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 routineI 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 • All 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 non-health sectors together to devise and (a system of governance based at rural sessions, and dispelling concerns about the apply specific communication plans and community level); Minority Affairs; Human adverse effects of vaccines. materials. Cycles of immunisation were Resource Development; and Information Monitoring and evaluating progress conducted each month between October and Broadcasting. The Ministries of Vaccination sessions were monitored. 2017 and January 2018, each lasting 7 Urban Development, Housing and Urban Administrative data collected by auxiliary on 2 October 2021 by guest. Protected copyright. working days. Poverty Alleviation were collaborators in urban areas. The Ministries of Defence, nurse midwives were transmitted through Home Affairs, Sports and Youth Affairs, the routine health management informa- Priority districts - 121 Railways, and Labour and Employment tion system. External monitoring was car- North eastern districts - 52 Urban areas - 17 supported specific activities, such as ried out by supervisors, and assessments expanding service delivery points and of small samples of households were made transportation of supplies to the last to validate childhood vaccination coverage. mile. Youth organisations such as the E-dashboards on mobile phones were used National Cadet Corps and National Service to collect monitoring data, which allowed Scheme were asked to provide support real time aggregation of vaccination data. for social mobilisation by national and Local monitoring was carried out by aux- state administrators. Standard operating iliary nurse midwife supervisors, district procedures for their involvement were supervisors, and medical officers, with sup- developed for these organisations.14 In the port from WHO and Unicef monitors. Dur- districts, participation was coordinated by ing vaccination rounds, daily supervisor the district magistrate through a district meetings reviewed the available data and task force team. In subdistricts, direct discussed problems and solutions. External interaction between field workers from supervision was provided by national, state, health and other departments was the rule. and partner monitors, who met to review Stakeholder mapping was conducted to progress and provide feedback to all. Popu- Fig 1 | Map of the 121 districts, 52 northeastern districts, and 17 urban identify available resources, which varied lation based evaluation surveys of house- areas identified for Intensified Mission between districts and communities. In most hold coverage were conducted in April and Indradhanush Ministry of Health and Family communities, facility based staff, such as June 2018 in IMI areas by WHO and the Welfare, India10 auxiliary nurse midwives, and community United Nations Development Programme.

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size cluster sampling. Estimates of coverage 1. Single phase Intensied Mission Indradhanush: October 2017 to January 2018 BMJ: first published as 10.1136/bmj.k4782 on 7 December 2018. Downloaded from • Each round 7 working days, excluding routine immunisation days and holidays before IMI came from a national population • Intensive monitoring based randomised cluster survey conducted • Addition of need based extra session sites • Integration of Intensied Mission Indradhanush sessions into routine immunisation for sustainability in MI districts after the first two rounds in 2015-16, which included all IMI districts4 (see suppl 2 on bmj.com). The 2015- 2. Gap assessment to identify additional needs • Manpower 16 survey estimated full immunisation • Social mobilisation coverage for children aged 12-23 months • Finances to be 50.5% in IMI districts and 62% for India as a whole. 3. Cascaded training of staff at all levels After IMI, the proportion of children with • Interpersonal communication full immunisation coverage in IMI districts • Microplanning was estimated to be 69%, representing an increase of 18.5% from pre-IMI 4. Head count for beneciary listing estimates (fig 3).4 16 Improvement in full • Done jointly by Health, and Women and Child Development • Enlisted or updated high risk areas of planning unit immunisation coverage within IMI districts ranged from 12% in Rajasthan to 31% in Assam. Full coverage increased by >30% 5. Mobilisation of identied beneciaries • Need based communication and social mobilisation plan at state, district, block, and community levels in 56 districts of the 190 districts surveyed (29.5%), by 10-30% in 83 districts (43.7%), and by <10% in 51 districts 6. Vaccination of beneciaries 4 16 • Fixed and outreach vaccination sites (26.8%) (see suppl 2 on bmj.comfor • Mobile vaccination teams data and confidence intervals by state and district). Since baseline survey data were

