Immunization Plus

Immunization Plus
A Framework for Action
(2003-2007)
May 2003
INDIA COUNTRY OFFICE

73 LODI ESTATE
NEW DELHI
Immunization Plus: A Frame work for Action
Acknowledgements
The following UNICEF staff contribution must be acknowledged in drafting, revising and
finalizing the current document:
Carrie Auer
Cleopa Mailu
Corinne Woods
Jean Gough
Johan Fagerskjold
John J Gilmartin
Kate Dickson
Kishanrao Suresh
Marzio Babille
Michael Galway
Nigel Ede
Rakesh Kumar
Satish Kumar
Shyamkumar Chaturvedi
Siddharth Nirupam
Suresh Joshi
Vijaykumar Moses
Werner Schultink
William Thompson
Wing-Sie Cheng
In addition, acknowledgement is extended to the Department of Family Welfare, Ministry of

Health & Family Welfare, Government of India (GOI) for offering technical insight, guidance
and approval; the Project Officers of Child Environment, Child Development and Nutrition, Child
Protection of both the Lucknow and Kolkatta UNICEF offices for their contribution to the content
and strategic direction.
1
Table of Contents
1. Introduction 2
Part One: Situational Analysis
2. Problem Dimension 3
3. Accelerating Immunization efforts 5
3.1 Polio Eradication: A Compelling Priority 5

3.2 Neonatal Tetanus Elimination 7
3.3 Measles Control 8
3.4 Introduction of Hepatitis B Vaccine 9
3.5 Vitamin A Supplementation 9
Part Two: The Case for Accelerating Routine Immunisation in India

4. Summary Goals and Principles 10
5. The Approach 10
5.1 Focus Intensive Interventions in Selected Areas 11
5.2 Adoption of a Proactive and Intensive Approach 11
5.3 Intensify Advocacy at National and State Levels 11
5.4 Intensify Partnerships for Planning and Service Delivery 12
5.5 Offer Leadership and Coordination 12
6. Guiding Strategies 13
7. Focus of Routine Immunisation Plan 15

8. Agenda for Action: The Phased-in Intensified Approach 15
9. Strategic Communication 17
10. Service delivery point activities 18
11. Expected Results by End 2003 in Phased-in Districts 19
References 20
Appendix I: 21
1. Accelerating Routine Immunisation within RCH-II Policy:
A Strategic Link to National Experiences
1.1 Rationale 21
1.2 Border District Cluster Strategy 22
1.3 Immunization Strengthening Project 22
1.4 Injection Safety 23
1.5 National Technical Advisory Group on Immunisation 24
1.6 Introduction of Hepatitis-B vaccine: A Window of Opportunity 24
Immunization Plus: A Framework for Action
1. Introduction
In India, the possibility of achieving the Universal Child Immunization goals appeared likely in
the 1990s, when reported coverage levels for all antigens reached more than 85% of eligible
children. The main objectives of Universal Immunization Program (UIP) UIP were: (i) Universal
immunization and reduction in mortality and morbidity due to vaccine preventable diseases
(VPDs); (ii) Self-sufficiency in vaccine production; (iii) Establishment of a functional cold chain
system; and (iv) the introduction of district level monitoring system.
In 1992, a policy change resulted in the UIP initiative being merged with the Child Survival and
Safe Motherhood Mission (CSSM). And in 1997, immunization activities were further
incorporated into the national Reproductive and Child Health (RCH) program. A further change
occurred in 2002, with the introduction of Hepatitis-B injection for the first time to the national
immunization schedule targeting the urban poor. This initiative will be expanded in a phased
manner to cover the entire country as part of the tenth Five-year Plan.
However, of concern to national and state governments was the conclusion of the 2002 RCH
survey that immunization coverage rates have been stagnating, if not declining since 1999, thus
posing a threat to the quality of and equity in service delivery. Weak internal communication
channels, inconsistent supervision and logistic management, and imprecise data collection and
analysis have flawed routine coverage reporting.
On the other hand, the comprehensive picture on routine immunization also demonstrates the
potential to regain the previous momentum. In India, while measles continues to be the major
vaccine preventable disease (VPD) afflicting children, leading to malnutrition and many other
complications, measles morbidity has been reduced by 85% and mortality by 70% since the
introduction of the measles vaccine in 1985.
The purpose of this paper, therefore, is to outline UNICEF’s framework for action designed to
support the Government of India to accelerate its Immunization Plus programme in selected
districts and throughout the country.
In general. Immunization services are provided through a network of Sub-centre, primary health
centres and community health centres in rural areas. In the urban areas, most of the government
hospitals and all post-partum centres provide immunisation services. In addition every state offers
fixed immunisation days especially for the outreach sessions. Villages having more than 1000
population are visited and out reach sessions held at least once a month. The fixed immunisation
day has proven to provide positive results for UIP since its implementation in 1985-90 despite the
fact that declining coverage rates in the low performing states depict weaknesses in the planning,
implementation and monitoring exercises.
In terms of policy development, the fixed immunisation day is also being used to expand the
primary care service components of an essential package that includes antenatal care, IFA and
vitamin A supplementation, contraceptive distribution and nutrition counselling.
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Part one. Situational Analysis
2. Problem Dimension
As mentioned above, research findings

for the period 1996-97 to March-May National Trend for Fully
2001 indicate that immunization Immunized Children (All Surveys)
coverage levels have declined over the
past 5-6 years.
80
70 6 7 .7
6 3 .3
Evidence also indicates that coverage 60
50
6 0 .8
5 0 .6 4 9 .8
levels are significantly higher in those 40
3 5 .4
41 42
3 7 .8
30
areas with regular access to the 20
services (63%) as compared to those 10
0
communities where sessions are less 9 2 -9 3 9 3 -9 4 9 4 -9 5 9 5 -9 6 9 6 -9 7 9 7 -9 8 9 8 -9 9 9 9 -0 0 0 0 -0 1
frequent or irregular (33%). N F H S1 R H S -9 8 -9 9 C E S -9 8 C E S -9 9
C E S -IC M R -9 9 N F H S-II M IC S 2 0 0 0 C E S -0 1
Years
Yearsindicate
indicate
Routine reporting is currently reference
referenceperiod
period
complemented by periodical coverage evaluation surveys that offer updated information. The data
indicates that DPT3 reported coverage was 89% in 2000 (MoHFW, GOI) while it was only
63.6% as per the CES-2001 results. Contrary to routine reporting, the 2000-01 DPT3 gap refers to
7 million fewer children under 1 year of age that have missed DPT3. The discrepancy in the
number estimated is more evident in Uttar Pradesh, Bihar, Madhya Pradesh, Orissa and
Rajasthan.
The following graph depicts the evaluated coverage of routine immunization in the Northern
States between 1998 – 2002. An analysis of the trends demonstrates that West Bengal and
Madhya Pradesh and Uttaranchal experienced a rise in coverage, while Bihar stagnated at a low
of 12%. Delhi underwent a rise to 70% in 2000 – 2001 that was not sustained in 2002 as coverage
dropped to approximately 65%.
Evaluated Coverage of Routine Immunization in the Northern States Between 1998 – 2002
80
70
60 1998-99
50 1999-00
40 2000-01
30 2001-02
20
10
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Amongst some of the reasons cited for the drop in immunization coverage including irregular
sessions are the following:
• Date, time and place of vaccination is not known (25.2 percent of respondents)
• Caregiver is not aware of the need for full immunization (24.0 percent of respondents)
• Child is sick during immunization days, probably a false contraindication. (18.8 percent of
respondents)
• Time and date inconvenient; no one is available to take child to clinic (16.0 percent of
respondents)
• No faith in immunization (5.5 percent of respondents).
Reasons for Low Coverage
Other Not aware of date,

