CRITICAL REVIEW ON IMMUNISATION POLICY IN INDIA
Vacccines are very important discovery of the times and essential preventive medicines for primary health care, and are critical component of a nation's health security. Mass immunisation for protection from infectious diseases is one of the greatest achievement of the modern medicine and its benefits have been eloquently setout. The 20th century saw tremendous advances in the vaccine development all over the world and its broadenend application to health problems afflicting the poor throughout the world. The vast improvement of health with the discovery of vaccines has lead to the need of developing an immunisation or vaccine policy all over the world. The first step towards global prevention of infectious diseases and protecting children from dreadful diseases was taken by the World Health Organisation (WHO) by formulating a global health policy for immunisation.WHO developed an immunisation policy for global chilhood vaccination in accordance with the WHO's policy of "Health for All by 2000" famously announced in 1978 at Alma Atta, Kazakhstan. The WHO's policy recommended universal immunisation of all the children to reduce child mortality under its expanded Immunsation Programme (EPI).
India now with more than 1 billion population, second most populous country accounting for 17% of the world's population and 25 million new births every year is one of the largest markets for vaccines. The current Indian market for vacines is estimated to be about US$260 million. With the increasing population the necessity for the prevention of dreadful diseases among the populations has been sensed and immunisation policy has been adopted from the WHO. After independence in 1948, India became a member country of WHO and eagerly joined and abided to the policies of the WHO and UNICEF. However, for the development a policy that was in alignment with the WHO's policy of "Health for All by 2000" and the Alma Atta declaration in 1978 which targets at the universal immunisation took almost three decades. In line with the declaration, in 1978 Indian governement started the Expanded Immunisation Programme by introducing six childhood vaccines (BCG, TT, DPT, DT, Polio and Typhoid). Measles vaccine was added much later in the year 1985. It gained impetus as Universal Immunisation Programme (UIP) in 1985 and was carriedout in a phased manner covering all the districts in the country by 1989-90 (MOHFW 2006-07). Several goals have been set to achieve the desired targets by the year 2000. Lots of efforts and funds have been exhuasted on UIP but the several surveys testified to a glaring gap between the goals aspired for and targets touched.
UNDERSTANDING THE HEALTH POLICY INITIATIVE:
When the question of why a health policy has to be developed for immunisation or vaccination of the children comes into existence the answer looks simple by looking at the burden of preventable diseases causing death in the world. The initiative of formulating a vaccination policy came into existence at the Alma Atta declaration.
Vaccination policy refers to the policy, a government adopts in relation to vaccination.the aim or goal of vaccination policies is to produce immunity to diseases. Besides inidividual protection from getting ill, vaccine policies also aim at providing herd immunity which is based on the idea that the pathogen will have trouble of spreadin when a large part of the population has immunity against it. The goals of vaccine policies with some vaccines may aim at completely eradicating a disease from the face of the earth. For example, the WHO co-ordinated the global effort to eradicate smallpox globally and achieved it. The last naturally occuring case of smallpox occurred in Somalia in 1977.
The immunisation policy was introduced as a part of the National health policy and the five year development plans in India. The expanded immunisation programme developed by the WHO is merged with the system and a Universal immunisation programme was developed in India according to the needs.
The report of the sub-committee on national health prepared for the consideration of National Planning Committee of the Indian National Congress had advocated state intervention to preserve and maintain health of the people by organising and controlling health care to achieve the proper integration of curative and preventive services (National Planning Committee 1948: 224-5). The UIP, a carefully planned strategy launched in 1985-86, aimed at systematic district-wise expansion to cover all the districts by 1989-90 (Govt. of India (GoI), MoHFW 1985; Sokhey 1985). More than 90 million pregnant women and 83 million infants were to be immunised over a five year period under the UIP (Sokhey 1988). The programme was given the status of a National Technology Mission in 1986 (GoI 1988) to provide a sense of urgency and commitment to achieve the goals within the specified period. UIP became a part of the Child Survival and Safe Motherhood (CSSM) Programme in 1992-93 (MoHFW 2002-03: 176). Since 1997, immunisation activities have been an essential part of the National Reproductive and Child Health (RCH) Programme (MoHFW 2005-06: 54). The GoI constituted a National Technical Committee on Child Health on 11th June, 2000 and launched Immunisation Strengthening Project on the recommendation of the Committee (MoHFW 2002-03: 173). The Department of Family Welfare established a National Technical Advisory Group on Immunisation on 28th August, 2001 to assist GoI in developing a nationwide policy framework for vaccines and immunisation (MoHFW 2002-03: 174).
Modelled on the WHO guidelines, the government of India's Universal Immunization Program (UIP) was introduced in 1985 and includes one dose of BCG (at birth), three doses of OPV and DPT (at 6,10, and 14 weeks), and one dose of measles (at nine months).
