Mission Indradhanush : How is it possible ?

Prestigious British Medical Journal has listed it as one of the 12 best practices in the world. It is evident that mission Indradhanush has been successful in achieving its desired targets. We are exploring the reasons behind its success.

The unmet need

In the year 1978, India launched its National Immunization Program which completed three decades in the year 2008. It was only partially successful in reducing the burden of vaccine-preventable diseases (VPDs). A significant proportion of VPDs still existed, and the primary reason was low vaccination coverage, with the percentage of fully immunized children around 60 percent. There was wide state-wise, geographical, religious, rural-urban, and gender variations in vaccination coverage in India.

There were straightforward reasons why we could not do any better . We did not have the capability requirements to do that. The vaccination was offered through major hospitals and primarily restricted to the urban areas, and thus the coverage remained low.

India did not have a robust cold chain system for the vaccination program. Till March 1991, maintenance of cold chain was under a contract between UNICEF and commercial agencies. It is only from April 1991 onwards; the states/union territories had taken responsibility for the maintenance of the cold chain.

India also lacked a robust district-wise system for monitoring and evaluation system which is very important to ensure that every one who should be vaccinated, is vaccinated. Only in 1997, we could establish an organized surveillance mechanism as the National Polio Surveillance Project (NPSP), which was a collaboration between the Government of India and the World Health Organization. After that, there have been additional national efforts to improve coverage, which include the launch of Immunization Strengthening Project (ISP), Urban Measles Campaigns and that of Border Districts Cluster Strategy (BDCS. Then we did not have self-sufficiency in vaccine production and manufacturing of cold chain equipment. India was importing most of the vaccine for the National Immunization programme. The National Technology Mission on immunization helped in modernization and up-gradation of vaccine facilities and by 1990-1991,  after which the country became self-sufficient for all vaccines (including measles) except for OPV.

The stage was set

By the year 2008, we have everything one needs for an effective vaccination program. The cold chain system was in place. We have locally produced all the required vaccines and evolved the evaluation and monitoring system. We needed someone to take the initiative and sphere head an idea that we can prevent the vaccine-preventable disease.

In the year 2013, the government of India rolled out National health Mission, by merging National rural health mission and national urban health mission into one. The purpose was to integrate the health delivery system into one cohesive unit.

Under the National health mission (NHM ), the government of India started many path-breaking health initiatives.The programmes were directed to address the different health-related issue, but have two things in common. All the programs were directed to solve one specific problem and have clearly defined measurable and time-bound objectives.

Evaluated full immunization coverage by district in India. credit: Lahariya C,. Indian J Med Res

The political will

Unlike any other health program, a strong political will was evident since the inception of the program. It was launched by no one other than prime minister Modi himself. In his independence day address to the nation, prime minister Modi saw this program as an instrument for the empowerment of the underprivileged segment of society.

The perfect strategy

There were some key factors in the strategy adopted by the government which ensures that the immunization targets are met without any chance of missing the targeted population.

SMART Objectives

The Mission Indradhanush aimed to cover all those children by 2020 who were either unvaccinated or were partially vaccinated against vaccine-preventable diseases. The objective was specific as it only intended to protect children only against  Tuberculosis, Diphtheria, Pertussis, Tetanus, Polio, Hepatitis B, Pneumonia and Meningitis due to Haemophilus Influenzae type b (Hib), Measles, Rubella, Japanese Encephalitis (JE) and Rotavirus diarrhea, and time-bound as it planned to do it  by 2020. The objective was achievable as we are already doing it in few districts and measurable as we have a robust district-wise system for monitoring and evaluation system in place. It was very much relevant as vaccine-preventable diseases account for no less than 1.5 million deaths in India.

Phased approach.

The program was implemented in a phased manner, with the district having the higher prevalence of un-immunized population is targeted first followed by the area with better immunization record.

Four phases of Mission Indradhanush

In a survey done by Ministry of Health and Family Welfare (District Level Household and Facility Survey 2007-08), when mothers of the children not immunized, were asked, only 2.3 percent mothers quoted the no availability of vaccine as the reasons for failure to get the child immunized. Around ten percent of cases attributed it to non-availability of the ANM to vaccinate he child. But in 45 percent of cases, parents were not aware of the importance of vaccination in a child.