Doctor's advice 10% time, place of
No faith
1%in immunization
immunization 25.2%
5.5%
Inconvenient date and

time; no one to take
16%
Not aware of need for

Sick child (false full immunization
contraindications) 24%
18.8%
The following table depicts the burden of vaccine preventable diseases in India (GOI, 1999).
Disease Est. cases Reported cases Est. deaths Reported deaths

Measles 2,300,000 21,013 230,000 457
Diphtheria 20,000 1786 400 257
Pertussis 60,000 11,264 600 Nil
N.Tetanus 12,200 610 7500 610
Polio - 1234 - Nil
In general, as recently outlined by the Department of Family Welfare (DFW) in its call to
accelerate routine immunization in the Northern States, reported coverage rates are typically
higher -- sometimes double those estimated by the surveys. Four of the ten states have statewide
coverage greater than 50% (Gujarat, Chhattisgarh, Orissa and West Bengal), but none of the ten
states have achieved coverage higher than 29% in their lowest coverage district. Cold chain
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equipment has been imported but technical assistance is lacking. The reliability and continuity of
power supply is also identified as a major system problem for adequate vaccine management and
cash to comply with fuel for generators sets represents a major state drawback in Uttar Pradesh,
Bihar, Jharkhand, West Bengal.
It has become apparent that unless routine immunization services are strengthened or accelerated
in all these states as a matter of urgency, there will be a generalized re-occurrence of Diphtheria
and Pertussis, as well as measles foci. Furthermore, Hepatitis B vaccine will be available to no
more than 5% to 30% of the children in the lowest coverage areas. Hence the opportunity to
widely introduce the GAVI-funded Hepatitis B vaccine will be missed.2
3. Accelerating Immunization efforts
3.1 Polio Eradication: A compelling priority
Recognizing that polio eradication is predicated on sound routine coverage of the susceptible
population, with particular reference to the new birth cohorts, the declining trend in coverage for
Routine Immunization in the least performing states requires urgent policy attention, government
commitment, and appropriate financial support from partners.
The following section outlines the history and present epidemiological situation of the wild
poliovirus in India.
Epidemiology of Wild Poliovirus in India
India has long been a major reservoir for wild poliovirus. Since the establishment of AFP
surveillance in 1997, the extent and intensity of wild poliovirus circulation has been effectively
documented. In 1997, it was clear that all three types of wild poliovirus were present in India and
that distribution of the viruses was widespread. In 1995, India began conducting supplementary
immunization activities (SIAs) for polio eradication.
As a result, polio in India declined 42 percent from 1934 virus positive cases in 1998 to 1126
cases in 1999. By 2000, India reported only 265 cases of polio, a decline of 76 percent in just one
year. Of the cases reported in 2000, UP accounted for 68 percent and Bihar 19 percent. With the
implementation of responsive mop-ups in states outside of UP and Bihar in 2000, the rest of India
was rapidly cleared of polio. This was confirmed by high quality AFP and poliovirus
surveillance, which achieved globally accepted standards in 1998.
Type 2 wild poliovirus has not been seen in India since October 1999 although few cases have
recently reoccurred in western UP districts due to a likely laboratory contamination. Given the
high quality of AFP surveillance, it appears that India may be free of type 2 when latest
laboratory investigations in Western UP are completed.
Between December 2000 and October 2001, India conducted a NID followed by two SNID
rounds in high-risk areas of UP and Bihar in April and May 2001, and a SNID in October in high-
risk states. In addition, responsive mop-ups were conducted following the isolation of wild
2
Of note is the possibility for UNICEF to provide complementary management, supply and mobility support to a
World Bank project presently underway to strengthen the Indian Universal Immunization Program. The weaknesses
outlined in this document lead to an expenditure of barely 8% in 2002.
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poliovirus in several states. In UP and Bihar, at least 5 rounds of SIAs were conducted, with
some districts in western UP implementing up to 8 rounds.
Despite these activities, 268 cases were reported in 2001. The increase in the absolute number of
cases between 2000 and 2001 was already concerning. The initial progress showing that the
geographic distribution of the virus had become more focal (i.e.: infected districts declined in
India from 89 in 2000 to 63 in 2001) and that bio-diversity had decreased in early 2002 were
countered by the dramatic resurgence of polio cases statewide.
The Situation of Wild Polio Virus in 2002 and early 2003
During 2002 to date, India reported 1677 cases (1599 in 2002 and 77 by mid May 2003) in 159
and 40 districts respectively. UP reported 1254 cases, Bihar 123, Haryana 38, Gujarat 26, West
Bengal 58, Madhya Pradesh 26, Uttaranchal 14, Jharkhand 12, and Delhi 27.
2002 (1599 cases) as 31 December 2002
Uttar Pradesh 1241

Bihar 121
West Bengal 48
Rajasthan 41
Haryana 37
Delhi 25
Gujarat 24
Madhya Pradesh 21
Uttaranchal 14
Jharkhand 12
Maharashtra 6
Orissa 4
Punjab 2
Chandigarh 1
Chhattisgarh 1
Jammu & Kashmir 1
2003 (77 cases) as for 15 May
Uttar Pradesh 24
West Bengal 23
Bihar 8
Madhya Pradesh 7
Rajasthan 4
Gujarat 3
Delhi 3
Orissa 2
Haryana 2
Maharashtra 1
In Bihar, transmission has so far been highly focused in districts north of Patna across the
Ganges, and all virus isolated is Type 1. All cases are from a single lineage. No virus has been
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reported from the previous focus of transmission in southeastern Bihar since October 2001.
Because of the very focused nature of transmission, the absence of type 3, and the single lineage
represented currently, one may conclude that Bihar has an excellent opportunity to interrupt
transmission in the forthcoming year.
Poliovirus circulation continued to be intense in 2002 in 18 districts and 61 blocks of west UP.
Based on analysis of data collected during NIDs/SNIDs, HRRIs and mop-ups, coverage surveys
and qualitative studies, it is now clear that the SIAs in these areas have not achieved uniform and
consistent quality. Data from SIA monitoring indicates that between 8% and 12% of households
have children under five years that have been missed each round. The principal reasons for
missing these children are:
• failure of immunization teams to correctly identify all eligible children once they have
reached the household,
• poor or non-existent supervision in many areas, so that immunization teams do not have their
work supported and mistakes corrected, and
• poor participation of families in areas which have under-served communities, through lack of
knowledge of the activities or lack of motivation.
The conditions in these areas greatly favour transmission of wild poliovirus namely:
• very high population density;
• very low routine immunization coverage;
• generally poor sanitation and hygiene conditions; and
• Children below 24 months of age in particular in under-served communities, be they Muslim
or Hindu depending on location, are vulnerable to infection.
There has been some questioning of the eradication strategies given ongoing transmission of wild
poliovirus in northern India, particularly western UP. Evidence demonstrates that ineffective
implementation has been the major problem in northern India and the SIA strategy needs to be
backed up by acceleration f routine immunization. Polio remains endemic in northern India, and
especially west UP, because not enough children are given sufficient doses of OPV.
Ongoing poliovirus transmission in Uttar Pradesh, Bihar, West Bengal, Rajasthan, Gujarat and
Madhya Pradesh and to a significant extent the rest of the country poses risks for polio-free
Indian states and other countries. It could mean that: 1) undue delay in interrupting transmission
results in frustration and fatigue in the field and communities that would be difficult to overcome.
and 2) the risk of importation of wild poliovirus from reservoir areas into other states and
countries will require continued activities throughout the region.
3.2 Neonatal Tetanus Elimination
The initial global target for neonatal tetanus (NNT) elimination was not met by 1995 and was
revised to 2007. In India today, nearly 49,000 NNT deaths are estimated to occur annually
(Global WHO/UNICEF estimates). India started reporting NNT cases separately since 1992.
There was a reduction of the reported number of cases from over 11,000 in 1988 to 1,527 in
1996. However since then the number of reported cases have fluctuated between 2000-3000 a
year, and rose to 3,214 in 2000.
Surveillance and case reporting was never satisfactory and has deteriorated further in the last 5
years. An assessment by WHO in 1996-97 indicated that around 251 districts out of 479, NNT
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was still endemic. More than one-fourth of the districts in some of the major states were endemic,
namely Assam (10), Bihar (36), Jammu and Kashmir (15), Karnataka (8), Madhya Pradesh (28),
Orissa (7), Rajasthan (22), Uttar Pradesh (45) and West Bengal (11).
In 1998, Rajasthan paved the way for a NNT elimination initiative, followed by Madhya Pradesh
in 1999, and West Bengal and Assam in 2000. Nearly 8.5 million women in the childbearing age
were immunized across the states of Rajasthan, 10 districts of Madhya Pradesh, one district of
West Bengal and two districts of Assam between 1998-2001. A subsequent joint WHO/UNICEF
study in 2000 underscored the potential of TT immunisation campaigns in Tonk district,
Rajasthan to achieve NNT elimination by vaccinating women in their child-bearing years.
The current strategy seeks to strengthen the routine immunisation program rather than pursue a
campaign approach. Towards this end, it is expected that the country will reach elimination status
in all districts by end 2007.
The immediate objectives of the strategy include:

