Decentralisation critical for Solving India's Immunisation Woes

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India's National Immunization Programme is one of the most extensive immunisation programmes in the world. But routine immunisation services in the nation were derailed due to pandemic this year. What strategies would help to bring India's Universal Immunization programme back on track? An HE report.

When Dr Saleem Nadaf, an emergency physician, joined a Primary Health Centre in 2008, he had several lofty aims in mind. But he soon realised that there are several insurmountable obstacles for a practitioner who works at a public health facility.

"A simple text message can disrupt the immunisation schedule of a PHC even during a non-pandemic time," says Nadaf, who used to work at Masthi Primary Health Centre (PHC). The PHC is located in Malur Taluk, in Kolar district in Karnataka. Majority of vaccination drives in India are conducted in such PHCs.

"Vaccine is one of the greatest discoveries in modern medicine. But even though it's a powerful public health tool, vaccine hesitancy is a big public health challenge," says Nadaf.

Risk Perception

Nadaf recalls how in 2008, hundreds of children were rushed to Masthi PHC after rumours spread that a child died due to the polio vaccine in Tamil Nadu. Hospitals were vandalised, and doctors were beaten across Karnataka," claims Nadaf. "Public perception plays a crucial role in fulfilling and accomplishment of immunisation schedule," adds Nadaf.

The pandemic has further complicated immunisation schedule in India.

Health Services hit Hard

Reports published by the National Health Mission (NHM) revealed that April (lockdown) led to dip in child immunisation by 64% (50% drop in BCG vaccinations & a 39% drop in oral polio drops). Approximately 1 million infants did not receive their BCG vaccination.

Dr V Mohan Chairman and Chief of Diabetology, Dr Mohan's Diabetes Specialities Centre and President, Madras Diabetes Research Foundation, Chennai, feels that lockdown was a measure that not only India, but most of the developed countries also instituted. "At that time there was no other alternative and India opted for an early lockdown. Undoubtedly, there were considerable benefits of lockdown like reducing both numbers of COVID cases as well as mortality.

However, the flip side of the lockdown is that several health services were indeed hit hard. Even routine care for chronic treatment of ailments like diabetes was affected."

He adds that the other services which were hit were women and children services, cancer care, kidney and dialysis services.

Catch-up campaigns

Dr Naveen Thacker, Executive Director, International Pediatrics Association seconds his views."The recent decline in the number of children receiving life-saving vaccines was in a large part collateral damage of lockdown, which helped control the spread of COVID. The good news is that the policymakers are aware of this and are taking proactive steps to bridge the gap. Late vaccination is far better than no vaccination, and the government and other partner agencies are making efforts to ensure that missed children receive their due doses. A statewide exercise for a listing of children who missed their routine vaccination due to lockdown is being undertaken in UP. These children will then be vaccinated from November to January on a campaign mode. Catch-up campaigns like these are the need of the hour, so that progress made over the last few years is not lost due to COVID," says Thacker.

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Relaxation in Containment Zones

Thacker also adds that in addition to catching-up campaigns, relaxation in containment zone guidelines to allow for routine immunisation sessions to continue is needed. "Also, to build confidence among the beneficiaries and mothers, COVID-related safety measures need to be in place in immunisation session sites. The government has issued guidelines in this regard, and their implantation is being monitored closely. According to monitoring reports, it was noted that these precautions were followed very well in the recently concluded Pulse Polio campaigns in states which is heartening and reassuring. Another critical factor is to address the issue of lack of awareness about vaccines and vaccine hesitancy, and initiatives in these directions will go a long way in improving vaccination rates," he adds.

Rural Vs Urban

Thacker says that the decline in immunisation has changed with the spread of COVID. "In the initial phase, when COVID was an urban phenomenon, the decline in vaccination was more in urban areas. With the spread of COVID into rural areas, villages, and areas with better coverage in the past have also seen a decline in immunisation rates," he explains.

But does the private sector play a critical role in India's immunisation programme? Thacker says that the private sector plays a minimal role in India's Immunization Programme. "It varies from 10-20 % uptake, that too only in urban areas. Now with the availability of vaccines like Pneumococcal and Rotavirus vaccines which are very costly, there is a greater inclination to go to a government set up," he adds.

