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June 2011
Health Network meeting 13th December 2011
Intensification of Routine Immunization (IRI) in India:
An Update and action plan for reaching the unreached inYear 2012
Presentation outline
• Status and performance of RI• Efforts to strengthen RI• Continued challenges in reaching the
unreached• Action plan for Intensification of RI (IRI)
2012• Conclusion
Routine immunization performance
RAJASTHAN
ORISSA
GUJARAT
MAHARASHTRA
MADHYA PRADESH
BIHAR
UTTAR PRADESH
KARNATAKA
ANDHRA PRADESH
JAMMU & KASHMIR
ASSAM
TAMIL NADU
CHHATTISGARH
PUNJAB
JHARKHANDWEST BENGAL
ARUNACHAL PR.HARYANA
KERALA
UTTARANCHAL
HIMACHAL PRADESH
MANIPUR
MIZORAM
MEGHALAYANAGALAND
TRIPURA
SIKKIM
GOA
A&N ISLANDS
D&N HAVELI
PONDICHERRY
LAKSHADWEEP
FI: 61%• OPV3: 70.4%• DPT3: 71.5%• Measles:
74.1%
Proportion of Fully immunized (FI) children
DLHS-2Below 4040 to 5050 to 6060 to 70Above 70
India State
FI: 62%• OPV3: 68%• DPT3: 68%• Measles:
71%
CES 2006
CES 2009
FI coverage: CES 2009 vs CES 2006
-30
-20
-10
0
10
20
30
AN AP AC AS BI CH CG DN DD DL GO GU HA HP JK JH KA KE LD MP MH MN ME MZ NA OR PD PB RJ SI TN TR UP UA WB
Delhi: - 14 %Haryana: -3 %
Punjab: +8 %
Rajasthan: +6 %
Bihar: +11 % UP: +4 %
MP: - 11 %
12 low performing states improved
However, 17 states declined
Jharkhand: +7 %
Maharastra: +6 %
WB: - 5 %
Assam: +20 %
Where are the missed children?
(Equity in Immunization)
Data not available
0-1 %
1-4 %
8 %
10 %
13 %
35 %
5 %
Where are the unvaccinated? Children not vaccinated with DPT3
Source: DLHS 2007-08; children surveyed were between 12-23 months 72% in 5 states
Where are the unvaccinated?District-level percentage of fully immunized children
FI (DLHS-2)Below 3030 to 5050 to 7070 to 90Above 90
Data not available
FI (DLHS-2)Below 3030 to 5050 to 7070 to 90Above 90
Data not available
Wide intra-state variations
Source: DLHS 2007-08; children surveyed were between 12-23 months
Urban
Rural
Oth
ers
Schedule
d Cast
es
Schedule
d Trib
es
Richest
Qunitle
Poorest
Quin
tile
63
50
63
53
46
73
36
37 %
Percentage of children age 12-23 fully immunized
District Level Household Survey 2007-2008
Immunization coverage varies significantly among different population categories
Continued Challenges
Key Programmatic challenges
• Shortage of trained human resources at all levels
• Coordination and planning:– Weak inter-sectoral coordination among Health, ICDS and
other ministerial departments (eg education)
– Lack of quality RI micro-plans and PIPs in many districts, states
• Data reporting and use:– Divergent coverage estimates – survey assessed and
reported
– Tracking children
• IEC – Communication for behavior change:– Inadequate social mobilization and demand generation for
immunization
RAJASTHAN
ORISSA
GUJARAT
MAHARASHTRA
MADHYA PRADESH
BIHAR
KARNATAKA
UTTAR PRADESH
ANDHRA PRADESH
JAMMU & KASHMIR
ASSAM
TAMIL NADU
CHHATTISGARH
PUNJAB
JHARKHANDWEST BENGAL
ARUNACHAL PR.HARYANA
KERALA
UTTARANCHAL
HIMACHAL PRADESH
MANIPUR
MIZORAM
MEGHALAYANAGALAND
TRIPURA
SIKKIM
GOA
A&N ISLANDS
DELHI
D&N HAVELI
PONDICHERRY
LAKSHADWEEP
0 – 10%
10 – 20% 20 - 28%
Source: DLHS 3 2007-08
System weakness in tracking and following children:
Percentage difference between BCG and MCV1 coverage
Improved access but declining utilization
Bihar-
2
Bihar-
3
Chhattisg
arh-2
Chhattisg
arh-3
Daman
& D
iu-2
Daman
& D
iu-3
Jhark
hand-2
Jhark
hand-3
Mad
hya Prad
esh-2
Mad
hya Prad
esh-3
Uttar P
rades
h-2
Uttar P
rades
h-30%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Full Immunization Partial Immunization No Immunization
Source: DLHS-2 and DLHS-3
Analysis of gaps
• Low Access :– Immunization session sites are not included in
microplan– Session not attended by ANM – leave, post
vacant, not going to the site• Poor utilisation:
