Intensified Mission Indradhanush 2.0

Transforming India’s Universal Immunisation Program

Rashmi Kumar

The government has launched Intensified Mission Indradhanush (IMI) 2.0 which is being carried out between December 2019 and March 2020. The IMI 2.0 aims to escalate efforts to achieve that goal of attaining 90% national immunization coverage across India by plugging the loopholes with lessons learnt from previous phases. The programme will be delivered in 271 districts of 27States and 652 blocks of Uttar Pradesh and Bihar among hard-to-reach and tribal populations.

The government has also launched IMI 2.0 portal that has been designed to capture information on the block wise target of children and pregnant women to be vaccinated during the IMI drive. The data will be entered at the district level. This will help the programme officers and administrators at the block, district, state and national level to have real time information on the progress of the campaign and also take timely action on slow progress in any particular area, according to Union Health Minister, Harsh Vardhan.

Salient Features of IMI 2.0

• Immunisation activity will be in four rounds over 7 working days excluding the RI days, Sundays and holidays;
• Enhanced Immunisation session with flexible timing, mobile session and mobilisation by other departments;
• Enhanced focus on left outs, dropouts, and resistant families and hard to reach areas;
• Focus on urban, under-served population and tribal areas
• Inter-ministerial and inter-departmental coordination;
• Enhance political, administrative and financial commitment, through advocacy;
• The 4 rounds of Immunisation will be conducted in the selected districts and urban cities between December 2019- March 2020;
• After the completion of the proposed 4 rounds, the States will be expected to undertake measures to sustain the gains from IMI, through activities like inclusion of IMI sessions in routine Immunisation plans. The sustainability of IMI will be assessed through a survey.

How Mission Indradhanush has been incremental in increasing the immunisation coverage in India

Ministry of Health and Family Welfare, Government of India, introduced its Immunization Programme in 1978 as 'Expanded Programme of Immunization' (EPI). In 1985, the programme was modified as 'Universal Immunization Programme' (UIP) to be implemented in phased manner to cover all districts in the country by 1989-90. India's immunisation programme is the largest in the world, with annual cohorts of around 26.5 million infants and29 million pregnant women. Despite steady progress, routine vaccination coverage has been slow to increase. According to the National Family Health Survey-4 2015-16 (NFHS-4), the full immunisation coverage is around 62%. The factors limiting vaccination coverage include the rapid urbanisation, presence of large migrating and isolated populations that are difficult to reach, and low demand from under-informed and unaware populations.

Owing to such limitations, the Ministry of Health and Family Welfare launched a revamped immunization drive in December 2014 and named it as Mission Indradhanush. It aimed to target the most vulnerable, resistant, and inaccessible population. Between April 2015 and July 2017, around 25.5 million children and 6.9 million pregnant women were vaccinated. This contributed to an increase of 6.7% in full immunization coverage (7.9% in rural areas and 3.1% in urban areas) after the first two rounds.

Mission Indradhanush initially aimed to immunize unvaccinated and partially vaccinated children of the country against seven vaccine-preventable diseases. These diseases were identified as diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis-B. Later, the basket of vaccines was expanded to cover 12 diseases including pertussis, meningitis and pneumonia (Hemophilus influenza type B infections), Japanese encephalitis (JE) in JE endemic districts with introduction of newer vaccines  such as rotavirus vaccine, IPV, adult JE vaccine,  pneumococcal conjugate vaccine (PCV)  and measles-rubella (MR).

Launch of Intensified Mission Indradhanush (IMI)

Encouraged by the success of Mission Indradhanush and to further intensify the immunization programme, Prime Minister Shri Narendra Modi launched the Intensified Mission Indradhanush (IMI) on October 8, 2017. It aimed to achieve 90% Full Immunisation Coverage (FIC) with focus towards districts and urban areas with persistently low levels. IMI was built on MI, using additional strategies to reach populations at high risk, by involving sectors other than health. It was an effort to shift routine immunisation into a Jan Andolan, or a "peoples' movement". It aimed to mobilise communities and deal with barriers to seeking vaccines.

