‘Once we have the vaccines…’: Accelerating Routine Immunization in India
by Nivedita Parashar and Catherine Cove
In 2014, India became the only country in the Southeast Asian Region to eradicate polio. The same year, the Government of India launched Mission Indradhanush (MI) with the goal of ensuring “full immunization with all available vaccines for children up to two years of age and pregnant women”, focusing on 201 districts across 28 states. Intensive Mission Indradhanush (IMI) was launched in 2017 to build off of MI and accelerate progress towards achieving immunization coverage. The government and its partners have also tried to streamline monitoring and implementation processes through innovations and system strengthening measures, including the Electronic Vaccine Intelligence Network (eVIN) for real-time monitoring of cold storage, the Integrated Disease Surveillance Project (IDSP) for ensuring the timely transportation of vaccines, and the Adverse Event Following Immunization (AEFI) guidelines for monitoring any adverse events after immunization.
While the government has made significant strides towards achieving full immunization, the National Family Health Survey (NFHS) 2015–16 reported that only 62% of children between 12–23 months were fully immunized (BCG, measles, and 3 doses each of polio and DPT), though this is an 18.5% increase from NFHS 2005–06. Furthermore, while the 2019 national budget allocated 62,398 crore rupees to the health sector, the allotment to reproductive and child health under NHM decreased by 12.6% from 2016–17 to 2019–20. The crores of missed immunization doses during the COVID-19 pandemic and lockdown also threaten to cause backsliding on the gains made so far. In other words, there is both a long way to go and an urgent need to accelerate progress.
The shortcomings in current immunization coverage raise important questions: How was Polio eradicated and why have other vaccine-preventable diseases not been eradicated in the same way? Despite efforts to promote immunization, why do immunization rates remain low?
Vaccine hesitancy, defined as the delay in acceptance or refusal of vaccines, is one factor that hinders immunization coverage. A study by Gurnani et. al. analyzed reasons for non-vaccination among under-vaccinated children in IMI districts. The most common reasons identified included “lack of awareness” (by 45% of respondents), “apprehension about adverse events” (24%), and “vaccine resistance” (reluctance to receive the vaccine for reasons other than fear of adverse events) (11%). It seems likely that vaccine hesitancy has been a key influencing factor in the uptake of immunization.
Why do people hesitate to accept vaccinations?
A range of factors influence perceptions of, and relationships with, vaccinations and the health system more broadly. Data from the NFHS reflects significant differences in immunization coverage rates between rural and urban areas, males and females, high- and low-income groups, and literate and non-literate populations. These social and environmental determinants impact the ways in which populations access, perceive, and desire vaccines. For example, low-income populations have more limited access to reliable information surrounding vaccines, which causes more vaccine hesitancy than in high-income groups. Lack of trust in the government or the health apparatus is another factor that has given rise to vaccine hesitancy across the world.
Vaccine hesitancy and its causes are often strongly context-specific, shaped by individual and community fears and a lack of knowledge surrounding vaccines. For example, data from Uttar Pradesh (UP), where vaccination is just 51%, 10 percentage points lower than the national average, suggests a complex amalgamation of realities at play. The state has poor socioeconomic conditions, high levels of female illiteracy, lack of healthcare awareness as well as gender inequality, all of which contribute to reluctance and apathy towards vaccines.
Vaccine hesitancy has also been fueled by waves of misinformation disseminated in India over the decades. During polio eradication efforts, a significant portion of the Muslim population of Uttar Pradesh refused to be vaccinated. Muslims are both a minority community and an economically disadvantaged one in UP. Their disenfranchisement has spurred distrust in the health system, enabling the spread of misinformation that immunization efforts were an attempt by the government to sterilize the Muslim community. Their concern was raised by an understandable question: When the state had neglected the health of their community for years, why was immunization suddenly so important?
Policy and Implementation Challenges
While ‘vaccine hesitancy’ is one of the factors behind low immunization rates in India, there are also systemic challenges that hinder access to vaccines. There are gaps between policy decisions and implementation in India which have slowed down Routine Immunization (RI) in the past. For example, under the Universal Immunization Program, Hepatitis-B was piloted in 2002–03 and scaled up to additional states in 2007–08, but was only fully implemented in 2012. The Haemophilus Influenzae Type b (Hib) vaccine was recommended in 2006 but was only introduced five years later in Tamil Nadu and Kerala at a time when it had been already introduced in 170 countries. These examples point to how government directives, policies, and procurement can either facilitate or hinder the effective implementation of immunization efforts.
When MI was implemented, the involvement of ASHA workers accelerated immunization outreach in the country. However, despite the important role they played in improving immunization rates, the quality of training provided to them has scope for improvement. Bahraich District in UP has reported the use of ‘blackmail’ tactics by ASHA workers to incentivize immunization. The workers threatened families by telling them that if they refused vaccines, they would not receive their rations from the public food distribution system. These types of occurrences are detrimental to establishing faith and trust in the public health system. Training ASHAs on strong counseling skills and providing them with the requisite tools to acquire free consent is crucial for increased uptake.
The Way Forward
Achieving complete vaccination coverage requires a strong health delivery system, an environment of trust among communities, and a shift in belief systems. There are several measures that can be taken to help achieve these ends:
- Impart quality training to ANMs, ASHA, and Anganwadi workers to not only vaccinate populations but also educate them about the importance of vaccines and quell misinformation
- Collaborate with partners at different levels who can facilitate more effective engagement with communities. For example, community level and faith-based leaders are well-positioned to address vaccine hesitancy due to existing relationships and trust with the communities they serve
- Assess the state and community level characteristics that impact vaccination coverage, and develop accordingly targeted immunization outreach programs in low coverage areas
- Monitor children born outside of hospitals and other identified groups that are prone to receiving delayed, limited, or no vaccinations
- Increase financial allocations for vaccine procurement, outreach, and implementation
- Increase expenditure on monitoring the system’s performance for timely feedback on house to house rapid monitoring, which was done during the push to eradicate Polio