Mission Indradhanush and Intensified Mission Indradhanush - Success Story of India's Universal Immunization Program and the Role of Mann Ki Baat in Bridging the Immunization Gap

"[O]ne of the major factors responsible for the success of the program was ownership by the topmost leadership of the country"

Despite the availability of effective vaccines, many children in developing countries, including India, remain unvaccinated or partially vaccinated. Although the Government of India introduced the Expanded Programme on Immunization (EPI) in 1978, which was followed by the Universal Immunization Programme (UIP) in 1985, in 2015-16, approximately 38% of infants did not receive all of the essential vaccines during their first year of life. Several factors contributed to low vaccination coverage, including inadequate demand from populations lacking information or with misinformation, concerns over potential side effects following vaccination, and challenges in reaching large, mobile, and isolated populations. This article explores the Government of India's push to address low childhood immunisation coverage through Mission Indradhanush (MI), which was launched in December 2014, and Intensified Mission Indradhanush (IMI), which was launched in October 2017.

As outlined here, Hon'ble Prime Minister (PM) Shri Narendra Modi captured the essence of MI in his Mann ki Baat (a monthly radio programme in which he interacts with citizens on themes and issues that matter to the nation) on October 30 2016. He highlighted the significance of vaccination of every child and lauded that the MI programme is striving to vaccinate every child with vaccine doses missed during routine immunisation (RI) through 3-4 special vaccination rounds of around 7 working days each. "The visibility of the program garnered by the advocacy by the topmost leadership during Mann ki Baat, not only created awareness among the population about the vaccination program and its health benefits but also stamped the credibility of UIP."

Efforts and innovations implemented during MI - evidence-based microplanning, cross-sectoral convergence, strategic communication to generate awareness and vaccine confidence, intensification of immunisation campaigns in low-performing areas, intensive monitoring, and strong political commitment - are integrated into RI to strengthen the UIP.

To overcome demand-side challenges, MI implemented measures to promote equity and combat misinformation, such as conducting social mobilisation, disseminating accurate information, and debunking vaccination-related myths. Local stakeholders, community and religious leaders, and social media platforms were leveraged to enhance engagement.

One of the distinctive approaches of MI was its emphasis on achieving equity by prioritising high-risk populations residing in traditionally underserved areas with low immunisation coverage. To reach children in these areas during MI campaigns and RI, a customised, evidence-based, and community-centric service delivery strategy was developed. As part of this strategy, the programme integrated the concept of vaccination on demand, empowering community leaders to request vaccination sessions at their preferred time and location and ensuring that all eligible children and pregnant women are vaccinated.

About a year after the aforementioned Mann ki Baat, the PM launched IMI, emphasising in his speech that immunisation is not just a government-led initiative but, rather, a social movement that requires the participation and ownership of all citizens. He urged everyone to own the programme and work towards reducing maternal and child mortality rates.

To assess the effectiveness of these immunisation intensification drives (MI/IMI) in increasing immunisation coverage in India, the researchers used a mixed-method approach. They found that, to date, 701 districts have been covered under 11 phases of MI/IMI, wherein 4.46 crore children and 1.12 crore pregnant women have been vaccinated. In every round, on average, 6 million children and 0.5 million pregnant women have been vaccinated. There is a correlation between the number of MI and IMI rounds and an increase in fully immunised children (FIC) in districts: Districts that conducted 5 or more IMI rounds experienced a maximum increase of 20.6% in FIC. Furthermore, more than 420,000 high-risk and underserved areas were included in these campaigns as well as in RI microplans to sustain the gains. MI/IMI also helped in reaching the urban slum and peri-urban population.

The communication interventions undertaken resulted in improvement in demand-side indicators for MI and for RI in the country. Concurrent monitoring data shows that as an outcome of these efforts, around 62% (127/202) of districts have a complete communication plan in place in 2021 as compared to 48% districts in 2017. Visibility of information, education, and communication IEC materials at the session site also increased from 26% in 2016 to 77% in 2021.

The researchers suggest that advocacy of MI/IMI by the PM himself was pivotal in effective intersectoral partnerships and coordinated activities. Continuous monitoring of the programme by the leader of the country ensured sincere supervision of the activities for effective implementation. Various departments of the health ministry as well as the other 12 ministries were engaged with defined roles and responsibilities. They provided support for expanding service delivery points, transporting supplies, raising community awareness, and carrying out social mobilisation. Since the intersectoral partnerships were successful, this effective collaborative way of functioning has been institutionalised through regular governance mechanisms of the UIP and "is bound to have a sustainable impact".

Having pointed to other immunisation system-strengthening initiatives under MI/IMI, the paper concludes that the active engagement and oversight of the PM played a crucial role in creating and maintaining the necessary political momentum for the MI/IMI initiative, which in turn secured the buy-in and support of government and non-government stakeholders across different sectors and levels. According to the research, MI/IMI succeeded in enhancing the planning of immunisation communication. "The improved vaccination uptake and its evolution to incorporate people-empowering initiatives like vaccination on demand is proof that the program is indeed a people's movement."