7. Monitoring collected in late 2015 and early 2016, new • Regular reviews from national level with states and districts (through video conferencing) coverage estimates will be influenced by • Programme monitoring for feedback and action at all levels the last two phases of MI, which ended in July 2017. Changes in coverage cannot 8. Progress therefore be attributed solely to IMI. In • Administrative data addition, since there is no comparison • Population based coverage survey population, the relative effect of IMI on

immunisation coverage compared with the http://www.bmj.com/ 10 Fig 2 | Strategy for Intensified Mission Indradhanush Ministry of Health and Family Welfare, India non-intervention population is unknown. Routine monitoring was conducted for 98% of sessions, with headcount lists Summary of progress funds were provided by the National Health available in 92%, and updated due lists Administrative data on IMI remain provi- Mission of the government of India. in 82% (internal communication, deputy sional. We report here internal analyses Population based coverage surveys commissioner (immunisation), Ministry of that have not yet been published. Adminis- were conducted in 190 IMI districts, 3–5

Health and Family Welfare, Government on 2 October 2021 by guest. Protected copyright. trative data estimate that between October months after the last IMI cycle. The unit of India; see suppl 2 on bmj.com for 2017 and January 2018, 97 628 vaccina- of analysis was the district. A total of process monitoring data by state). Due tion sessions were conducted in IMI areas, 84 497 households were selected from 190 lists of eligible beneficiaries, comprising delivering over 15 million antigens. During districts using probability proportionate to unimmunised and partially immunised this period, an estimated 5.95 million chil- dren were vaccinated, with around 850 000 children being vaccinated for the first time Before IMI (National Family Health Survey 4 - 2015-16) Aer IMI (IMI Coverage Evaluation Survey - 2018) and 1.4 million children aged ≥12 months 100 being fully vaccinated. An estimated 1.18 18.5% increase in full immunisation coverage million pregnant women were also vacci- 80 nated, with over 660 000 thought to have been fully vaccinated (internal communica- 60 tion, deputy commissioner (immunisation), Ministry of Health and Family Welfare, 40 Government of India). Vaccine monitoring internal data, show that vaccine and lack 20 of stock were uncommon during the IMI Full immunisation coverage (%) period, with 98% of monitored sites hav- 0 15 Assam Bihar Madhya Maharashtra Rajasthan Uttar North east Rest of All states ing adequate supplies. Eleven states dis- (n=7) (n=16) Pradesh (n=11) (n=12) Pradesh except the states pooled (n=14) (n=60) Assam (n=25) (n=190) tributed additional funding for IMI rounds, (n=45) estimated to be a total of $7.8 million (inter- States or regions (districts) nal communication, deputy commissioner (immunisation), Ministry of Health and Fig 3 | Proportion of children aged 12-23 months fully immunised in 190 Intensified Mission Family Welfare, Government of India). All Indradhanush (IMI) districts, by state or region before and after IMI the bmj | BMJ 2018;363:k4782 | doi: 10.1136/bmj.k4782 3 Making Multisectoral Collaboration Work

­temporary transfer to underserved areas,

Others 9% BMJ: first published as 10.1136/bmj.k4782 on 7 December 2018. Downloaded from taking staff away from routine duties: Operational gap 4% “There is no need of IMI if all ANM [auxiliary nurse midwife] posts are Child travelling 8% filled. Politics is spoiling routine immunisation because a few blocks have surplus ANMs whereas some do Reasons for missing not have a single ANM. This is for politi- vaccination Resistance 11% cal reasons” District stakeholder, Bihar; (n=38 209) July 2018 Both states and districts were concerned about the long term sustainability of this approach. “There will be no sustainability of these Fear of adverse events processes, because it is so intense. The aer immunisation 24% focus should be on strengthening the Awareness gap 45% routine immunisation including micro- planning, monitoring and supervision” Fig 4 | Reasons for missing vaccination sessions obtained by routine monitoring interviews with care givers of undervaccinated children between October 2017 and February 2018 State stakeholder, Madhya Pradesh; July 2018

