Addressing Immunization Inequity - What Have the International Community and India Learned over 35 Years?

"How can public health programs and donors adapt learning from the Indian immunization evolution and apply the latest equity approaches and tools, particularly in lower-resource settings?"

The majority of people around the world participate in vaccination services. However, several decades of polio eradication, the need for repeated measles campaigns in areas with pockets of unvaccinated clusters of people, and the global urgency of the COVID-19 pandemic have highlighted challenges with sustaining and expanding a large-scale immunisation programme to ensure coverage, quality, equity, and inclusiveness. This article reflects on these challenges in the context of India's Universal Immunization Program (UIP), which offers a legacy of learnings (such as from the Polio Eradication Initiative) about generating demand for vaccines, boosting coverage, and reducing inequities in routine immunisation.

As argued here, 2 critical components for addressing equity and moving towards immunisation programme sustainability are (i) the commitment and incorporation of local resources (particularly at subnational levels) and (ii) engagement and partnerships with civil society. India's routine immunisation programme can be summarised around these major milestones:

• India's UIP was launched in 1985 by the Indian Government. As part of this system, 2-way communication between the service provider and the beneficiaries is augmented through digital web-based platforms like the Mother Child Tracking System and availability and use of Maternal and Child Health cards that include all antigens and reminder dates. Particularly in the last 10 years, UIP has collaborated with Gavi, the Vaccine Alliance, and partners to augment skills of health workers and frontline program managers, such as via initiatives like Routine Immunization Skills Enhancement.
• In 1995, India launched the nationwide pulse polio immunisation programme, including National Immunization Days for supplemental polio vaccination. These efforts, linked with routine vaccination that also emphasised birth dose polio vaccination, encouraged multi-stakeholder coordination, programme innovation, and community mobilisation and engagement at every level of programme planning and implementation. This work included collaboration with civil society partners, such as Rotary and the multi-partner Social Mobilization Network led by the United Nations Children's Fund (UNICEF) and the CORE Group Partners Project (CGPP). India's recognition of being polio free in 2014 also elevated the value of vaccination and contributed to a shift in focus on routine immunisation. The experiences gained from polio eradication to reach populations with immunisation services cut across vaccine supply, access, and community mobilisation and have been institutionalised in India's immunisation and health systems. A few examples of this institutionalisation include house-to-house immunisation campaigns and community radio for peer-to-peer conversation in the community.
• To further address equity in reaching often missed or underserved communities, India launched the National Health Mission in 2013, which was a step towards integration of immunisation with other programme deliverables in primary health care. The programme also integrated two previously vertical and siloed initiatives that began in 2006: National Rural Health Mission and National Urban Health Mission.
• The Mission Indradhanush (MI) programme, launched in 2014, and the subsequent launch of Intensified Mission Indradhanush (IMI), launched in 2017, were designed to address vaccine inequity in a subset of districts and facility clusters across geography and gender, based on evidence from data collected from districts. Important within both initiatives is the role of civil society as key partners, including engaging the accredited social health activist (ASHA) programme for linking missed communities with immunisation services.
• In recent years, the UIP has expanded to include rotavirus vaccine, pneumococcal conjugate vaccine, inactivated polio vaccine, measles-rubella vaccine, and the Japanese Encephalitis vaccine (for adults). Political and bureaucratic administrator interest has been high at all levels, including from the Prime Minister. UIP and several donor and resource partners supported these introductions at a national scale, including through civil society partner engagement for communications and confidence and trust building. The new vaccine rollouts also provided opportunity for strengthening health systems with technologies, such as the electronic Vaccine Intelligence Network (eVIN).
• COVID-19 vaccination necessitated rapid, wide-scale digital technology to facilitate vaccine access across the majority of India's population. Some of the most heavily disrupted populations were remote, economically challenged people with specific needs (such as the differently-abled), the transgender community, and populations that migrated from their workplaces. The COVID-19 vaccination tracking software, known as CoWIN, enabled citizens to choose their vaccination place and time at their convenience with strong community acceptance, as evidenced in the high COVID-19 vaccination rates in India. Expansion of the tool with Indian resources is anticipated to benefit routine immunisation equity and coverage, enabling health workers and citizens to track routine immunisation through the digital application known as UWIN.

As the COVID-19 pandemic response shifts, India is reviving and sustaining its routine immunization coverage improvement program with experience, equity, evidence, and empowerment. To address the equity gap, India is tailoring efforts across geographies, gender, and socio-economic strata. States are partnering with community-based organisations and civil societies to tailor services that will enable better access to populations with specific and special needs. Examples of such initiatives are the iHEAR project of Sangath that generated evidence around challenges faced by the disabled and transgender communities during COVID-19 vaccination and the Vaccine on Wheels project of Jivika that provided doctor-supervised mobile medical units for immunisation.

As the COVID-19 pandemic demonstrated, health workers are not only essential for preventing and managing outbreaks but they are also clients themselves. However, oftentimes health systems are not meeting their basic needs for a positive service experience, such as balanced workloads and sufficient supplies. Figure 2 in the paper provides a visual example of service experience components that consider the needs of both health worker and service recipient clients. The broader public and private sector health practitioner networks, such as the International Pediatric Association and the International Council of Nurses, also play a critical role in linking people with services for a positive experience of care.

On that note, a key priority going forward in terms of sustaining equity is to foster coordination and long-term resourcing with local institutions, such as civil society networks, that are best placed to generate workable solutions with their populations. As has been the case with Rotary's involvement in polio eradication, civil society networks are more likely to garner local support, including for day-to-day operational funding, if they are part of planning and monitoring. This participation includes having access to data and opportunities for regular review meetings with health service representatives. "Equitable sustainability also requires partnering with local institutions and engaging with communities, which often takes more time and investment but is arguably more likely for public health programs to be able to maintain, particularly in lower income countries."

In conclusion, "sustained immunization program success requires continuing political and administrative buy in, technical quality, program review at the district level upwards, and community partnerships. As the Immunization Agenda 2030 progresses, the global immunization community and countries can benefit by tailoring their immunization equity strategies from previous experiences, such as the components shown in the India example, and incorporating approaches that include behavioral science and person-centered care to support and empower health workers and clients."