• 90% decrease in NNT deaths and 80 % reduction in NNT endemic districts
• Tetanus toxoid vaccine will be accessible to 100% women in UNICEF supported and other
districts)
• skilled birth attendance available in 50% of home deliveries and
• 50% of primary caretakers of pregnant women should adequately explain why repeated TT
immunization is needed.
In addition, states and districts will be encouraged to document the status of elimination using the
UNICEF/WHO Algorithm and thereafter undergo a validation exercise.
3.3 Measles Control
Measles is a relentless disease and kills more children than any other disease currently
preventable through vaccination. Just 20 countries account for 85% of all global deaths and India
alone contributes 27% of the measles deaths of under five children. In 2000, the reported measles
cases were around 38,000 in comparison to 247,519 in 1987. Needless to say, it is estimated that
about 20 million cases and 200,000 deaths still occur annually. This indicates a high degree of
under reporting and also a lack of understanding amongst families regarding the seriousness of
measles as a potential childhood killer.
A strategy undertaken to control measles in India focussed on 13 cities in 1999, 47 additional

cities in 2000, and 14 more in 2001. Reports indicate that more than 3 million children between
the ages of 9-59 months were immunized between 1999-2001 (3-calendar years). The evaluation
done in Gujarat indicates a decline in the number of cases, thus demonstrating the potential of
such interventions and control strategies in the reduction of measles mortality and incidence in
selected cities.
Measles control efforts will now be implemented through improving routine immunisation. It is
anticipated that the strategy will lead to a 90% decrease in measles deaths and 80 % reduction in
measles cases/outbreaks by the end of 2007. Measles vaccine will be accessible to 100% of the
children residing in UNICEF-supported districts while 50% of primary caretakers of pregnant
women will be able to correctly explain the importance of repeated measles immunization.
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3.4 Introduction of Hepatitis B Vaccine
Within the RCH framework, financial and human resources are being freed for undertaking fresh
initiatives to eradicate polio, increase coverage for multiple antigen immunisation, and offer
quality RCH services closer to where people live. At the same time, the Ministry of Health and
Family Welfare is taking measures to strengthen the immunisation programme as well as to
improve the outreach of reproductive and child health services. The intention is to improve the
quality of services and ensure an enhanced coverage of infants with the vaccines used in the
Universal Immunisation Programme.
Hepatitis B vaccine is now being integrated into the existing routine/universal immunisation in
India. The strategy seeks to promote healthy competition among districts and states for
heightened performance and to give priority attention to the most needy. This new vaccine is
being introduced in 15 cities and 32 districts in the initial phase.
An overriding objective in the selection specific cities and districts for this new vaccine is to
achieve 80% DPT3 coverage or more under routine immunisation of infants with the existing
vaccines based on the coverage evaluation surveys. The vaccine is being provided free of cost to
the infants living in the slums. The programme will be expanded to include additional cities and
districts within a certain timeframe.
In addition to the new vaccine being introduced, UNICEF and other donors, together with
technical support to ensure their safe disposal and to improve hospital waste management will
initially supply auto-disable (AD) syringes. There will also be a renewed emphasis on the
maintenance of the cold chain to ensure the quality of the vaccines. The country envisages that
Hepatitis B vaccine will be introduced in all districts of India by 2007, and that AD syringes will
be used for all routine vaccines in the areas introducing Hepatitis B vaccine.
3.5 Vitamin A supplementation
Vitamin A deficiency in India has officially been recognized as a public health problem as far
back as 1970. At that time a supplementation program was initiated with the main aim to
eliminate blindness caused by Vitamin A deficiency. Vitamin A supplements are distributed
through the routine contacts with the public health system linked to routine immunization and
health service delivery. Ideally, a child should get 100,000 I.U at 9 months and 200,000 I.U at 18,
24, 30 and 36 months of age. Bi-annual monthly supplementation of Vitamin A is a key strategy
in ensuring reach and adequate coverage.
In the latter half of the 1990s the performance of the vitamin A supplementation program was not
satisfactory. A nationally representative survey conducted in 1998-1999 (National Family Health
Survey; NFHS-2) among some 20,000 children aged 12-35 months indicated that about 17% of
the children had received a vitamin A dose in the period 6 months prior to the survey, and that
about 30% of the children had received at least one dose of vitamin A ever.
As part of the current program of cooperation between UNICEF and the Government of India,
support is provided to reduce vitamin A deficiency. The objective is to improve Micronutrient
supplementation rates (Vitamin A and Iron-Folate) through the strengthening of routine
distribution systems. This support is in line with the recommendations of the Steering Committee
on Nutrition for the Tenth Five-Year Plan in which the elimination of vitamin A deficiency as a
public health problem is set as a goal.
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Part Two: The Case for Accelerating Routine Immunisation in India
4. Summary Goals and Principles
In dealing with accelerating RI, GOI and UNICEF should address not only the theoretical issues
that guided the base UIP/CSSM Programme, but also ways to overcome the existing system
problems that are: vacancies; poor motivation of health workers; insufficient supervision; lack of
feedback and support; and, finally, the idea that UIP is an old-fashioned intervention. Therefore,
the fundamental question is how to ensure correct and consistent reorientation of existing routine
immunization at all levels? The response revolves around the already articulated Government of
India policies and interventions and the commitment of partners to support them succeed.
Towards this end, UNICEF’s ultimate goal of intervention is to increase children’s access to
multiple antigen immunization and Vitamin A coverage.
UNICEF:
• Positions itself to promote awareness among decision makers, donors/partners,
state and local government and programme managers that effective routine
immunisation is a crucial investment on the overall health of the community. It
also represents a decisive component in strengthening and reforming the health
system and to increase recognition of and commitment to an expanded financial
support for public health services delivery.
• Helps MOHFW build stronger infrastructures, management and monitoring for
immunisation than ever before in those states where these are required (UP,
Bihar, WB, Rajasthan, MP, and other emerging states).
• Points out that as required by the 73rd Amendment, the three-tier structure of PRI
(Zila Panchayat, Panchayat Samiti and Gram Panchayat) at state level can be
strengthened with respect to its functions and powers in the revitalization of
routine immunization efforts.
• Intimates that vaccine and vitamin A supply security and costs are issues to be
better and more realistically focused. Immunization cannot be done well or
revitalized on the cheap.
• Reiterates also that funding is not everything: a critical requirement for success is