children under 2 years and pregnant The prime minister sent letters to chief min- Household listing to improve reach women, were created using door-to-door isters stating the goal of 90% full immu- Detailed microplanning and listing of bene- head counts in each targeted area—usually nisation coverage in their states, advised ficiaries (creating due lists) was at the heart a village or urban unit. Of those on the due on engagement of non-health ministries, of the IMI approach, essential for reaching lists, an average of 57% (range 13-95%) and participated in IMI review meetings. high-risk populations, and carried out for received the needed vaccinations during The use of data based criteria meant that most sessions (see table 3 in suppl 2 on sessions. all stakeholders understood the ration- bmj.com). Achieving household listing External monitors conducted household ale for selection of focus areas. Intensive was central to the roles of auxiliary nurse interviews of a sample of undervaccinated microplanning, using the “Reaching Every midwives, accredited social health activists, children in IMI districts as part of routine District” strategy helped to emphasise the and Anganwadi workers and where all were

programme monitoring. Reasons for non- need to reach all sections of communities available and motivated this was feasible. http://www.bmj.com/ vaccination included lack of awareness and promoted participation of other sec- However, household listing was difficult, 17 (45%), apprehension about adverse events tors. No new structures or governance particularly in districts with staff shortages (24%), vaccine resistance (reluctance models were established; building on rou- and in urban areas. In these cases, staff to receive the vaccine for reasons other tine systems and mechanisms already in from outside the district and locally avail- than fear of adverse events) (11%), child place allowed rapid uptake. able nursing students were used to support travelling (8%), and programme related door-to-door household listing and other Decentralisation of management to district gaps (4%) (fig 4) (internal communication, IMI activities using IMI funds. In addition levels on 2 October 2021 by guest. Protected copyright. deputy commissioner (immunisation), to additional staffing needs, household list- To encourage the participation of non- Ministry of Health and Family Welfare, ing in more remote areas required substan- health sectors and development partners, a Government of India). Apprehension about tial time, innovation, and transportation. lead partner was identified in every district. adverse events and programme related Field staff found that household beneficiary The responsibility for managing IMI was gaps fell, from 31% and 12%, respectively, lists needed monthly updating because of passed on to the districts and subdistricts, compared with routine monitoring data frequent population shifts. In some areas, which developed plans tailored to local from the same districts before IMI. therefore, the household listing was prob- circumstances. District magistrates and These data show that more needs to ably incomplete, thus reducing coverage. immunisation officers took responsibility be done to educate beneficiaries, dispel To improve reach, all districts will need to for mobilising health and non-health sector misinformation, and mobilise some provide adequate staffing to enable house- resources to fill staffing gaps, improve -com households. hold listing and targeting to work. munication, and increase community mobi- Systems factors associated with effective lisation for vaccinations. This approach Social mobilisation to improve access and cross-sectoral involvement was effective when staff were motivated, equity Political support and data based targeting and when additional funds or incentive In subdistricts, local stakeholders were cen- Close involvement and supervision by the payments were available. It was less effec- tral to mobilising families and communities prime minister of India was important for tive in areas that were short staffed and for vaccination sessions (table 2). They used generating and sustaining political will when incentive payments were delayed. a range of measures to provide information, for IMI. It ensured the commitment of non- Key informants in two areas reported delays mobilise communities for vaccination, and health government and non-­government in staff payments due to district adminis- to discredit myths or rumours about vac- staff at all levels and promoted cross-­ trative and procedural weaknesses. This cinations. In many areas, a wide range of sectoral involvement. Ministries of 12 other may also have slowed deployment of staff partners were mobilised to contribute. sectors were invited to participate and and other activities. In addition, the staff Several mechanisms were used to involve informed of IMI objectives and their roles. time commitment sometimes required families; social media platforms provided

