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| DR. J. E. PARK MEMORIAL ORATION |
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| Year : 2010 | Volume
: 54
| Issue : 2 | Page : 71-74 |
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Time to revamp the universal immunization program in India
SK Pradhan
Director, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
| Date of Web Publication | 27-Nov-2010 |
Correspondence Address:
S K Pradhan
Director, All India Institute of Hygiene and Public Health, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-557X.73273
How to cite this article:
Pradhan S K. Time to revamp the universal immunization program in India. Indian J Public Health 2010;54:71-4 |
 Introduction | |  |
The universal immunization program (UIP) in India does not need any introduction to any public health expert in the country. The UIP is the largest immunization program in the world and caters to 27 million infants and 30 million pregnant women annually. The first organized efforts in India to immunize children were started in 1978 under the name of Expanded Program on Immunization (EPI), where the intention was to expand the program reach but unfortunately program still remained focused upon the urban areas. Things seemed to change and it was universalized in 1985 to cover six vaccine preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, polio, and measles) and rechristened as universal immunization program (UIP) to cover all the districts in the entire country. [1] The name still continues, although, the program has seen many changes since the very inception. It was part of one of the Technology Missions since 1986 and was monitored under the 20-point program by the Prime Minister's Office. Going through the phases of Child Survival and Safe Motherhood (CSSM) program in 1992, Reproductive and Child Health-I (RCH-I) program, from 1997, and finally under National Rural Health Mission (NRHM) in 2005, it has, in a way, witnessed many changes. [2],[3] The only thing remaining common is that even after the 25 years of implementation, the coverage with six antigens is poor in many states, more than 9 million infants still do not receive all the vaccines they should, polio is still endemic in India, and more children die due to measles in India than the rest of the entire world. [4],[5]
In the common discussion, the UIP is also known as the routine immunization (RI) program. The RI program is a national immunization schedule prepared by the Ministry of Health and Family Welfare; it makes vaccines available free of cost and delivered through various central/state government agencies, health workers, and private practitioners.
| Policy process and planning over the years | | |
The UIP was independently reviewed, at least twice till 2000, first in 1989 and then in 1998, but no systematic effort was made during this period besides scattered activities and projects like Immunization Strengthening Project (ISP), Border District Cluster Strategy, etc. The government has established a National Technical Advisory Group on Immunization (NTAGI) in 2001. [1] The NTAGI is a group of experts from the Government of India, state governments, academic institutions, development partners, and professional organizations, who meet on an annual basis to discuss the technical and policy issues pertaining to the program and advise on the introduction of newer vaccines, based on the available disease burden data. Any major immunization decision is first discussed by the NTAGI and the recommendations given are then operationalized by the Program Division within the Ministry. This was followed by another review of UIP in 2004, conducted in six poor performing states, which led to the basis of first multiyear strategic plan for UIP in India (MYP 2005-2010) and outlining the strategies for improving the UIP in India. [1],[2],[3],[4],[5]
| The current status of the UIP in India | | |
Over the years, the UIP has developed self-sufficiency in all material, manpower, and intellectual property related to vaccination and there has been a significant decline in major vaccine-preventable diseases. The small pox has been eradicated, while polio is on the verge of eradication. Nevertheless, there are millions of children and pregnant women not getting benefits of immunization, and there are regional, racial, and gender differences in vaccination coverage. The National Family Health Survey III (NFHS III), conducted in 2005-2006, showed that there was a marginal improvement of fully immunized children from 42% to 44% nationally. There has been some improvement in comparison to NFHS II conducted in 1998-1999. Improvement from NFHS II to NFHS III in the state of Uttar Pradesh is from 20.2 to 22.9, in Bihar from 11.62 to 32.8, in Jharkhand from 8.8 to 34.5, and in Rajasthan from 17.3 to 26.5. However, in some of the good performing states like Tamil Nadu, Maharashtra, Karnataka, Kerala, and Punjab, the coverage of fully immunized children has gone down. [6]
In last 3.5 years since the launch of RCH II/NRHM, the improvement in the immunization coverage has been reported by District Level Household Surevy-3 (DLHS 3) of 2007-2008 and has shown that the overall rate of fully immunized children has increased from 43% in 2002-2004 to 54% in 2007-2008. The country has two spectrums, while some poor performing states have increased in their coverage, Assam 16-48%, Jharkhand 26-54%, Rajasthan 24-49%, and Bihar 21-41%; some states like UP and MP have shown only 5-7% point increase. [7]
| Major challenges to the program | | |
During the various interactions and in the review meetings of UIP in India, there are some areas which have been identified for improvement. [1],[2],[3],[4],[5] The major issues being reported are as follows:
- Human resource gap
- Lack of adequate health infrastructure
- Poor microplanning and immunization sessions not being held regularly, in the community
- Reported and evaluated data
- Low capacity to supervise, monitor, and implement micro-plan and feedback at district and health facility level
- Inadequate supervisory visits
- Lack of proper supervision and monitoring, and delay in taking corrective measures in areas of concern at the Government level
- Failure to assess the program in terms of outcome, i.e., incidence/prevalence of the disease (GOI monitors program success by the number of vaccine vials consumed)
- Tendency to work independent of private/other agencies resulting in either duplication of effort or absence of services in some areas
- Records not maintained properly and reporting are other major areas and the reported coverage is always much higher than the evaluated one
- Low managerial and support capacity
- Community participation and IEC are still major constraints
If we further analyze these challenges and categories, it would be noted that these challenges are at almost all levels. These problems and bottlenecks need a multifaceted and an immediate readdressal.