Reasons for missing vaccination sessions obtained by routine monitoring interviews with care givers of undervaccinated children between October 2017 and February 2018 credit: BMJ

Accountability

The lack of accountability of the government health staff delegated with this critical responsibility was a major hurdle faced during the implementation of previous vaccination programs. There was a significant gap between the reported coverage of vaccine and the actual evaluated coverage. Even in states like Maharashtra which has as overall very high coverage of vaccination, there were districts like Nandapur which has a coverage of less than 40 percent.

Monitoring

The most impressive of all feats were to install an elaborate, multi-tiered and understandably complicated framework for a rigorous monitoring system for the largest immunization programmes of the world. The operational activities were monitored from the top at the national level and down to the house to house monitoring of the actual immunization services delivered on previous days.

Mission Indradhanush also had a well-carved strategic communication plan needed to reach communities and hard-to-reach populations and building trust in health care services.

Communication and awareness

Planners of the mission knew that they could not meet the target if the people are not willing to accept that. Some of the communication strategies adopted for Mission Indradhanush were remarkably innovative, some not expected from a government-funded immunization program.

One person was designated at the state/social media agency to plan, execute, monitor a social media plan. There was a message approval team in case any new messages were created/adapted, especially for social media.
Mission developed special communication products such as talk shows on television/radio with pediatricians, short videos of influencers appealing to communities, short videos of parents who have full confidence in vaccines and have completed immunization for their children and had a separate budget for same.
Mission Indradhanush had a Google email Group/ WhatsApp group of selected communication coordinators at the state and district level for real-time information sharing. A may also be created with clear responsibility/coordination.

There were clearly defined roles of people responsible for communication/ coordination at each level of district, block, and village; indicating who is in charge and who is responsible for what and by when. 

Mission used geographical/community mapping to identify LODOR families (Leftouts-Dropouts-Resistant), with disaggregated demographic characteristics such as tribal areas, rural or urban; difficult terrain, hilly, riverine or desert regions; conflict regions.

Mission converged with the health department to generate awareness about immunization through school curriculum/extra-curricular activities around the planned phase of Intensified Mission Indradhanush.

Mission coordinated with Indian Broadcasting Federation, Private Radio channels and explore areas of support including CSR for private FM channels.

Mission generated awareness on immunization in minority communities and their mobilization to ensure full coverage of all children.

Mission utilized spots on trains & railway stations; railway stationery

like tickets, etc., for immunization branding.

The time-tested phased approached was adopted for covering the entire country for vaccination. in the first phase the districts with the most mediocre record in vaccination percentage and high frequency of Vaccine-preventable disease were chosen, the second phase included districts with a relatively better track record.

Micro planning

The experience gained by polio eradication program has greatly helped in the planning required for successful implementation of  Mission Indradhanush. Meticulous planning was done for immunization sessions schedules training of frontline workers and their supervision.  But that was not all. Effective communication and social mobilization and accountability framework were planned well in advance.

One can get an idea of the extent of micro-planning by the fact that there was not just well-crafted media policy, but also a crisis management strategy to take care of any mishap or any attempt to spread myths and rumors by anyone

The right partners

One of the great achievements of the mission Indra Dhanush was to forge meaningful collaboration between different ministries of the government, and with non-governmental agencies. From Defence to  Minority Affairs, a total of 14 different ministries of the government of India worked in tandem to make it possible.

The Government effectively collaborated with   WHO, UNICEF, UNDP, Global Health Strategies, IPE Global, Rotary International, Technical Support Units (TSUs) to complete this massive task.

Outcome 

The program was finally able to vaccinate 32.8 million children and 8.4 million pregnant mothers in the last three years. Prestigious British Medical Journal has listed it as one of the 12 best practices in the world.

Proportion of children aged 12-23 months fully immunised in 190 Intensified Mission Indradhanush (IMI) districts, by state or region before and after IMI credit: BMJ

But more important is the fact that it has changed the perception we had about the coverage of immunization of children and pregnant women. Earlier the average of 60 percent coverage was accepted as okay. Now, Mission Indra Dhanush has raised that bar to 90 percent plus. The future immunization programs and similar health-related initiative will be evaluated against this high bar set by Mission Indradhanush.