Root of the Problem

Rakhal Gaitonde, Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology rues that the disruption is due to multiple factors. "Our primary healthcare system was not in optimal condition even before the pandemic. An already overburdened public health system is currently under more strain. Our frontline workers are exhausted with additional responsibilities like disease surveillance and are unable to do their routine chores. Even communities are concerned about COVID. They are hesitant to go for deliveries, routine health check-ups at government facilities. The disruption of health information systems and the vaccine supply chain could have also been another reason."

Significance of Trust in Healthcare Providers and Policy Makers

Gaitonde, who is also a member of National ASHA Mentoring Group, points out that trust is an essential part of a healthcare system. "When you have a health system, which has not been providing basic healthcare services to the community, then you can't expect the community to start trusting the healthcare system abruptly. There is an implicit trust in well-performing health systems like Kerala. But that has nothing to do with what the government is doing today. It is the effect of what Kerala's public health system has been delivering over the years. How the state government has handled H1N1 and Nipah has instilled confidence in people. When you have a Chief Minister, who comes every day and conducts a press conference every day for six months, it creates trust in the system."

Dumbing Down of Healthcare Communication doesn't Work

Gaitonde also asserts that the common man does understand the seriousness of the pandemic. "Most health communication makes their message sound like everyone is going to die due to COVID. Clear and transparent communication is essential for building trust among people. You don't have a time machine, but what you can do is have clear and transparent communication at the village level. Policymakers should also listen to people. Their issues might not be immunisation. It could be livelihood and food."

ASHA Workers

ASHA-which began as a volunteer programme in India-play a vital role in India's UIP. These healthcare activists were supposed to be the link between the health department and the community. Eventually, they started filling the gap in the primary healthcare system. "They have done remarkable work during pandemics and floods in various states. But the health system slowly started adding responsibilities on them. If you expect a person to work 10 or 12 hours for a specific programme, then they are no longer volunteers. Unless you take steps to resolve this issue, you are going to put the whole public healthcare programme in jeopardy. The resolution would require steps like recognition for ASHA workers and a strong public health system to ensure that they don't exist as standalone units," Gaitonde adds.

Decentralisation is the Key

Gaitonde says that ASHA workers in Kerala are not a standalone unit. There is a powerful decentralised system in the state. "There are very active panchayats, integrated health communities, ward members, Kudumbashrees and volunteer groups of political parties. The state government has multiple schemes for ASHA workers. Therefore, ASHA workers are in a better situation."

Role of Local Governance Bodies

The Kerala model is the flavour of the season. This raises the question: Can we adopt it in other states?

Dr Joy Elamon is the Director-General of Kerala Institute of Local Administration (KILA). He insists that decentralisation is one of the reasons for Kerala's success story, while one cannot replicate it in other states, the model can definitely be modified and adapted. "Focus on preventive health has been an integral part of Kerala's health system. Further, the health system is powerful enough to manage these issues. People's participation is also really high in Kerala."

Community participation, Elamon adds, is integral to the success of the civic campaigns: "Ernakulam was the first district in Kerala to organise a first Total Literacy Campaign. The story of Ernakulam— where volunteers wanted to focus on universal immunisation and oral rehydration campaigns— shows the power of participatory planning."

He also insists that there is a need to look at the health system with the right lens.

"There is a dual governance system in the Kerala healthcare system, as a result of the reforms of 1996 led by the People's Plan Campaign. Health departments look after technical aspects, and local bodies manage day-to-day affairs and local level planning. PHCs are with the Gram panchayats, CHCs are with the block-panchayats, taluk hospitals with municipalities and district hospitals with district panchayats. So, local health systems are a component of the local governance system. Panchayats play an integral role in community mobilisation and community participation. They want a healthy population, so it's a win-win situation for both," he explains.

A Wake-up Call?

In the future, there will be more hurdles to surmount. But the scenario is not altogether bleak.

Mathew George, Professor at Centre for Public Health, School of Health Systems Studies at TISS Mumbai, strikes a note of caution that any health programme, when planned in isolation from the ongoing programmes, will surely disrupt the ongoing programmes. "This had happened when Polio immunisation was implemented independently when the coverage of Measles was reduced. Alternatively, any crisis can become an opportunity if the interventions to prevent the crisis are structurally and functionally integrated into the existing health programmes. This is what we should adopt as an approach during the pandemic response," he adds.