the commitment of each state government to improving its own immunization
systems, a “buy-in” at state and country level.
• Notes that the introduction of Hepatitis B immunization is an extraordinary
opportunity as a multiplier effect helping to strengthen the sub-centre level and
the health system as a whole.
5. The Approach
In India, the 2001 National Population Policy contemplates the achievement of "Universal
Immunisation of Children against all vaccine preventable diseases (VPDs)". Further, it calls for a
policy framework to give an added impetus to the Universal Immunisation Programme (UIP).
Lessons learned over the past years are leading UNICEF’s work to strengthen and reinforce the
immunization plus activities in UP, Bihar and other least performing states.
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The approach takes into account work already been done by GOI, state governments,
development agencies and funding partners as part of the polio eradication and strengthening
immunization interventions. It is therefore not intended to replace existing initiatives and efforts,
but to complement and enhance them in the interest of accelerating progress on immunization and
bridging the immunity gap. While UNICEF continues with its current involvement in IPPI,
special efforts and resources will be devoted to the acceleration strategy in order to achieve
credible outcomes by 2004, so we can keep our promise to the Indian children.
The main purpose of the strategy is to provide an agreed platform for accelerating and
coordinating work on progammes and activities in immunization, in a manner that would result in
robust and sustainable outcomes. Whilst the central focus is clearly on the achievement of
Millennium Development Goals for 2005 and 2015, it should be emphasized that the rationale for
this acceleration strategy is to address multiple agendas. They relate to contributing to the
achievement of goals outlined in the World Fit For Children and, finally reaching MTSP targets
for immunization plus.
5.1 Focus Intensive Interventions in Selected Areas
Given UNICEF widespread presence in the field, the focus on a set of high-risk, low performing
states will be maintained. Within those states, priority for acceleration will be given to BDCS
districts. Whilst other projects will continue everywhere, there would be a concentration of
additional resources and intervention measures also in selected districts as suggested by GOI and
state governments, that will result in accelerated and maximum impact on children’s
immunization and supplementation of Vitamin A by 2004.
5.2 Adoption of a Proactive and Intensive Approach
Urgent work needs to be done on enhanced strategies for advocacy and communication in favour
of children’s immunization. Critical to the results-based approach is the need to adopt a proactive
and intensive approach that concentrates expertise, knowledge and other resources on reaching
the unreached children and households and helping them to overcome the barriers to obtain
routine immunization and vitamin A supplementation as part of the minimum package of primary
health services for a good start in life.
5.3 Intensify Advocacy at National and State Levels
Accelerating progress in routine immunization implies to intensify advocacy at the national, state,
district and sub-district level in order to: (i) Transform political will into government action to
fulfil their obligation on children’s immunization and ensure this is reflected in national and state
plans and budgets; (ii) Contribute to polio eradication efforts as part of the two-track strategy
necessary to reduce the immunity gap and protect the incoming birth cohorts; (iii) Create a
groundswell of local demand for routine immunization and primary services, transparency and
accountability; (iv) Mobilize financial resources and donor commitment to immunization as the
main leverage on the national RCH II plans for achieving increased coverage and impact on
infant mortality and morbidity.
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5.4 Intensify Partnerships for Planning and Service Delivery
UNICEF will build on the success of existing progammes and initiatives in order to enhance the
presence, quality and effective engagement of other stakeholders in the acceleration efforts and
prioritize the coordination of efforts by partner agencies, donors, professional associations, civil
society and private sector. UNICEF will contribute to the monitoring and evaluation process and
help other agencies to obtain the best possible data for decision making. UNICEF will have a
stronger presence at policy fora ensuring sufficient coordination to make a unified contribution
where key decisions are taken on investments and strategies to achieve the RCH II goals.
5.5 Offer Leadership and Co-ordination
UNICEF will coordinate activities of partner agencies (government line ministries, NGOs, private
sector, etc.) being brought on board for both routine immunization and polio communication;
match partner resources with high risk areas; provide technical and planning inputs to partners in
developing and implementing action plans; identify and solicit support from new partners on an
ongoing basis; help monitor partner activities; identify gaps where communication activities are
absent; liaise with NPSP SMO network to ensure no duplication of effort.
UNICEF will continue to promote an integrated routine immunization strategy for polio
eradication, measles control, neonatal tetanus elimination accelerating routine immunization and
Vitamin A supplementation at states, district and sub-district level. The focus will be in EAG
states (Uttar Pradesh, Jharkhand, Bihar, West Bengal, Rajasthan, Madhya Pradesh) and BDCS
districts starting from May-June 2003.
Priority will be given to promoting and training of district and sub-district level capacity to
manage, expand and improve the quality of RI through the reduction of drop out rates and
increase outreach sessions.
Strong management principles and systems are at the core of UNICEF’s approach to ensure its
resources are used efficiently and with maximum impact. The first tier of focus must be at the
sub-centre and block level, as a prerequisite for improving the immunization services. Existing
and new management tools will ensure that UNICEF expands its coordination/networking role to
identify social mobilizers with the most appropriate profile guided by clear terms of reference.
UNICEF will provide/share with states criteria for identifying where to best deploy resources,
systems to evaluate performance effectively, and mechanisms to collect and analyse activities
planned and undertaken. Specific support to management and supervision will be provided.
A higher degree of co-ordination and a strategic role of supervision are management

challenges that could be facilitated by UNICEF presence in all technical cells or working groups
established or to be established at the DFW, and in UP, the communication cluster in Lucknow
and the district task force groups. The success in building better co-ordination mechanisms at the
national and district level, drawing lessons from all projects experimenting improvement of
routine immunization and social mobilization is an evidence that work can be done together more
effectively.
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6. Guiding Strategies
The global strategy recommended by UNICEF is pragmatic and results oriented. The strategy
comprises a set of tasks as follows:
• The first set of tasks pertains to continuous monitoring and supervision to ensure
high quality full coverage paving the way for accelerated disease control (Polio
eradication, NNT elimination and Measles control).
• The second set of tasks regards the identification of underserved children,