IMI had inter-ministerial and inter-departmental coordination, action-based review mechanism and intensified monitoring and accountability framework for effective implementation of targeted rapid. IMI was supported by 11 other ministries and departments, such as Ministry of Women and Child Development, Panchayati Raj, Ministry of Urban Development, Ministry of Youth Affairs among others. The convergence of ground level workers of various departments like ASHA, ANMs, Anganwadi workers, Zila preraks under National Urban Livelihood Mission (NULM), self-help groups also ensured for better coordination and effective implementation of the programme.

IMI has contributed to a significant increase in fully immunised children in 190 selected districts in India. IMI showed that cross-sectoral participation can be effective in vaccinating children at the highest risk of infection. However, a number of systemic and practice-related changes, particularly with regards to the communications strategy, are needed for this approach to be even more effective.

Strategy and systems in rolling out Mission Indradhanush.

According to the Ministry of Health and Family Welfare, all children aged up to 5 years and pregnant women were targeted, with a focus on ensuring full vaccination for children under 2 years. Vaccines included in the routine immunisation schedule were given-namely, tetanus toxoid for pregnant women based on their vaccination status; and for infants, Bacillus Calmette-Guerin, oral polio vaccine and hepatitis B at birth or first contact after birth, three doses of pentavalent, oral polio vaccine and injectable polio vaccine between 6 and 14 weeks, measles or combined measles and rubella vaccine at 9 and 18 months, and DPT and oral polio vaccine boosters at 18 months. Three doses of rotavirus, pneumococcal conjugate, and Japanese encephalitis vaccines were also given between 6 and 14 weeks in areas where these had been added to the routine schedule. A chain of support was established from the national level through states to districts. Senior staff provided regular reviews of progress and received updates on progress.

An analysis done by Ministry of Health and Family Welfare in its paper publish in the British Medical Journal (BMJ) titiled--Improving Vaccination Coverage In India: Lessons From Intensified Mission Indradhanush, A Cross-Sectoral Systems Strengthening Strategy-showed that cross-sectoral participation can contribute to improved vaccination coverage of children at high risk. The ministry analysed that strengthening of the system and practice changes could make the program more effective. Sustained high level political support, advocacy, and supervision across sectors, together with flexibility to reallocate financial resources and staff were essential for success of Mission Indradhanush.

The paper recommended that districts must strengthen staff capacity to list household beneficiaries, add additional vaccination sites, and invest in the transportation required for both. Better communication and counselling skills tailored to local beliefs are needed to deal with barriers to seeking vaccinations. Also, districts and primary care facilities work was must more effectively with non-health stakeholders by involving them early in logistics planning, communication, and messaging strategies, the ministry officials summed up. The ministry said that in rolling out the IMI, a seven-step process was developed to support district and subdistrict planning and implementation of IMI, with staff at all levels receiving training. Door to-door headcount surveys and due listing of beneficiaries were conducted by facility staff (auxiliary nurse midwives), community based workers (accredited social health activists), and non-health workers (Anganwadi workers), and validated by supervisors for completeness and quality. Session micro-planning identified new sites for conducting vaccination sessions if needed, organised mobile teams for remote areas, and ensured that supplies were available.

Despite certain limitations and challenges, India has achieved groundbreaking success in eradicating/eliminating life-threatening vaccine preventable diseases by systematically implementing vaccination programmes. These include small pox, polio and more recently, maternal and neonatal tetanus. Despite persisting challenges such as a vast population, poor sanitation and hygiene, and a difficult geographical terrain that make containing outbreak of disease and increasing access to vaccines difficult. The Ministry of Health and Family Welfare has employed an effective approach - such as involving the community, seeking support from other Ministries and partner agencies, establishing an organised surveillance system, and employing mass campaign management strategies to reach every unreached child for vaccination.

With the launch of Intensified Mission Indradhanush 2.0, India has the opportunity to achieve further reductions in deaths among children under five years of age, and achieve the Sustainable Development Goal of ending preventable child deaths by 2030. By building on successes of the past, learning from challenges, and consolidating efforts across stakeholder groups, the country can fulfill its aim of attaining a disease-free India. Vaccines are a truly critical intervention in this journey, and are the key to safeguarding our present, and building a healthier tomorrow for our future generations.

(The author is a senior health journalist who has worked with eminent news channels and publications).

Views expressed are personal.

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