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information about vaccination days, about tends to occur in pockets of the population, Building a sustainable system using BMJ: first published as 10.1136/bmj.k4782 on 7 December 2018. Downloaded from the benefits of immunisation, and dispelled reinforced by local social and community experience from IMI fears. Ration dealers, who provide govern- connections.21 Better understanding of IMI has contributed to significant increases ment subsidised food and other supplies, the roots of false beliefs and how they are in fully immunised children (from 50.5% were a source of information. Elected com- reinforced in communities will be essential to 69.0%) in 190 of the lowest performing munity leaders and religious leaders gave to combating them: districts in India, a 37% increase in cover- information during routine meetings or “There are two types of refusal here: age over baseline. It was financed solely by weekly religious gatherings. one group believes that vaccines are the government, using existing staff and However, process monitoring data not important. They listen to us and governance systems. IMI showed that cross- showed that many eligible children on then say that we understand what you sectoral participation can be effective in due lists were not brought to vaccination say, but we don’t want [it]. The other vaccinating those children at highest risk. sessions. For those not attending, the group are in the anti-medication faith However, a number of system and practice key reason for almost half was lack of group: they believe disease is a result changes, particularly in communication, awareness, and for another quarter, of sin and that vaccines are not needed are needed for this approach to be even concerns about the adverse effects of by the faithful.” State stakeholder, more effective. vaccines. This suggests that mobilisation Meghalaya; July 2018 Four areas need strengthening. Firstly, activities were inadequate in changing Secondly, influential community sustained high level political support, the attitudes of some care givers. Gaps fall personnel and partners did not always play advocacy, and supervision across sectors, into four main areas. Firstly, inadequate an active part in community mobilisation. and the flexibility to allocate finance communication plans, messages, and This was more likely in areas where they and people where needed, is essential. materials. False beliefs, such as rumours were not involved in early planning, not Secondly, all districts must strengthen staff about adverse events or vaccines causing clear about their roles, or not provided capacity to list household beneficiaries, sterilisation, were often not targeted: with the means of communication. In some add additional vaccination sites to improve “There were rumours circulated cases, this was reported to be due to a lack access, and invest in the transportation on social media, especially on of recognition and financial incentives. required for both. Thirdly, better WhatsApp about immunisation and Thirdly, community health workers in communication and counselling skills, the Naturopaths played a big role in several areas reported that inadequate tailored to local beliefs, are needed by creating hurdles in implementation of time and skills limited their ability to community providers in health and partner IMI.” District stakeholder, Kerala; July provide effective counselling. Fourthly, in sectors. Fourthly, districts and primary care 2018 some cases, sites chosen for additional IMI facilities must work more effectively with Vaccine hesitancy was an important vaccination sessions (including private non-health stakeholders across sectors challenge during the previous measles homes, businesses, and schools) had by involving them early in planning and http://www.bmj.com/ rubella campaign and the polio eradication inadequate toilets, and other facilities, communication strategies. All sectors programme.18-20 Resistance to vaccination which might have discouraged attendance. are willing to support immunisation

Table 2 | Summary of effective strategies and the challenges of multisectoral collaboration for Intensified Mission Indradhanush (IMI) Strategies identified as important Challenges Improved links between health • Joint meetings between field staff from various sectors to plan • Inadequate infrastructure for new session sites