– Irregular sessions, variable quality of services– Non-availability of vaccine/logistics– Poor messaging and communication – Low community confidence in services
Reasons for being partially immunized: June 2010 – May 2011
*WB data for May & June, ’11 only
33%41% 37% 37%
8%5% 9% 5%
23%23%
11%26%
18%16%
22%
16%
18% 16%22% 16%
0%
20%
40%
60%
80%
100%
Bihar UP J harkhand WB
Awareness & Information gap Operational gap
AEFI apprehension Other reasonsData not available
Efforts to strengthen RI
Efforts to strengthen RI
1. Policy level initiatives
2. Expanding RI micro planning and monitoring
3. Capacity building
4. Cold chain and vaccine mgt. strengthening
1. Policy level initiatives
• New draft Multiyear Plan (cMYP) developed 2010-17
• Decentralized and flexible funding as per state Project Implementation Plans (PIP) under NRHM– District/block specific plans for hard to reach areas
(inaccessible, tribal and urban) are reflected in PIPs
– Funds for Addl. Vaccinators, alternate vaccine delivery, ASHA
• Indian Public Health Standards (IPHS) – revised
• Human resource assessment at national and state level for UIP ( IIM Ahmedabad 2010)
• Developed National Vaccine Policy in 2011
National Vaccine Policy
• Made by Consultative process
• Core committee incl. experts, NTAGI members, UNICEF and WHO
• Guided by principle of vaccine security
• Newer vaccine introduction kept in mind
Improving RI microplan
• State initiative supported by partners
• RI micro-plans revised using more frequently updated polio micro -plans
• Exercise lead to increase in number of outreach sessions planned
19,978
9,797
21,104
12,596
0
2500
5000
7500
10000
12500
15000
17500
20000
22500
UP (12 districts) BIHAR(4 districts)
Sessions planned prior to microplan exerciseSessions planned after microplan exercise
1,126 added sessions
2,799 added sessions
Harmonization of Polio SIA & RI Microplan
District: Bulandshahr, Uttar Pradesh
Every polio SIA team carries this plan and must inform
parents of when and where RI sessions are held
SIA component
RI component
Village visited by SIA team
Improving and expanding RI monitoring
• In 2011, more than 9,000 session sites and 90,000 children monitored per month in 3 high priority states
• RI monitoring expanding to other states: West Bengal, Karnataka, Rajasthan, Punjab, Orissa, Delhi, Assam
RI monitoring: June 2010 – May 2011
State Sessions monitored
Children surveyed
0 to 11 months 12 to 23 months
Bihar 36,362 200,015 87,474
Jharkhand 5,158 24,303 12,998
UP 83,890 500,719 170,100
TOTAL 125,410 725,037 270,572
47
57
35
51
20
25
30
35
40
45
50
55
60
65
70
Jun'10 Jul Aug Sep Oct Nov Dec Jan'11 Feb Mar Apr May
per
cen
tag
e (%
)
UP State HR blocks
Full immunization coverage: RI monitoring
UP & HR Blocks, June’10 – May’11
Visited1
Up.shp
BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100
Visited1
Up.shp
BCG_0M0 - 4040.1 - 6060.1 - 8080.1 - 100
Data not available
<= 40%
40% to 60%
60% to 80%>= 80%
Not monitored
UP State State Average = 51%
Children 12-23 months: 207,811HR Blocks CumulativeAverage = 43%
Children 12-23 months: 39,346 KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
<Empty Picture>
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
<Empty Picture><Empty Picture>
BAD
BJN
PIL
SHA
BRL
MZN
AGR
SHP
ALG
BLS
MRD
MTR
MAI
ETA
MRT
JPN
FER
FKB
RMP
ETW
KAN
GZA
HTR
BGT
GBN
% RI sessions not held: UP & HR blocks
June’10 to May‘11
UP districts – cumulative
State Average: 8.5%Sessions not held: 6,613 out of 70,851
> 20%
15% to 20%10% to 15%
< 10%
% Sessions not held
HR BlocksState Average:
8.6%Sessions not Held:
1,196 out of 13,856
SHP
PIL
RMP
FKB
SHA
ETA
KAN
ALG
MTR
JPN
BRL
AGR
BAD
HTR
GBN
BJNMZN
BLS
ETW
MAI
MRD
MRTBGT
GZA
FER
SHP
PIL
RMP
FKB
SHA
ETA
KAN
ALG
MTR
JPN
BRL
AGR
BAD
HTR
GBN
BJNMZN
BLS
ETW
MAI
MRD
MRTBGT
GZA
FER
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
<Empty Picture><Empty Picture><Empty Picture>
By ICDS
