On April 26 this year, Prime Minister Narendra Modi chaired one of his regular ‘PRAGATI review sessions’ with bureaucrats from different ministries and chief secretaries from the states. Thirteen of the fifteen issues for the day pertained to railways, highways and other infrastructure. On health, he addressed ‘Mission Indradhanush’, the universal immunisation programme, and the ‘Swachh Bharat Mission’.

In his address, the prime minister told the Union health ministry to buck up. He told them not to wait till 2020 to achieve the goal of 90% immunisation, but to make it happen two years earlier – by 2018. The advancement of this deadline means that the government is now embarking on the ‘Intensified Mission Indradhanush’ this week – from October 8.

The calling is large – every year, five lakh children die in India due to vaccine preventable diseases and another 89 lakh remain at risk due to incomplete or absent vaccination.

India’s universal immunisation programme (UIP) was launched in 1985. In 2014, the new Bharatiya Janata Party government re-launched India’s UIP, named it ‘Mission Indradhanush’, and tasked it with achieving 90% immunisation coverage by 2020, which it now attempts to do by next year.

The UIP is one of the world’s largest health programmes and believes that “full immunisation against preventable childhood diseases is the right of every child.” It provides vaccines to children and pregnant women against 12 vaccine-preventable diseases. ‘Mission Indradhanush’ has now vaccinated 2.47 crore children, out of which 55 lakh children have been fully immunised. It has also vaccinated 67 lakh pregnant women. This has happened over four phases since 2015, spread over 528 districts.

Between 2009 and 2013, the increase in immunisation coverage had been at 1% per year. Between 2015-16, India’s immunisation coverage increased by 6.7% per year, with more success in rural areas compared to urban areas.

The UIP provides vaccines against life threatening diseases like Tuberculosis, Diphtheria, Pertussis, Polio, Tetanus, Hepatitis B, Measles, Pneumonia, Haemophilus influenzae type B and Japanese Encephalitis. India partners with global organisations like the World Health Organization (WHO) on this.

According to documents viewed by The Wire, the intensified ‘Mission Indradhanush’ will be launched in 190 districts. These districts represent the “lowest quintile” of under-performers on immunisation. One hundred twenty-one of these districts are in rural areas, 17 are in urban areas and 52 are in the northeast. The states receiving the highest attention are the ‘BIMARU’ and NDA states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. Fifteen, 13, 11 and 52 districts in these states respectively, will receive attention under the intensified programme. All the eight northeastern states will be targeted as well, with Arunachal Pradesh and Nagaland seeing the most attention with 13 and 11 districts covered.

A government official says this is “the highest level engagement by the Prime Minister’s Office.” About 11 ministries and departments will be roped in for this, including the railway ministry, women and child development ministry, the National Cadet Corps (NCC), and even the army and Border Security Forces (BSF).

Why are children being missed?

One of the concerns for the government is that children are still being missed from the immunisation coverage. The government counts as missed those who have either not had any vaccinations or those who have had incomplete vaccinations. Government data shows that in percentage terms, the number of children and mothers who are missed, has not dropped drastically, despite the gains of the four phases of ‘Mission Indradhanush’ – 27 % and 21 % have been missed from the government’s programme, over these four phases.

Sixty-four to sixty-five percent of this section has remained unconverted because they either had “apprehensions of adverse effects following immunisation (AEFI),” or because of an “awareness and information gap.”

The percentage of children missed due to “operational gaps,” which would be attributed to the faltering of the mission itself, has also remained consistent at 10% and 11%.

On this, Dr Pradeep Haldar, deputy commissioner for immunisation at the health ministry, says, “What the data shows is a clear picture that the ones who are holding out are doing so because they either don’t have the information or they do not believe the information. Both in urban and rural areas, the goal of 90% vaccination is not being achieved.” He says this is due to parents often thinking that vaccines are unnecessary because their children appear healthy or that children may fall sick but may recover. The service gap occurs because health workers may not have visited some families or vaccines may not have been delivered. “We have been doing community-monitoring to study what are the barriers to immunisation and from the data we know that we have to keep on having interpersonal education and awareness on this so that beneficiaries come forward,” says Haldar.

Accelerating immunisation is going to be challenging

“Achieving full immunisation is not as simple as announcing an advanced target and having political will. Not only is the government wanting to increase its coverage of children and women, it has even increased the number of vaccines that have to be administered. Announcing a new target does not take care of manpower, supplies, budget and coordination that also needs to happen for such a quantum jump,” says Anant Phadke, a doctor with Jan Arogya Abhiyan in Maharashtra. “It is unrealistic to expect such miracles of any government,” he adds.

Although it seems the last mile only has to cover about a quarter of those who need to be immunised, this might just be the hardest part. “In any sample, it is easier to go up from let say, 50% to 60%. But every additional jump in the higher levels gets harder,” says Phadke. This final hold-out group is often rigid, and had been escaping the net of immunisation before, and some of those rigidities will remain.

‘Indradhanush’ itself was a response to immunisation coverage falling drastically in 2014. “States like Tamil Nadu who had achieved even 90% immunisation had begun to fall to around 60% according to National Sample Survey data. And this was after adverse reactions were being reported on introduction of the pentavalent vaccine. This was the push for ‘Indradhanush’. When the government says there is an information gap, it should be giving information about the possibility of risks and not just about the necessity to vaccinate,” says a researcher on immunisation who declined to be named.

Scientific and cultural confusions about immunisation combined earlier this year, as rumours, spread via WhatsApp, saw families declining the government’s introduction of the measles-rubella vaccine in Kerala and Tamil Nadu. Religious leaders had to be roped in to counsel and convince parents.

Adverse effects following immunisation have been a major worry for parents. The Wire has reported that Indian researchers Phadke and Jacob Puliyel have studied Indian data between 2012 and 2016, and seen that of 132 serious AEFI cases which were reported including 58 deaths, not a single death was attributed to vaccines. Instead, the deaths were written off as being “unclassifiable” or “coincidental due to something other than vaccines.” This was a result of the WHO changing the definitions of how it categorised adverse effects following immunisation in 2013.

Unlike with polio, where the vaccination has focused on total eradication, here, the government says its focus is on routine immunisation. “With polio and perhaps now with measles and rubella, we have a zero tolerance approach. The very last child needs to be vaccinated. But with other diseases, we are looking to control the disease. Which means having at least 90% coverage of immunisation,” says Haldar.

Figuring out this dynamic and getting the last rigid group of hold-outs to convert will determine if the government can keep with the high targets it has set for itself. The enduring success of India’s immunisation story will not be in achieving a goal in just 2018. It will mean achieving the same success year on year. “Every year, we have to achieve 90% coverage. It needs to be sustainable, or else there will be fatigue. So, for ‘Mission Indradhanush’ to be sustainable, it needs to be a people’s movement and not just about providing services.”