vaccine logistics, cold chain and the critical need to ensure injection safety.
Create a user-based reporting for tracking immunisation for every child and
defaulter tracking and tracing.
• The third set of tasks addresses issues of management and technical assistance
aimed at sensitising and involving community level PRI members to use powers
and functions at each of their levels for RI revitalization. More specifically, use
PRI powers to I) allocate resources 2) provide co-ordination at lower levels 3)
exercise control over government functionaries 4) establish, manage and regulate
melas and 5) advise the state government.
• The fourth set of tasks encourages governments to be forward looking and start
introducing Hepatitis B and other newer vaccines, allocating adequate financial
resources and removing structural barriers to immunisation.
Based on the foregoing broad strategies and the set of tasks deemed necessary to improve
coverage, and bring about quality, there are a number of needs and commitments which have
been identified in which:
• UNICEF and its partners will support GOI and state governments in their
response to the request for routine immunization and other services. Steps
are being taken to respond to the existing demand, starting from the most
disadvantaged areas, as shown by the CES 2002. Support to expand outreach
sessions in all villages will be the main strategy to achieve increased and sustain
the immunization coverage. This will also benefit the Polio Eradication program,
and prevent reemergence of vaccine preventable diseases like diphtheria,
whooping cough and neonatal tetanus. As a strategic priority UNICEF will
continue to strengthen the current administration of vitamin A within the existing
routine mechanisms
• Management support to district and sub-district operations has been shown one
of the weakest points in the UIP management in least performing states. During
the weeks prior and following the NIDs/SNIDs UNICEF and partners will
provide maximum support, supervision and monitoring to the sub-district and
district level to ensure identification of catchment areas and service delivery to
users (multi-antigen immunization, distribution of vitamin A, curative care to 0-2
year children).
• Supply and support systems have suffered lack of supervision and need a
managerial boost for the revitalization of RI to be successful over the mid- long
term. Performance of cold chain in different states remains quite varied and
-13 -
continuous power supply is a major drawback in EAG states. UNICEF and state
officials recently assessed the status of equipment classified as ‘under/awaiting
repair’ in 16 major states. The overall downtime status and need for repair of
ILR/Freezers amount at present to approximately 2.3% (against a target of <2%).
This is mainly due to a considerable amount of outdated equipment. Maintenance
systems in the states of UP, Jharkhand, Bihar and West Bengal are the most
problematic since in these states the percentage of ‘equipment under/awaiting
repair’ is considerably higher than the national average (>5%). UNICEF has
offered over many years monitoring and supervision of the status of the cold
chain equipment. Supporting offshore spare parts and supervision needs to
continue for proper planning and implementation of immunization activities.
Specific, ad hoc support would be considered upon request.
• There is widespread consensus to increase the coverage of fully immunized

children to 60% by end 2004 and Measles vaccination to 80%. It would be
difficult for the states to achieve the target unless UNICEF and partners provide
logistics support. In particular, the supply of AD syringes remains crucial to the
Injection Safety that recently emerged as a major policy concern at national
level. The introduction of Hepatitis B vaccine as part of the UIP in selected areas
and the establishment of the injection safety (IS) Coalition at national level
already contributed to raise the awareness towards the use of AD syringes for
routine immunization or catch-up rounds for measles. The use of AD syringes for
hard to reach and outreach sessions is considered mandatory.
• A stronger educational component will be integrated within the immunization

plus interventions. Monitoring current health services for immunization will
guarantee sustainability of effort, provide training to strengthen capacity of
existing staff reducing drop out rates, increasing outreach, programme
communication will complement other sets of strategies. As evidence shows,
illiterate people are easy victims of rumours and misconceptions. Therefore, it is
important to think in terms of people right to information and services and
consider caretakers as “clients”, rather than “beneficiaries”. Immunization is not
about charity, but about fulfilling the children’s right to health and development.
• UNICEF’s support for IEC/social mobilization will be built around strong

community participation and responsibility, by actively engaging community-
based groups, women self help groups and activists, with the specific
involvement of underserved representatives of the community.
• Communication efforts will keep up the commitment of health workers and

vaccinators to do an effective job to reach all villages/municipal slums, to
sustain demand and talk to clients in a respectful way, and to respond correctly to
their questions. Ensuring their commitment implies recognition of their efforts by
their supervisors and local authorities. It also requires a clear guide of conduct for
health workers and vaccinators.
• The behavioural change communication strategy is built around the principle that
while accessibility can be improved by implementing outreach sessions strategy,
acceptability cannot be imposed without appropriate information. Breaking
reluctance and making communities understand the sense of urgency to revitalize
-14 -
the RI system and start addressing the issue of vitamin A supplementation and
environmental degradation are an integral part of UNICEF strategy. A mid term,
community based approach will be implemented. Acceptability needs to be
gained by addressing socio-cultural and behavioural issues and improving the
provision of complementary health and environmental services.
7. Focus of Routine Immunisation Plan
As mentioned above, strengthening RI in India is a felt need at the national and across states. This
is as a result of declining trends in coverage emerging from a series of Coverage Evaluation
Surveys (CES) including data from NFHS-2. With this recognition, GOI and state governments
have continued to mobilise partners and resources to implement activities that will address the
mitigating factors to reverse the trend. At the same time, the country has been faced with an
upsurge of wild poliovirus transmission that threatens to erode previous gains in the polio
eradication initiative.
Within the context of the Government of India and State Governments’ planning processes,
UNICEF will lead with its partners, the formation of Routine Immunization Units, Task Forces
and Working Groups established to consolidate the routine immunization initiative at state and
district levels.
Planning at the district, block and sub-centre levels will broadly revolve around five components
namely 1) Management, monitoring and supervision 2) Training and capacity building 3) Cold
chain, logistics and supplies 4) Social mobilisation and strategic communication 5) Transport and
mobility support. In addition, plans will include a component defining approaches and
interventions to reach the disadvantaged in municipalities.
The plans will also specifically endeavour to: a) create awareness and a sustained demand for
services, b) building on the existing good practices and experiences, c) bring about community
empowerment via local government institutions and self-help groups, d) enhance community
participation, including children e) reach the un-reached, the underserved and disadvantaged, f)
strengthen monitoring and collecting of new data for decision making (BDCS framework for
action), g) bring about integration and or Programme convergence, cross sectoral collaboration,
and h) child rights to health linked to the rights of others.
8. Agenda for Action: The Phased-in Intensified Approach
The underlying principle in this approach is to demonstrate results and build on the lessons
learned as activities are extended to other districts. Towards this end, the BDCS districts will be
the essential part of the acceleration strategy country and statewide. In specific instances, and
responding to state governments’ requests, UNICEF will activate RI acceleration in broader
areas.
The phased-in approach relies on a specific geographical area programming. Its rationale is to
prioritize interventions according to coverage data and epidemiological evidence. It encompasses
not only the BDCS districts where micro planning and monitoring is already addressed by a
sustained effort, but also those districts that have been and are struck by highest risk of incidence
of poliomyelitis.
A series of state consultations will be advocated by UNICEF and organized by state governments.
UP and West Bengal successfully undertook these consultations in late February and March 2003.
-15 -
The participation of district task forces with multiple representation from DFW, DWCD and local
government allowed a participatory analysis of coverage and bottlenecks at district and sub-
district level as well as a detailed mapping exercise. Further state level consultations, starting
from Jharkhand in June 2003 will offer opportunities for state officials and partners to use a
planning and policy forum where the most striking managerial priorities are discussed and rapidly
addressed. Of utmost importance, the quality of micro plans, supervisory checklists and timeline
of activities will be focused on. As it has been said at the outset, while it is very important to
enhance and maintain the operational quality of SIAs to guarantee wide immunization by OPV,
the time of operations should not exceed 7-10 days. This would offer enough room for the health
system to undertake fixed-day, fixed-site immunization and, in particular, outreach sessions in
order to cover every village eligible children at least once a month.
In UP, the first phase will involve 11 districts (6 BDCS districts; Ghazipur where and intensified
approach on vitamin A supplementation takes place under the MOST targeted intervention; and,
finally other high priority districts) starting from April 2003 and phase-in other districts every
quarter, according to government and partners determinations. A suitable alternative would be for
partners to “adopt” districts and start simultaneous work with UNICEF and other stakeholders. In
the former way, the acceleration process will be completed within fifteen months.
In West Bengal, activities will start in 6 high-risk districts, one of which is part of the BDCS lot.
Jharkhand, Bihar, Rajasthan, and Madhya Pradesh will be phased-in in the process by the same
logic starting from BDCS districts and expanding upon request and discussion among partners.
UNICEF’s targeted interventions will be to:
• Improve the quality of micro planning, management, monitoring and

