India's national immunisation programme: Moving from policy to action

About a year ago, the Prime Minister’s Office in India announced the introduction of four new vaccines in the national immunisation programme. In this article, Chandrakant Lahariya, a public health policy expert, discusses the significance of the decision. He highlights gaps between policy decisions and action with respect to the immunisation programme in the past, and emphasises the need for speedy and effective implementation of the announcement.

In July 2014, the Prime Minister’s Office (PMO) in India announced the introduction of four new vaccines - Rotavirus vaccine, Injectable Polio vaccine (IPV), Rubella vaccine, and Japanese Encephalitis (JE)¹ vaccine (for adults) in the Universal Immunisation Programme (UIP)². This announcement was a significant event, at least on two accounts: one, it is not routine that the PMO announces a health-related policy decision, and second, the number of vaccines proposed for introduction equals the total number of vaccines that have been added to the programme since its inception in 1985 (Lahariya 2014). In the first 17 years of UIP, until 2002, no new vaccine was added to the programme. This was despite the fact that during this period a number of new vaccines became available, and were licensed and introduced in national immunisation programmes of other countries, and those vaccines were available in the private sector in India as well on pay-for-use basis.

Although a number of internal activities have been initiated by the government since the announcement in July 2014, the proposed vaccines have not yet been offered through UIP in any state in India.

Why expanding the national immunisation programme is important

Vaccines are amongst the most cost effective preventive public health interventions. Worldwide, an estimated 20% of all deaths amongst children younger than five years of age are preventable by currently available and licensed vaccines. For example, among children in India, Rotavirus diseases are estimated to cause nearly 80,000 deaths and pneumococcal diseases another 140,000 deaths annually. A large proportion of these deaths are preventable, if vaccines against these pathogens are made available to all children. This would bring down the infant and child mortality rate in India, which remains high³. In addition to the deaths, vaccines prevent illnesses not leading to deaths and reduce visits to health facilities, long-term conditions such as mental retardation and physical disability, and hospitalisation. Vaccines reduce indirect costs such as school absenteeism, loss of wages of caregivers, reduced productivity from illnesses etc.

Moreover, the decision opens a window of opportunity for promoting investment and R&D (research and development) in vaccines in India. Other potential benefits are an uninterrupted supply of these vaccines at low cost for Indian children, better affordability of these vaccines in low- and middle-income countries⁴, and an economic boost to the healthcare and vaccine industry in India.

Thus, vaccines are considered a good ‘return on investment’, and this announcement by PMO would undoubtedly generate various benefits in both the short and long term.

From policy to action: Past experiences

The implementation of this decision means that these vaccines should be available through the national programme in all states and union territories and reaches 100% of the targeted beneficiaries at the earliest. The announcement gives rise to some ‘cautious optimism’ as implementation of major policy decisions in India tends to be slow. For example, India introduced the Hepatitis B vaccination in UIP on a pilot basis in 2002-03; this was scaled up to additional states in 2007-08. However, it took almost until 2012, a decade from the pilot introduction, for the benefits of this vaccine to reach all states of India. In late 2010, India was the last country in the world to introduce a second dose of measles (measles containing vaccine second dose or MCV2) vaccine in their national immunisation programme, even though almost two-third of measles-related global deaths were taking place in the country. Ironically, India produces 70% of measles vaccine doses that are being used in the entire developed world (Lahariya 2014).

Another instance of the gap between policy decisions and implementation in India is the introduction of Haemophilus influenzae type b (Hib) as a combination pentavalent⁵ vaccine. The recommendation to introduce this vaccine was made by a technical committee in June 2008⁶ . However, it was only in December 2011 that it was first introduced in two (Tamil Nadu and Kerala) of the 35 states and union territories of India (Gupta et al. 2012). By then, 170 countries in the world already had this vaccine in their programmes. Six years since that decision, in June 2014, all but 10 countries in the world have introduced this vaccine; however, it was still not available in UIP in 27 states and union territories of India. In the case of Japanese Encephalitis (JE) vaccine, it took nearly five years (2006-2011) to provide the vaccine to the targeted children in nearly 112 endemic districts of the country.

Ensuring speedy and effective implementation

Effective implementation of this pronouncement is possible if the lessons from the past inform decision-making. Also, what is needed is additional supportive policies to facilitate the vaccine introduction such as increase in the financial allocation for vaccine procurement in a sustained manner⁷, upgrading storage capacity for vaccines at all levels, and capacity building in terms of human resources for implementation and monitoring. Most importantly, the currently available vaccines do not reach all of the targeted children in India⁸. This should not happen with the vaccines, which are proposed for introduction. Introduction of these new vaccines should be utilised as an opportunity to strengthen the health systems in the Indian states and increase coverage of existing vaccines as well. These are some of the areas in which high-level policymakers could take the lead and direct concerned ministries and programme managers to plan and ensure timely implementation.

Even as the new national health policy for the country is being drafted and new initiatives and interventions to ensure universal health coverage are being deliberated upon, it is the implementation of the existing policies, which will determine how people perceive the seriousness and intent of the government in translating policies into implementation. A delay in the implementation has the potential to erode the credibility of the government institutions and policymakers in India. Interestingly, three decades ago, UIP had started as one of the five National Technology Missions, which were directly supervised by PMO. Perhaps the immunisation programme in India has reached a key milestone and there is a new beginning in this decision.

The views expressed are personal.

Notes:

Rotavirus vaccine prevents death from diarrhoea in children under five years of age. Rubella vaccine prevents German measles, which causes fever, rashes and severe complications in children under six years of age. Injectable Polio vaccine is expected to help maintain India’s polio-free status, which it obtained in 2014. Japanese Encephalitis (JE) is a disease that can result in paralysis and death.
Universal Immunization Programme (UIP) in India was launched in 1985 to prevent infants and children from six vaccine-preventable diseases namely Tuberculosis, Diphtheria, Pertussis, Tetanus, Poliomyelitis and Measles by administering BCG (Bacillus Calmete Guerin) vaccine against Tuberculosis, DPT (against three diseases namely Diphtheria, Pertussis and Tetanus), OPV (Oral Polio Vaccine against Poliomyelitis disease) and Measles vaccines. Additionally, UIP provided prevention from maternal tetanus for adolescent girls and pregnant women through TT (Tetanus Toxoid) vaccine. It is one of the largest immunisation programmes in the world. With the proposed new vaccines, the programme will provide free vaccines against 13 life-threatening diseases to 27 million children annually.
The infant mortality rate (IMR) or mortality rate for children up to one year of age in India in 2013 was reported at 40 per 1,000 live births, with wide variation across states - from 11 in Goa to nearly 56 in Madhya Pradesh (Sample Registration System, 2014). Most developed countries have single-digit IMR.
This is because, upon inclusion of the vaccines in the national immunisation programme, additional manufacturers in India are likely to start manufacturing them as they have an assured market for the product.
This refers to a combination vaccine that provides protection from five antigens (DPT+HepB+Hib).
The recommendation to introduce any new vaccine in Universal Immunization Programme (UIP) in India is given by National Technical Advisory Group on Immunization (NTAGI). The NTAGI was set up by the Ministry of Health and Family Welfare, Government of India in 2001. It comprises senior policymakers from various government departments, key stakeholders and independent technical experts.
Currently, a number of vaccines are being provided through external funding. For sustainability, government allocation for vaccine provision should be increased.
As per the most recent nationwide Coverage Evaluation Survey (CES) data (2009), only 61% of children in India received all vaccines offered under UIP. This proportion is around 95% in countries such as Bangladesh and Sri Lanka.