and non-health sectors strategies, roles, and responsibilities • Inadequate manpower and lack of engagement of the community on 2 October 2021 by guest. Protected copyright. • Household reminder slips about IMI sessions stakeholders to do household listing in their own areas • Mobile immunisation teams; sessions held at convenient times • Suboptimal partner participation and cooperation when not and places involved in planning, consulted on their roles and availability • Providing prompt medical care for adverse events • Limited recognition for non-health collaborators • Team home visits – auxiliary nurse midwives, workers from non-health sectors and community stakeholders to improve ­acceptance and reduce hostility Engagement of influencers • Involvement of religious leaders to dispel fears and instil confi- • Continued concerns about circulation of misinformation about dence in vaccination vaccines and rumours about adverse events; conspiracy theories • Youth groups: awareness generation and mobilisation including vaccines causing sterilisation • Community political leaders: public endorsement • Prabhat pheri (morning rallies): school children and youth cadets • School promotion: teachers and students to mothers and families Better use of local c­ ommunities • Peer counselling: mothers of fully immunised children counsel care • Requests by some community workers and groups for incentives/ and institutions givers of non-immunised children payments • Vikas Mitras and Tola Mitras–community level link workers—­ • Financial shortfalls for social mobilisation and information, mobilised marginalised communities and helped to set up education, and communication activities in some areas additional IMI sessions for Mahadalit (marginalised and extremely • Youth groups and Rotary participation limited to urban areas vulnerable caste groups) • Grievances about the food ration system led some families with • Ration dealers used for mobilisation and to provide information distrust of government to resist vaccinations Improved messaging • Distribution of brochures, stickers, buttons, umbrellas, public • Limited competency of community health workers in announcements ­communication and mobilisation (soft skills) so that concerns were • Use of print and electronic media: joint media briefings by nor always identified and dealt with ­government and partners • Accurate information not always provided about adverse events • Use of social media ­after immunisation; further work needed to dispel false percep- • Productions by the song and drama division (Ministry of tions about immunisation and improve vaccine seeking through ­Information and Broadcasting) social mobilisation campaigns • Street plays • Baby shows with prizes for healthy, fully immunised children the bmj | BMJ 2018;363:k4782 | doi: 10.1136/bmj.k4782 5 Making Multisectoral Collaboration Work

guarantor. VG and PH are guarantors for unpublished 5 Laxminarayan R, Ganguly NK. India’s vaccine deficit:

