Developing a Roadmap to Reach and Sustain 90% Full Immunization Coverage through a Cross-sectoral System Strengthening Strategy in Bihar, India

"With immunization services generally available and accessible to most beneficiaries in Bihar, effective demand-side processes for immunization services are critical for the next phase of growth."

A strong momentum exists in India towards routine immunisation (RI) strengthening, as evidenced by multiple initiatives and policies. However, full immunisation coverage (FIC) in the state of Bihar has reached ~ 71%, which is far from the government's aspiration of 90% FIC - this despite several high-impact coverage improvement interventions in the state that collectively indicate a strong political will to achieve high FIC and equity. This study reviews the factors leading to underimmunised children in the state of Bihar and offers a forward-looking roadmap to reach and sustain 90% FIC by adopting a system strengthening approach.

From July to September 2020, the researchers conducted a desk review, followed by stakeholder interviews and field visits to document and analyse data and evidence relevant to RI system performance in the state of Bihar. The 86 stakeholders included the state immunisation officer, district immunisation officers, block-level health officials, representatives from development agencies, healthcare workers, and caregivers.

Before describing the interventions and associated implementation scale used in this study, the researchers conceptualised a maturity index as a mechanism for subjectively assessing the level of maturity or readiness of identified programme components based on criteria such as policies, procedures, training, infrastructure, and governance. Each thematic component and subcomponent was assigned a maturity index for the current level and the target level. After the index was assigned, potential interventions were identified through a process of research, consultation, and brainstorming and then arranged into short (< 6 months), medium (6 months to 2 years), and long (2 to 5 years) time horizons.

The first two phases of the study shed light on the relative shortage of health infrastructure in Bihar, emphasised through high population loads per facility and accessibility challenges. Health infrastructure and staff capacity need to be augmented to match the needs of the population across the state. The focus must be placed on both the availability of healthcare workers and the skill building and mentorship of healthcare workers. It is also recommended that the state build the capacities of community leaders to engage in nontraditional mobilising techniques to instill community ownership in promote vaccine demand. There is a need to expand the level of caregiver knowledge regarding the specifics of the immunisation schedule, session location/timings, and management of postvaccination effects.

The third phase of the study focused on converting the in-depth assessment of the collected data and insights into strategies, identifying key areas for action, and assessing the feasibility and potential impact of the interventions. This activity was conducted in November and December 2020. The roadmap enlists 40+ interventions across key thematic areas and has been prioritised over a 5-year time horizon as short-, medium-, and long-term milestones to achieve 90% FIC. This staggering of interventions is a strategy for helping the government break down the strategic goal of achieving and sustaining 90% FIC into manageable steps and to allocate resources effectively. (See figure 7 in the paper.) These interventions include strengthening data availability and quality, improving the governance and review mechanism, augmenting the capacity of health workers involved with the immunisation programme, and launching initiatives to increase demand for immunisation services.

For example, in the area of demand generation, evidence indicates that healthcare-seeking behaviour for immunisation across population groups in Bihar falls on the side of the public sector, with only 1.4% of rural children being immunised at private facilities. Key challenges include an awareness gap among caregivers (39%), apprehension about adverse events following immunisation, or AEFIs (27%), and other reasons, such as an operational gap (9%), refusal (6%), and child travelling (16%). With a proclivity to miss documenting the migratory population during headcount surveys and microplanning exercise, migrants are often the contributors to cases of delayed and sometimes missed vaccination.

As the article outlines, multiple districtwide and statewide innovations have been implemented to increase the demand for immunisation. Examples include the Mukhyamantri Kanya Utthan Yojna (a state government-led policy aimed at uplifting girls), the Aapki Sarkar Aapke Dwar (Your Government at Your Doorstep initiative) drive, the establishment of Model Immunization Centers (providing high-quality immunisation services in a comfortable environment), and the pursuit of interdepartmental collaboration with self-help groups to generate awareness and demand for immunisation services.

Interactions with interviewees indicated that, nonetheless, there exist some areas and communities in Bihar where context-specific demand generation work is needed. These communities typically have a population that has historically faced social exclusion and vulnerabilities that disproportionately impact their access to immunisation services and inequity. Community members from such population cohorts need targeted visits by health workers or sometimes even by senior government officials to convince them to take their children for immunisation. To mobilise such communities, Vikas Mitras (a "development friend") acts as the interface between health workers and their community to spread information about public health among other government services. As they belong to the same community as beneficiaries, there is an increased sense of trust among beneficiaries. Such examples highlight the complex and intertwined role of social, cultural, and economic factors in the demand for and uptake of immunisation and vaccination services.

Conversations with caregivers and beneficiaries indicated that their awareness of the technical aspects of immunisation services is low and that they are usually dependent on their Accredited Social Health Activists (ASHAs) for much of the informational support, including the next service delivery date. The incidence of AEFIs tends to influence caregivers against continuing with the immunisation schedule and potentially dropping out.

In conclusion: "The key contribution of the researchers here is to conduct a structured diagnosis of the immunization system and recommend a set of interventions that would support the government to reach and maintain 90% full immunization coverage. The lessons learned from Bihar's Immunization Roadmap development project can provide insight for other states and countries that aim to formulate similar action plans."