| Issues at the community level | | |
- Poor voluntary community participation
- Parents are not aware of vaccine availability, efficacy, immunization schedule, sometimes even of the immunization site in their own villages
- Unsuitable timings of vaccination for many people when the community actually goes to the work
- Program independent of other health-care initiatives, needs integration
- Missed opportunities
| Problems recently emerged | | |
- Weak service delivery
- Low coverage rate
- High dropout rates in many states
- Injection safety
| Key challenges at the program management level | | |
- Service delivery and injection safety
- Surveillance
- Monitoring
- Vaccine distribution and cold chain
- IEC and social mobilization
| Is NRHM changing the immunization program for better? | | |
If we analyze the initiatives taken under National Rural Health Mission [8] in India for betterment of immunisation program, it seems that the increased fund flow has helped in some of the areas: alternate vaccine delivery (AVD) to ensure that vaccine reaches to each session site; alternate vaccinators to ensure sessions are held at the site where no regular vaccinator is available; social mobilization to ensure demand creation in the community; strengthening supportive supervision; half yearly meeting at state level with districts to ensure monitoring; and support for POL to assist active supervision. Furthermore, the auto-disable (AD) syringes have been introduced to ensure injection safety, and the aging and poorly maintained cold chain is being replaced with new and chlorofluro carbon (CFC)-free equipments. The BCG vaccine vial has been downsized from 20-dose to 10-dose vial to reduce wastage; the NRHM has helped in improving the immunization infrastructure in urban, periurban slums, and rural areas.
| The ways out | | |
India runs such a large program, even then in 2007, but more than 9 million infants were not fully immunized in India. The vaccine not reaching approximately 3 million children, who do not receive any vaccination, is a point of major concern. [3],[4],[9] It is the time country starts working at multiple levels and strengthening the immunization program by acting at different levels.
| At the government level | | |
- Fix responsibility
- Measure success in terms of outcomes
- Strengthen RI monitoring, both by government and partner agencies
- Encourage debate and discussion to find a solution
- Program ownership and political will power
- Independent review
| Logistics and infrastructure | | |
- Fill all vacant posts and train the staff under different categories involved in the immunization program
- Sort out problems related to vaccine availability, transportation, storage, and distribution
- Develop an alternate plan for events such as disruption of power supply, breakdown of cold chain, etc. (generators or inverters may be provided)
- Recording of events
| At a managerial level | | |
- District immunization officer (DIO): Many districts in the country have DIOs in-charge and do not have a full-time DIO. Further, they are assigned multiple works at a district level. Many of them are involved in the clinical practices and consider immunization a secondary activity.
- Role of medical colleges: The medical college should be made responsible for immunization activities in the adjoining four to five districts. There is a need for a coordination cell between medical colleges and Department of Health Services - both are working in watertight compartments. The academic excellence of medical colleges and infrastructure in Health Services is complimentary.
- Public-private partnership: Government could partner with Public Health experts, pediatricians/obstetricians to provide services. The models are successfully working in states like West Bengal and Gujarat and need to be further explored and expanded.
| Actions needed for community involvement | | |
- Service delivery is more efficient if people come to service (fixed site) rather than service going to people (house to house)
- Involvement of Panchayat, community leaders
- Health workers, Anganwadi workers, Accredited Social Health Activists (ASHAs) to work from and within the community.
| Actions for improving IEC and social mobilization | | |
- Identification of newborns and tracking defaulters
- IEC brand tool kit for routine immunization (prototypes for fliers, banner, posters, handouts, etc.)
- A series of media spots for advocating key immunization messages
- Coordination meeting with the Health and IEC bureau of weak performing states to develop communication plan - at a national level
| Conclusion | | |
Twenty-five years of program implementation is a reasonably long time to strengthen the program at any level. There are still some issues at different levels in UIP, which should be immediately addressed. India is still vaccinating children with the same vaccines which it started in 1985. Only few states or districts have introduced MMR, hepatitis B, and JE vaccines. Globally, many new and underutilized vaccines (Hib, pneumococcal, rotavirus, typhoid, etc.) have been introduced, the benefit of which is not reaching to the infants in the India, because the existing program is not functional well.
The price of a poorly functioning program is being paid by the infants of India, as they do not receive the vaccines, which majority of the children in both developed and developing countries are receiving for long. It is time that the country cleans the mess and strengthens the immunization program. The solutions are all well-known and well within the reach.
| References | | |
| 1. | Ministry of Health and Family Welfare, Government of India. Review of Universal Immunization Program in India 2004. New Delhi, India 2005. 
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| 2. | World Health Organization. Immunization and biological. Available from: http://www.who.int [last accessed on 2008 Mar 24].
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| 3. | Lahariya C, Paul VK. 2 Million Child deaths in India: What needs to be done for improving child survival in India? Indian J Pediatr 2010;78:23-7.
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| 4. | World Health Organization. Global immunization data 2008. Available from: http://www.who.int/immunization/newsroom/Global_Immunization_Data.pdf [last accessed on 2008 Mar 24].
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| 5. | Government of India. Multi year Strategic Plan for Universal immunization program in India (2005-10). Ministry of Health and Family welfare, New Delhi 2005.
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| 6. | International Institution for Population Sciences. National Family Health Survey -3 (2005-06). Mumbai and ORC Macro, Maryland: IIPS; 2007.
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| 7. | International Institution for Population Sciences. District Level Household Survey -3 (2007-08). Mumbai and ORC Macro, Maryland: IIPS; 2007.
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| 8. | Government of India. National Rural Health Mission. Ministry of Health and Family Welfare, New Delhi, India 2005.
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| 9. | Lahariya C. A review of Preventive and Social Medicine. New Delhi: Jaypee Brother Medical Publishers; 2008.
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