programming, provided that their roles are BMJ: first published as 10.1136/bmj.k4782 on 7 December 2018. Downloaded from clearly defined, predictable, and feasible administrative IMI data and concurrent monitoring why more than half of Indian children are not data for the routine immunisation programme fully immunized, and what can—and should—be with partner resources. collected by the Ministry of Health and Family Welfare. done. Health Aff (Millwood) 2011;30:1096-103. To meet sustainable development goals, doi:10.1377/hlthaff.2011.0405 there is strong political commitment to Competing interests: We have read and understood 6 Kumar C, Singh PK, Singh L, Rai RK. Socioeconomic BMJ policy on declaration of interests and declare: disparities in coverage of full immunisation health in India, including the vaccination VG, PH, MKA, AC, MJ, and PS work for the Ministry among children of adolescent mothers in India, system. Investments in new vaccines and of Health and Family Welfare, Government of India; 1990-2006: a repeated cross-sectional analysis. universal healthcare are imminent. IMI PH, MKA, and AC work directly on MI and IMI in the BMJ Open 2016;6:e009768. doi:10.1136/ Immunisation Division, Ministry of Health and Family will play a role in reaching vulnerable bmjopen-2015-009768 Welfare; support was received from the World Health 7 Taneja G, Sagar KS, Mishra S. Routine immunization populations in the short to medium term. Organization (Partnership for Maternal, Newborn, in India: a perspective. Indian J Community Repeat IMI rounds in 75 lagging districts and Child Health) for the submitted work. The views Health 2013;25:188-92. expressed in this article are those of the authors and are planned from October 2018 onwards, 8 Ministry of Health and Family Welfare (MOHFW). do not necessarily represent the views, decisions, or Mission Indradhanush, operational guidelines. Delhi, incorporating experience from the early policies of WHO or the institutions with which they are India: MOHFW;2014. http://164.100.158.44/ rounds. A campaign focused on village affiliated. showfile.php?lid=4258 9 Immunization Technical Support Unit. Report of empowerment and development (Gram Provenance and peer review: Commissioned; Integrated Child Health & Immunization Survey externally peer reviewed. Swaraj Abhiyan and Extended Gram (INCHIS)-Round 1 and 2. Ministry of Health and Swaraj Abhiyan), led by the Ministry of This article is part of a series proposed by the WHO Family Welfare, 2014. Rural Development, will also introduce Partnership for Maternal, Newborn, and Child Health 10 Ministry of Health and Family Welfare (MOHFW). (WHO PMNCH) and commissioned by The BMJ, which Intensified Mission Indradhanush, operational IMI as one component of a multisectoral peer reviewed, edited, and made the decision to 21 22 guidelines. MOHFW, 2017. https://mohfw.gov.in/ development effort. publish the article. Open access fees for the series are sites/default/files/Mission%20Indradhanush%20 In the longer term, it is hoped that funded by WHO PMNCH. Guidelines.pdf the lessons learnt from IMI will be Vandana Gurnani, joint secretary1 11 Bhatnagar P, Gupta S, Kumar R, Haldar P, Sethi R, incorporated into routine programming Pradeep Haldar, deputy commissioner Bahl S. Estimation of child vaccination coverage immunisation1 at state and national levels in India. Bull World and overall development, with cross- Health Organ 2016;94:728-34. doi:10.2471/ sectoral participation leading to a people’s Mahesh Kumar Aggarwal, deputy commissioner BLT.15.167593 immunisation1 movement (Jan Andolan), for reducing 12 Ministry of Health and Family Welfare, United Nations Manoja Kumar Das, director projects2 Development Programme, Global Alliance for Vaccine vaccination inequities through social Ashish Chauhan, senior consultant immunisation1 Initiative. Improving efficiency of vaccination systems change. 3 in multiple states: e-VIN factsheet. United Nations John Murray, international health consultant Development Programme, 2017. http://www.in.undp. We thank the technical experts from development 2 partners (WHO, Unicef, United Nations Development Narendra Kumar Arora, executive director org/content/india/en/home/operations/projects/ Programme) and the Immunisation Technical Support Manoj Jhalani, additional secretary and mission health/evin.html 1 13 Ministry of Health and Family Welfare (MOHFW).