supervision at all levels.
• Support for planning and conducting assertive outreach sessions in all

villages of the sub-centre. At least one session will be held in each of the village
every month.
• The availability of safe vaccines, safe injections, safe delivery of vitamin A

lies at the center of immunization services and vitamin A supplementation.
• Reach and mobilize families and individuals at the community level especially
in resistant pockets to ensure that all children are fully protected against all
vaccine-preventable diseases. Appropriate supply and use of immunization cards
would be supervised and ensured.
• Inform, educate and motivate families, local influencers and service providers
about the importance of routine immunization through research-based and
professionally designed IEC materials.
• Advocate with decision-makers and influencers at all levels to strengthen and

sustain routine immunization.
• Enhance collaboration with other organizations with a geographic presence and

with different comparative advantages, while sharing the same objectives.
-16 -
9. Strategic Communication
UNICEF’s overall communication strategy is available as a separate document. This paper does
not supercede or replace it, but rather uses it as a basis for action in accelerating routine
immunization.
UNICEF-supported activities will take a two-pronged approach, 1) reach with targeted

interventions the underserved or hard to reach and convince those who have never participated
before, or who are not participating consistently out of sheer lack of knowledge, or because of
doubts or misconceptions. Whereas services may be inadequate, in some cases health care
providers and information have never reached the people, and 2) sustain demand for services of
those who have historically participated in routine immunization, but whose interest might be
decreasing due to insufficient institutional support for RI. The comprehensive communication
strategy is already outlined in the strategic document depicting polio and routine immunization
together.
Inter-personal communication (IPC) with families and communities through the use of local
mobilizers and influential persons represent the strategies of choice to bring about the desired
change in attitude and behaviour of users. This approach will be combined with continued media
interventions that address users’ doubts and misconceptions. It will also be combined with well-
placed advocacy efforts to create an enabling environment for strengthening and revitalizing
routine immunization services.
9.1 Communication Imperatives
Communication activities will try to infuse in clients a body of knowledge to be able to make
positive, informed decisions and choices for themselves and their children. This will not only spur
demand but also ensure sustained utilisation for services. The strategy will ensure that parents and
caregivers including women of childbearing age (WCBA) have information on the need for
timely and full immunisation for pregnant mothers and children (< I year), understand the routes
of administration for each antigen and possible adverse effects following immunisation (AEFI).
With regard to safety of injection, caregivers will be made aware of the use of AD or disposable
syringes during fixed or outreach sessions. Families will also be made to understand the rationale
of providing TT to pregnant mothers and WCBA. Above all, families will be informed well in
advance on the date/day, time, and place of the fixed and outreach sessions to enable them to
attend or bring eligible children.
RI Strengthening requires a sound strategic communication plan and activities, whose main goals
are to:
1) Reduce dropouts due to user barriers
2) Reach the “underserved”
3) Advocate among key constituencies to sustain the immunization program.
Specific activities will be conceived according to state priorities and funding status, according to
the current, agreed upon Communication Strategy Paper for 2003.
-17 -
Reduce Dropouts Due to Consumer Barriers
The objectives are to: 1) ensure caregivers know the date and time of vaccination programs, 2)
ensure caregivers know when to come for the next vaccine 3) educate parents on the importance
of measles vaccine 4) dispel myths about side effects and contraindications 5) reduce number of
AEFI i.e. improve injection safety 6) maintain a high profile for immunization throughout the
year and 7) market the concept of “full immunization”
Reach the“Underserved”
The objectives are to: 1) Increase participation/ownership of professional groups, institutions,

and NGOs in underserved areas 2) increase health service access and utilization 3) increase
distribution/utilization of immunization cards 4) increase outreach to slum areas 5) increase
outreach to low-literate and poverty-level mothers and 6) increase outreach to tribal groups and
scheduled castes.
Advocate within Government to Sustain the Immunization Program
The objectives are to: 1) increase participation of government in reinforcing key messages 2)
improve public perception of immunization program 3) increase number of supporters for
immunization services 4) engage other governmental departments in the effort to improve
immunization coverage and 5) engage other NGOs and give them a long-term role in sustaining
the program.
10. Service Delivery Point Activities
Essential components will be:
• to ensure one planned session in every village every month

• to ensure availability of adequate logistics and supplies (syringes, vaccine,
injection equipment) and
• to ensure effective social mobilization and communication.
A schematic, exemplified approach would include the following:
• Development/improvement of Sub-centre and village level micro plan.

• All the villages under a sub-centre will be divided into two categories namely
easy to reach and difficult to reach villages. The difficult to reach villages would
require extra inputs like mobility support. In a sub-centre’s catchment area of
nearly 8,000, around 240 new births are expected every year (20 per month).
Each child requires 4-5 contacts for the completion of Routine Immunization
schedule. Thus, the total number of contacts that an ANM is supposed to
establish is 100-125 per month.
• When organizing 8 sessions per month, every ANM would have a workload of
15-20 contacts per village. Taking children up to 2 years of age then the number
may double if no immunization sessions have been undertaken earlier. Similarly
the logistic support can also be calculated.
-18 -
• While holding a session, the ANM would maintain a MCH/Immunization

register, which specifies the reasons for a visit and the services, extended. She
would also up-date the Immunization card
• Mobility support will be provided for hard to reach areas.
• Injection equipment: Re-usable syringes for the routine immunization
strengthening. One rack of sterilized syringes/needles (45-50) would be sufficient
for one planned session in a village. AD syringes are to be introduced for every
outreach session.
• Monitoring support will be by the existing public health system (Health
supervisors, MOs, MO I/Cs, Deputy CMOs, and CMOs). Neutral cross-sectoral
observers may also be deputed for monitoring.
• Support to ensure adequacy of the cold chain will have been factored in the micro
plan.
• IEC targeting the involvement of communities through Village Health
Committees and their revitalization.
11. Expected Results by end 2004 in Phased-in Districts
• RI coverage will exceed 60% for all EPI vaccines (BCG, OPV, DPT, and
Measles) in children < 12 months in selected districts of selected states.
• District Task Force in place with under-served segments' representation,
statewide.
• Verified by survey, all immunization sessions will be able to demonstrate
adequate supply of vaccines and appropriate quality of cold chain.
• Leveraging the existing health infrastructure and system to take on additional
integrated health services for children.
• Creation of full awareness and involvement of the PRI.
• Block Development Committees geared up on RI and a working with a
demonstrable inter-sectoral collaboration.
• Sub-centre level catchment areas identified and mapped (focus on newborn and
0-2 yr. old children).
• Availability and implementation of quality district and sub-centre micro plans for
outreach.
• Village level organization, plan and logistics via Swastya Ghar or similar
initiatives.
• Training of health workers in the use of AD syringes at district and sub-centre
level completed.
• AD syringes for all UIP vaccines including Hepatitis B vaccine introduced in a
phased manner.
• Combined DPT-Hepatitis B vaccine introduced for use when it becomes
available.
• State Assessment on Injection Safety in 2003 and support to implementation of a
National Injection Safety policy.
• Strengthening the strategy for integration of new vaccine in the existing
Programme.
• Address health sector reforms by use of AD syringes.
• Together with WHO, support establishment of Surveillance systems for VPDs
and AEFI.
-19 -
References
AIIMS. (2000). Lessons learnt from pulse polio immunization programme: Report. Journal of the
Indian Medical Association, 98 (1): 18-21.
Gounder, C. (1998). The progress of the polio eradication initiative: What prospects for
eradicating measles? Health Policy and Planning, 13 (3): 212-233.
Hull, H.F., Ward, N.A., Hull, B.P., Milstien, J.B., & de Quadros C. (1994). Paralytic
poliomyelitis; seasoned strategies, disappearing disease. Lancet, 343: 1331-1337.
Pande, R.P., & Yazbeck, A.S. (2002). Beyond national averages for immunizations in India:
Income, gender, and regional inequalities. HNP Discussion Paper. World Bank, DC
Razum, O., Liyanage, J., & Nayar, K.R. (2001). Difficulties in polio eradication. Lancet, 19: 357.
EPOS (2002). Cultural barriers to polio eradication: a quantitative and quantitative assessment,
a joint WHO/UNICEF supported study, New Delhi, 2002.
Bonu, S., Ravi, M., Baker, T.D. (2003), in press. The impact of national polio immunization
campaign on levels and equity in immunization coverage: evidence from rural North India.
Social Science and Medicine, 2003.
Das J., Das S., (2003). Trust, Learning and Vaccination: a case study of a Northern Indian
Village. Social Science and Medicine, 57: 97-112
-20 -
Appendix I
1. Accelerating Routine Immunisation within RCH-II Policy:

