs, incentives communities and simultaneously deal with departments, non-governmental for staff, transportation, social mobilisa- barriers to seeking vaccines. organisations, religious leaders, mothers’ tion, and production of communication Nationally, coordination between groups, community and political leaders, materials. Guidelines for requesting addi- health and 12 non-health ministries private medical providers, and others. The tional resources and their allocation for was facilitated by the prime minister’s support provided depended on local needs office and cabinet secretariat. Non-health specific activities were developed; addi- and the area covered by the stakeholders. It http://www.bmj.com/ tional funds were provided on demand sectors included the Ministries of Women usually focused on education of women and to states.13 District task forces bought 12 and Child Development; Panchayati Raj families and mobilisation for vaccination