Unit; leadership and staff in health and partner director http://www.bmj.com/ ministries and departments at district and state Intensified Mission Indradhanush- financial Preeti Sudan, secretary1 guidelines. MOHFW, 2017: Annexure 6. https:// levels; and the technical experts from various medical 1 colleges: Rajib Dasgupta, Jawaharlal Nehru University, Ministry of Health and Family Welfare, Government of mohfw.gov.in/sites/default/files/Mission%20 New Delhi; Anand Prakash Dubey, ESI-Postgraduate India, New Delhi, India Indradhanush%20Guidelines.pdf Institute of Medical Sciences and Research, New Delhi; 2The INCLEN Trust International, New Delhi, India 14 Ministry of Health and Family Welfare. Standard operating procedures for engaging with youth Pragya Sharma and Raghavendra Singh, Maulana 3Iowa City, Iowa, USA Azad Medical College, New Delhi; Mubashir Angolkar, institutions (NCC, NSS, NYKS) and Rotary for Correspondence to: N K Arora J N Medical College, Belagavi, Karnataka; Muneer social mobilization for Intensified Mission [email protected] Masssodi and S Muhammad Salim Khan, Government Indradhanush (IMI) and routine immunization. Medical College, Srinagar, Jammu and Kashmir; Harish MOHFW, 2018. https://mohfw.gov.in/sites/default/ on 2 October 2021 by guest. Protected copyright. Pemde, Lady Hardinge Medical College, New Delhi; files/SOPs%20Engagement%20of%20Youth%20 Pankaj Jain, U.P. Rural Institute of Medical Sciences Organizations%20and%20Rotary%20for%20 and Research, Etawah, Uttar Pradesh; Satinder Aneja, Immunization%20.pdf 15 Ministry of Health and Family Welfare. United Nations School of Medical Sciences and Research, Sharda This is an Open Access article distributed under University, Greater Noida, Uttar Pradesh; Sanjay K Development Programme, Global alliance for vaccine the terms of the Creative Commons Attribution IGO initiative. E-VIN Tracking Database, October 2017 – Rai and Kiran Goswami, All India Institute of Medical License (https://creativecommons.org/licenses/ Sciences, New Delhi; Sanjay Chaturvedi, University April 2018. Delhi, India: MOHFW; 2018 http://www. by-nc/3.0/igo/), which permits use, distribution, College of Medical Sciences, New Delhi; Muzammil in.undp.org/content/india/en/home/operations/ and reproduction for non-commercial purposes in Khurshid and Swarna Rastogi, Muzaffarnagar Medical projects/health/evin.html College, Muzaffarnagar, Uttar Pradesh; Ashok Kumar any medium, provided the original work is properly 16 Ministry of Health and Family Welfare. Coverage and Prabhat Kumar Lal, Darbhanga Medical College, cited. Evaluation Survey- Intensified Mission Darbhanga, Bihar; A Althaf, Government Medical Indradhanush. MOHFW, 2018. College, Malappuram and Sairu Philip, T.D. Medical 17 Microplanning for immunization service delivery College, Alappuzha, Kerala; Himesh Barman and Star using the Reaching Every District (RED) strategy. Pala, North Eastern Indira Gandhi Regional Institute Geneva: World Health Organization, 2009. http:// of Medical Sciences, Shillong, Meghalaya; Satish apps.who.int/iris/bitstream/10665/70450/1/ Saroshee and Suraj Sirohi, Mahatma Gandhi Memorial 1 Ministry of Health and Family Welfare, Government of WHO_IVB_09.11_ eng.pdf Medical College, Indore and Abhijit Pakhre, All India. Immunization handbook for medical officers. 18 Ministry of Health and Family Welfare. National India Institute of Medical Sciences, Bhopal, Madhya WHO, 2016. http://www.searo.who.int/india/ Certification for Polio Eradication (NCCPE). Pradesh. publications/immunization_handbook2017/en/ Minutes of 29th meeting of the NCCPE 2 Lahariya C. A brief history of vaccines & vaccination in (13-14 November 2017), New Delhi, India: Contributors and sources:VG, PH, MKA, MJ, PS, and India. Indian J Med Res 2014;139:491-511. MOHFW, 2017. NKA conceptualised the case study and approach. 3 Vashishtha VM. Status of immunization and need 19 Singh P, Das JK, Dutta PK. Misconceptions/rumors PH, NKA, MKD, and JM developed the method. Group for intensification of routine immunization in India. about oral polio vaccine in western UP: A case study. members PH, AC, MKD, and JM collected data and Indian Pediatr 2012;49:357-61. doi:10.1007/ Indian J Prev Soc Med 2010;41:28-32. oversaw data collection. AC, MKD, and JM analysed s13312-012-0081-x http://medind.nic.in/ibl/t10/i1/iblt10i1p28.pdf the data. PH, AC, NKA, MKD, and JM conducted 4 International Institute for Population Sciences (IIPS) 20 Onnela JP, Landon BE, Kahn AL, et al. Polio vaccine the data synthesis. NKA, MKD, and JM drafted the and ICF. National family health survey (NFHS-4), hesitancy in the networks and neighborhoods of manuscript. All authors reviewed and commented 2015-16: India. IIPS, 2017. https://dhsprogram. Malegaon, India. Soc Sci Med 2016;153:99-106. on the manuscript before finalisation. NKA acts as com/pubs/pdf/FR339/FR339.pdf doi:10.1016/j.socscimed.2016.01.024

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