A Strategic Link to National Experiences
1.1 Rationale
During three public national and international occasions in April and May 2003, the Secretary
DFW indicated that routine immunisation has been neglected and requires attention and
revitalization. Of concern is the principal finding of the 2002 RCH survey that the immunisation
coverage rates for other non-polio vaccinations have declined or stagnated despite the
implementation of the PPI campaign. While a number of studies have shown a positive link
between the polio eradication programme on other EPI vaccinations and health systems, they are,
however, qualitative and anecdotal in nature, and are primarily based on interviews with
community leaders or health staff (AIIMS, 2000; Gounder, 1998; Hull, Ward, Milstien & De
Quadros, 1994.). On the other hand, a number of studies have reported some disruption of other
health activities as an outcome of PPI (AIIMS, 2000; Chowdry & Ramos-Jimensez, 1999a, b;
Razum et al., 2001, John et al., 2002). And in some instances, there is a growing concern that the
PPI campaign might have helped to stem the deterioration in routine immunisation that was seen
in the early 1990s.
Chincholikar and Prayag (2000) concluded from their evaluation of PPI in rural areas of
Maharashtra that the PPI campaign raised general awareness about polio immunisation among
illiterate mothers, but not specific knowledge of the importance of immunisation in general. Data
from the World Bank funded Reproductive and Child Health surveys conducted in 1998 (after
implementation of six rounds of NIDs) also suggests that almost two-thirds of mothers of un-
immunized children from rural areas were either unaware of the need of routine immunisation, or
did not know a source of immunisation services (Pande & Yazbeck, 2002).
Beyond other relevant issues, a recent UNICEF-WHO sponsored study on cultural barriers to
polio immunisation in UP suggests that under-served and illiterate mothers, regardless of specific
communication techniques used, are unlikely to distinguish between various vaccines, and may
not take the child for other immunisations, on the assumption that the child received all the
vaccines during NIDs/SNIDs (EPOS, 2002). Evidence from health workers and public
perceptions in the same study indicates that rigid hierarchies, as in the case of Uttar Pradesh (UP),
and single-minded commitment to achieve short-term quantitative goals for polio immunisation
through SIAs may have discouraged long-term efforts for creating and sustaining the demand for
preventive services in general, and immunisation services in particular.
Finally, data from 2002 and 2003 PPI indicates that persistent inequities in coverage by caste and
religion may impede PPI from achieving its ultimate goal – eradication of polio – as lower castes
and minorities tend to live in clusters in Northern India. Persistence of even small pockets of
unvaccinated new-borns and young children increases the risk of resurgence of local transmission
foci in polio-free states such as West Bengal, Rajasthan, Gujarat, Madhya Pradesh and the risk of
sudden outbreaks of poliomyelitis as occurred in 2002 in Uttar Pradesh (UP).
Experience has shown that a development objective, however well-meaning could not be imposed
upon supposed beneficiaries unless their right to information, knowledge and consultative
dialogues, and in many instances their right to basic services is addressed.
-21 -
Since 1999-2000 the national government with the help of many partner agencies has started
steps towards revitalising routine immunisation with an emphasis on quality improvement of
service delivery. Schemes to Strengthen Outreach Services have been devised by the GOI within
the current policy framework that contributes to improve the quality of services and enhance
coverage of infants namely:
1.2 Border District Cluster Strategy
The Border District Cluster Strategy (BDCS) is a joint GOI-UNICEF supported initiative to
contribute strengthening the health system and improving the quality of service delivery. Its main
thrusts are community based planning and monitoring and providing a minimum intervention
package of basic services (immunisation plus and basic maternal care) and an expanded
intervention package (Integrated Management of Neonatal and Childhood Illnesses—IMNCI,
Emergency Obstetric Care--EOC). Forty-eight districts are covered under the scheme in 15 major
states. Villages in the intervention districts are classified into three categories. Type ‘A’ villages
are the head quarter village of the sub-centre (SC), while type ‘B’ villages are those which could
be reached within half-an-hour walk or having public transportation available from the SC and
type ‘C’ are those which are beyond half-an-hour walking distance. Comprehensive primary
health care services are provided through the health and nutrition teams once every month
through out-reach sessions. In order to improve out-reach sessions, an incentive of Rs20/- per
session for 4 sessions per sub-centre per month has been provided. Provision of mobility support
for routine catch-up sessions in hard to reach areas has also been made.
After the last national review in April 2002, the introduction of the concept of “learning
districts” initially in selected areas and over time in all BDCS districts contributes to secure:
a) Immunization Plus: acceleration of EPI Plus (including Vitamin A) and of expanded ANC at
sub-centers and RCH outreach.
b) I-ECD and survival: Community and home based interventions, especially home based
prevention and management of Asphyxia, Hypothermia, Low Birth Weight, Neonatal Sepsis as
well as Pneumonia and Diarrhea in young children.
c) Referral Care especially improved EOC, Neonatal Care and IMNCI in FRU’s.
1.3 Immunisation Strengthening Project
This is a major attempt made by the GOI to address the inadequacies and constraints identified by
coverage evaluation surveys and other similar studies. It takes advantage of the new experiences
gained in the Pulse Polio Programme (PPI), namely, mass mobilization, surveillance and building
commitment among programme implementers and the public towards the immunisation
programme. The project is a three-year undertaking initiated in 2000-01 as a component of the
ongoing World Bank supported RCH Programme and its cost estimate is Rs.1, 118.41 Crores. It
recognizes the following objectives:
1.3.1 Eliminating polio incidence and achieving polio eradication.