UP districts - cumulativeState Average = 34.2%
ICDS found present: 24,249 out of 64,653
By ASHA
< 20%
20% to 40% 40% to 60%
> 60%
Mobilization of beneficiaries at monitored RI session sites, U.P. April ’10-March ‘11
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
<Empty Picture><Empty Picture><Empty Picture>
UP districts - cumulativeState Average = 63.5%
ASHA found present: 44,981 out of 64,653
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
KRI
SBD
STP
LLP
HDO
JAL
JNS
AHB
BJN
BAD
BRC
PIL
SHA
MZP
BRL
FTP
BNA
JNP
UNN
AZG
MZN
AGR
ALG
SHP
BBK
HMP
BLS
GND
PTG
KSN
MRD
BRP
RBL
FAI
GZP
BAL
GRPBST
KPN
CKT
MTR
MAI
KPDSULCSN
MHB
ETA
SDN
MRT
LNO
DOR
JPN
FKB
CND
FER
ABN
RMP
MHG
ETW
KNA
KAN
AUR
GZA
HTR
KSM
SRW
MAU
SKN
VRN
BGT
GBN
BDH
<Empty Picture><Empty Picture><Empty Picture>
Training & Capacity Building
• Health Workers:– Re- started in year 2007, majority of HW got 2
days training exclusively on immunization– Evaluation of HW training done in year 2009-10– New Training material developed, refresher
training started this year (Feb 2011)• Medical Officers:
– Ongoing in most states– 60,000 Medical Officers to be trained – Approx. 60% have been trained by now
Action Plan to improve RI coverage with Equity
( Year of intensification 2012)
Detailed guidelines under development
Prioritization of the statesCategory DPT3 coverage Names of the states Remarks
Poor performing states
DPT3 coverage less than national average (NE states excluded)
MP, UP, Bihar, Rajasthan, Jharkhand, Orissa, Gujarat, and Chhattisgarh
Good and medium performing states
DPT3 coverage more than national average(NE states excluded)
Rest of the states
North Eastern states
Not considered Assam, Sikkim, Arunachal Pradesh, Manipur, Mizoram, Nagaland, Tripura, Meghalaya
Difficult to access, geographical terrain, during a large part of the year
Grouping of the states for IRI in India-2012
North-East states
Poor performing states
Good & medium performing states
Note: These states have been categorized, based upon DPT3 coverage in India, as per CES-2009
Identification and prioritization low coverage areas
Strategy• Risk analysis using block as unit • key basic parameters for risk analysis are
– Immunization coverage, drop-out, – outbreaks of measles or other VPDs, – session monitoring data, – accessibility, and availability of services,– human resource availability– high risk population data collected for Polio
under the RRT (EPRP)
Special strategies (1/3)
• Development of action plan with clear timelines.
• Suggested components to include but is not limited to – Up-dation of micro-plan– Reallocation of human resource– Trainings– Intensive IEC activities– Catch up vaccination (Immunization weeks)
b/w Jan- April 2012 to raise the profile of Imm. Program and to reach the unreached
Special strategies (2/3)
• Communication strategy and operational plan to be rolled out in Q1, 2012– Awareness about session site (visibility)– Branding of immunization– Advocacy with media and partners
• HR strengthening– strengthening in management structure,
Technical support unit (TSU) be set up at national/ state level in accordance with HR assessment report
– Filling up vacancies at all levels including ASHA and AWW
– Detailed guideline under development
Special strategies (3/3)
• Teeka Express– Strengthening AVD– to provide a branded vaccine
delivery van to cold chain point for the delivery of vaccine to the session site and return back
– In underserved populations, tribal, hard to reach areas, LWE areas, urban and peri-urban areas
• Improved supervision (addl. Funding under PIP)
• Cold chain & VM
To conclude..
• India accounts for highest number of un- immunized children in the world
• Disparity exists among rich/ poor, rural/ urban and social groups
• Year of intensification 2012 has provided an opportunity to accelerate efforts to reach the unreached.
