Indian Pediatr 2009;46: 991-992
Routine Immunization in India: A Reappraisal
of the System and its Performance!
Vipin M Vashishtha
Consulting Pediatrician, Mangla Hospital, Bijnor 246 701,
pproximately 2.5 million children
under five years of age die every year as a result of diseases that can be
prevented by vaccination using currently available or new vaccines(1).
India houses a large chunk of these unimmunized children. According to
2006 estimates, around 12 million children were not immunized, Uttar
Pradesh with more than 3.0 million unimmunized children tops this list(2).
Current Status of Routine Immunization
The current status of routine immunization depends upon
which survey’s results are you referring to. If one follows the state-wise
routine reporting system under RCH program (monthly reports submitted by
the states to the Central government), the coverage against almost all
antigens is nearly 90-100%. There are currently 4-5 nationwide surveys
capturing data on immunization, which include National Family Health
Survey (NFHS), District Level Household Survey (DLHS), Coverage Evaluation
Survey (CES) of UNICEF, and Multi-Indicator Cluster Survey (UNICEF). They
vary in their methodology and questionnaire used for data collection.
There is wide variation in the reports of the surveys. However, according
to most recent DLHS-3 data, the National fully immunized (FI) coverage
against the six EPI vaccines in the age-group of 12-23 month old children
is only 54.1%, whereas for similar age group NFHS-III (2005-06) cites only
47.3%. According to NFHS-III, only 14 states have >50% FI coverage while
CES found >29 states achieved same status. Similarly, for DTP-3 coverage,
NFHS-III reports 55.3% coverage amongst 12-23 mo old with 21 states
crossing >50% mark nation-wide, whereas CES reports figures of 68.4% and
31, respectively. As far as newer antigens are concerned, first dose
coverage of Hep-B is reported as 66.0%, and 50.2% for the 3rd
dose. These are the figures supplied by the 10 states to MOHFW, GOI where
Hep-B vaccination is introduced in the RI. However, birth dose
administration is still a challenge in these states. No cross evaluation
was done. However, it can safely be stated that overall coverage have been
stagnant over the years with recent marginal improvement in many states.
Six states with high population contribute to 80% of 8.1 million
unimmunized children in the country, 52% of the total unimmunized reside
in Uttar Pradesh and Bihar alone. Other than UP and Bihar, states with
<40% FI include Nagaland, Rajasthan, Arunachal Pradesh, Assam, Meghalaya,
What Needs to be Done?
There are marked inter-regional disparities with very
low achievement at many places. There is disarray of documentation with
poor quality coverage data, falsification and inflation due to political
pressure in some key states. According to a recent review of RI(2), there
are many missed
opportunities to review and provide feedback on reported data at monthly
meetings by RI managers. At PHC/sub-center level, health workers are not
using the standard tools to track, document, and report
immunized children. Often registers are not provided and
often incorrectly filled in
by the ANMs; practically never used to track children (leading to both
left outs and dropouts) or monitor performance. One major lacuna of an
effective RI system is failure to assess ‘output’ of the program, i.e. lack
preventable disease (VPD)
In some cases, reporting of
VPDs may have been suppressed due to fears of reprisals of higher-ups. And
lastly, private physicians play little role in reporting their vaccination
coverage, VPDs, and adverse events following immunization (AEFI).
On the positive side, immunization system is in place
with adequate manpower at most places, cold chain equipments have adequate
capacity and are well maintained, detailed micro-planning for RI sessions
down to the level of immunization site do exist at almost all places, and
effective coordination do exist between ANMs and AWWs in the field. Hence,
the basic infrastructure for immunization to reach every child is in place
in all the states. But, the system is largely failing to deliver. It
appears that, the unsatisfactory performance of UIP is not due to
technical problems or financial constraints, or due to the reluctance of
parents to get their children immunized. It is, in fact, due to
managerial, administrative and governance-related inade-quacies(4).
What is Needed?
There is an urgent need to increase political and
bureaucratic commitment, conduct refresher courses at all levels
(injection safety, waste disposal, cold chain, VPD surveillance and AEFI),
formulate operational guidelines to improve vaccine management, improve
monitoring and supervision, and increase involvement of other community
resources for providing immunization. The existing National level "Inter
Agency Coordination Committee" (ICC) needs to increase its focus on
routine immunization. A public-private partnership between GoI, NTAGI,
Indian Academy of Pediatrics (IAP), Indian Medical Association (IMA),
development partners, ICDS, Ministries of Railways, Education and Defence,
and key NGOs involved with immunization and State representation should be
strengthened. The program managers need to ensure and monitor that funds
are appropriately released in a timely way for operational costs. Ensure
an uninterrupted supply of all antigens to state level through a vaccine
stock management system that includes annual forecasting and wastage
rates. Central level should provide technical support and resources for
states to develop evidence based social mobilization plan. In specific low
performing States, a district / block based operations research scheme
could be considered and scaled up if successful. All hard-to-reach and
urban slum areas should be reached at least four times per year with
routine immunization or catch ups(2).
India has the resources and the potential to convert
its RI delivery system in an efficient unit and to lead other LMI
countries of this region. However, to accomplish this, we need to show
urgency and commitment to put RI on the top of the health agenda of the
states and the Nation.
Competing interests: None stated.
1. Global Immunization Vision and Strategy (GIVS)
2006-2015. Available from: http://www.who.int/vaccines-documents/DocsPDF05/GIVS_Final_
EN.pdf. Accessed on October 4, 2009.
2. Universal Immunization Programme (UIP) Review. World
Health Organization. Available from: http://www.whoindia.org/EN/Section6/Section284/Section286_507.htm.
Accessed on October 4, 2009.
3. National Family Health Survey (NFHS-3), 2005-06:
India: Volume I, 2007. Available at: http://www.nfhsindia.org/NFHS-3%20Data/VOL-1National%20Family%20Health%20Survey%
202005- 06%20India%20Report%20-%20Volume %20I%20.pdf. Accessed on October
4. Polio Eradication Committee: Indian Academy of Pediatrics;
Vashishtha VM, John TJ, Agarwal RK, Kalra A. Universal immunization
program and polio eradication in India. Indian Pediatr 2008; 45: 807-813.