1.3.2 Strengthening routine immunisation and Vitamin A supplementation with the
aim of raising the percentage of fully immunised children to above 80%.
1.3.3 Reviewing and developing a new vision of the immunisation programme in the
medium term keeping in view the development of new epidemiological patterns,
availability of new vaccines and delivery mechanisms and advances in cold chain
technologies.
1.3.4 Improving surveillance and monitoring mechanisms.
-22 -
The polio eradication component of the project facilitated the ongoing efforts of the Government
in Polio eradication. The other two components of the Project relating to strengthening of routine
immunisation and Strategic Framework Development are currently operationalized.
The inputs of the project include:

• assistance for the cold chain equipment replacement or new installation;
• replacement of injection safety equipment, supplied about 15 years ago
• computerisation of information related to vaccine and cold chain logistics for
improving supervision and monitoring
• mobility support for state programme officers
• operational system of quarterly review meetings at the national and state levels
• technical assistance for programme monitoring
• finance activities for formulating mid-term goals for the programme as well as
for programme development. In particular, it will support extension of disease
surveillance of measles, support epidemiological studies and community
surveillance in UP and Bihar
• strengthening outreach services by providing inputs for micro planning,
supervision, IEC (Information Education Communication) development, social
mobilisation and improving service delivery mechanisms.
This scheme was started in 50 poorly performing districts of 8 priority states of UP, Bihar,
Madhya Pradesh, Rajasthan, Orissa, Gujarat, Assam and West Bengal during 2000-01. In 2001-
02 an additional 101 weak districts from other poorly performing States have also been included.
The scope of the scheme is likely to be expanded to cover some additional districts in 2003.
1.4 Injection Safety
Since its inception, UIP provided reusable glass syringes and needles with the necessary
equipment for sterilization. Unfortunately, recent evidence has indicated that over 30% of
vaccinations were unsafe. Since 1998, Auto-disable Syringes (ADS) for catch up rounds of
measles (target: children of 9-59 months) and tetanus toxoid (target: women of childbearing age)
have been supplied with the help of UNICEF. Over 10 million syringes have been used so far in
the country and the experience has been encouraging indicating user friendliness and satisfaction
among clients. The introduction of Hepatitis B in select areas under GAVI support mandates use
of AD syringes for all vaccines. Towards this end, the national government has recently decided
to replace the reusable syringes with ADS in a phased manner as part of the RCH-II policy.
To provide an insight, a nation wide study on the prevalent injection practices in the country has
been commissioned. India-Clinical Epidemiological Network of medical colleges will conduct
this study. The study would focus on issues such as injection prescribing behaviour of providers
and the adoption of safety measures by health professionals in order to investigate practices of
disposal of syringes and needles at the point of service delivery. The study will be conducted not
only in the public sector but also include private sector institutions and health care providers.
Injection practices will be studied both in programme situations (focusing on the Immunisation
Programme) and clinical facilities. The Indian Academy of Paediatrics (IAP), Indian Medical
Association, Federation of Obstetricians and Gynaecologists Society of India, Neonatology
Forum, and the Indian Association of Preventive and Social Medicine have been associated to get
a realistic situational analysis of injection practices in the country. Based on the study results and
the recommendations, specific interventions will be launched.
-23 -
1.5 National Technical Advisory Group on Immunisation
The Department of Family Welfare has established a National Technical Advisory Group on
Immunisation (NTAGI) on 28 August 2001. The committee has been set with comprehensive
Terms of Reference for its effective functioning to take on the following major roles:
• To be an advisory body to assist the Government of India in developing a nation-

wide policy framework for vaccines and immunisation;
• To prioritise immunisation activities and set attainable targets;
• Identify critical gaps in policy and programme and identify studies, assessments
and research areas to address the same; and
• To review periodic assessments of the national immunisation programme
including immunisation performance and disease incidence.
1.6 Introduction of Hepatitis-B Vaccine: A Window of Opportunity

It is estimated that 60% of liver diseases are due to Hepatitis-B infection and 80% of liver cancer
cases in India arise from Hepatitis B. Vaccination against Hepatitis B protects individuals from
the risk of Hepato-cellular carcinoma and Hepatitis-B vaccine is thus the first vaccine available
against any type of cancer.
In India, the Ninth Five-Year Plan Approach Paper has recommended introduction of Hepatitis-B
immunisation in the UIP. Within the 10th National Health Plan, both financial and human
resources will be freed for undertaking fresh initiatives. Concurrently, as a measure to strengthen
the immunisation programme and improve the outreach of RCH services, Hepatitis B vaccine is
now being integrated into the existing routine/universal immunisation in India by the MOFW.
The strategy of its addition is planned to promote healthy competition among districts and states
for better performance and to provide due priority to the most disadvantaged.
One of the main objectives in selecting specific cities and districts for the introduction of this new
vaccine is to achieve 80% coverage or more under routine immunization of infants with the
existing vaccines on the basis of coverage evaluation surveys. This strategy is designed to
encourage more cities and districts to be included as the program expands. In the pilot phase the
vaccine is being provided free of cost only to infants living in slums to ensure that the most
disadvantaged get due preference. Additional inputs being provided for the introduction of this
new vaccine are: 1) Auto-disable (AD) syringes (to be supplied by UNICEF and other donors
initially) and their safe disposal (to attract attention towards bigger issues of hospital waste
management) and 2) Renewed emphasis on maintenance of cold chain (for ensuring potency of
all the vaccines).
-24 -

Immunization Plus - A Framework For Action (2003-2007)

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A Framework for Action

INDIA COUNTRY OFFICE

In addition, acknowledgement is extended to the Department of Family Welfare, Ministry of

Part One: Situational Analysis

3. Accelerating Immunization efforts 5

3.1 Polio Eradication: A Compelling Priority 5

Part Two: The Case for Accelerating Routine Immunisation in India

7. Focus of Routine Immunisation Plan 15

11. Expected Results by End 2003 in Phased-in Districts 19

Part one. Situational Analysis

As mentioned above, research findings

Reasons for Low Coverage

Other Not aware of date,

Inconvenient date and

Not aware of need for

Disease Est. cases Reported cases Est. deaths Reported deaths

3. Accelerating Immunization efforts

3.1 Polio Eradication: A compelling priority

Epidemiology of Wild Poliovirus in India

The Situation of Wild Polio Virus in 2002 and early 2003

2002 (1599 cases) as 31 December 2002

Uttar Pradesh 1241

2003 (77 cases) as for 15 May

3.2 Neonatal Tetanus Elimination

The immediate objectives of the strategy include:

3.3 Measles Control

A strategy undertaken to control measles in India focussed on 13 cities in 1999, 47 additional

3.4 Introduction of Hepatitis B Vaccine

3.5 Vitamin A supplementation

Part Two: The Case for Accelerating Routine Immunisation in India

4. Summary Goals and Principles

5.1 Focus Intensive Interventions in Selected Areas

5.2 Adoption of a Proactive and Intensive Approach

5.3 Intensify Advocacy at National and State Levels

5.4 Intensify Partnerships for Planning and Service Delivery

5.5 Offer Leadership and Co-ordination

A higher degree of co-ordination and a strategic role of supervision are management

• The second set of tasks regards the identification of underserved children,

• There is widespread consensus to increase the coverage of fully immunized

• A stronger educational component will be integrated within the immunization

• UNICEF’s support for IEC/social mobilization will be built around strong

• Communication efforts will keep up the commitment of health workers and

7. Focus of Routine Immunisation Plan

8. Agenda for Action: The Phased-in Intensified Approach

UNICEF’s targeted interventions will be to:

• Improve the quality of micro planning, management, monitoring and

• Support for planning and conducting assertive outreach sessions in all

• The availability of safe vaccines, safe injections, safe delivery of vitamin A

• Advocate with decision-makers and influencers at all levels to strengthen and

• Enhance collaboration with other organizations with a geographic presence and

UNICEF-supported activities will take a two-pronged approach, 1) reach with targeted

9.1 Communication Imperatives

Reduce Dropouts Due to Consumer Barriers

The objectives are to: 1) Increase participation/ownership of professional groups, institutions,

Advocate within Government to Sustain the Immunization Program

10. Service Delivery Point Activities

Essential components will be:

• to ensure one planned session in every village every month

A schematic, exemplified approach would include the following:

• Development/improvement of Sub-centre and village level micro plan.

• While holding a session, the ANM would maintain a MCH/Immunization

11. Expected Results by end 2004 in Phased-in Districts