Universal Immuisation programme schedule:
Goals of the program:
The goal of the program is to immunise the children against vaccine preventable diseases like Tuberculosis, Diphtheria, Pertusis, Tetanus, Measles and Poliomyelitis. The goal is to achieve universal immunisation by the year 2000 abiding with the policy Health for All by 2000. Although the goals have not been achieved there was a noticeable decline in the prevalence of these diseases.
FACTORS AFFECTING IMMUNIZATION:
Decentralization is also a highly popular component in policy reform. Within the health sector, decentralization of finances and responsibilities is one of the essential topics that have emerged in the agenda of national governments and international organizations. Devolving some of the centralized responsibilities to local levels is likely to improve both technical efficiency and allocative efficiency (Peabody, 1999). Robalino et al (2001) shows that higher fiscal decentralization is consistently associated with lower mortality rate and the benefits of fiscal decentralization is predominantly important for poor countries. Khaleghian (2003) finds that decentralization has a positive impact on immunization in low-income countries but the reverse happens for middle-income countries. 'Efforts to augment demand generation and community participation for immunization must focus on the consumers of the programme with due regard to their problems, needs, biases and aspirations.
Education is an important determinant of immunization coverage. It also affects mortality and fertility inversely (Ghosh, 1991). Role of education/ literacy/ female literacy is also agreed by many researchers (Gupta et al, 1992; Dreze, 1993; George et al, 1993; Rajan et al, 1993; Rajan et al, 1993a; Pebley et al, 1996; Gage et al, 1997; Desai et al, 1998; Gauri et al, 2002) in making people more health conscious. Padmanabha (1992) also agrees to the importance of literacy and argues that 'because of low literacy levels in a large part of the country, communication with masses, particularly at the community level is only effective through political and local leadership'.
Bottle Necks of Supply:
There are some bottlenecks from both supply- and demand-side. In a developing country like India, any programme like UIP could be affected by supply-side financial constraints when the overall Central and State budgetary allocations on health care are meagre and availability of supply-side data at disaggregated level is rare
Effective coverage vs Full immunization-
Every program depends on the effectiveness of its coverage. It's always important how effective the immuniation program is covered rather than concentrating on the full coverage and reaching the populations.
Proper microplanning of immunization by health functionaries-
The immunisation program success also depends on the proper planning and implementation of a micro plan by the health functioneries because without a proper implementation plan the immunisation program cannot reach the masses and successful.
There should be an effective monitoring tool developed which should be based on - Availability, Accessibility &Utilization to measure effectiveness of the immunisation.
Accountability& motivational factors of health staff:
Also the accountability and motivation of the health staff is plays an important role in the progress or the success of a program like the immunisation. Without the continuous efforts of the health staff the effectiveness of the immunisation cannot be increased.
Transport & cold chain failure:
The minor factor and often forgotten factor that effects immunisation is the transport and effective cold chain system which makes the effective delivery of the vaccines possible.Without a proper transport and cold chain system the whole process of vaccinnation would be a mere waste.
Infrastructural indicators such as electrification, all weather roads are also important factors (George et al, 1993).
There is slight gender discrimination of being vaccinated in India. Chance of being fully vaccinated is 41 percent for girls and 43 percent for boys. This gender discrimination is statistically significant also. Some researchers also noted such behavior of families to neglect and discriminate female children (Das Gupta, 1987; Rajeshwari, 1996; Islam et al, 1996). However, Hill et al (1995) noted that although there are substantial mixed variations in immunization coverage by sex, the median difference across all countries is very close to zero.
There is a consistently inverse relationship between immunization coverage and birth order of a child. Majority of first-order births occur to younger women who are more likely than older women to utilize maternal and child health care services. The different likelihoods of immunization for different birth orders are also strongly significant. One can think of two countervailing effects of increasing birthorder on likelihood of vaccination. The positive one could be some kind of learning effect about immunization which almost does not vary with higher birth-order. The negative one could be some kind of negligence effect to the higher order births and this effect perhaps increasingly increases with higher birth-order. Thus for higher order births, it seems that the negligence effect more than offset the learning effect.
Another variable namely, sex-wise birth-order is constructed to see whether likelihood of vaccination decreases with increase in birth-order for girls only or not. Likelihood (unadjusted) of vaccination decreases with increase in birth-order irrespective of sex of a child, and surprisingly, the rate of decrease is lower for girl children except third birth-order
Urban vs Rural:
Urban children are much more likely to be fully vaccinated than rural ones. The chance of being fully immunized is 37 percent for ruralchildren whereas it is 60 percent for urban children.
High immunization coverage in urban areas is however supported by many researchers (Pebley et al, 1996; Padhi, 2001).
There is a strong positive relationship between mother's education and children's immunization coverage. The chance is almost three times higher for the children of mothers with high school or above education than the children of illiterate mothers.
Chance of immunization of children increases with their mother's age only up to the age group of 25-29 and then decreases. A positive relationship is also noted by Steele et al (1996). In the context of rural Bangladesh, Islam et al (1996) shows that likelihood of vaccination decreases for the mothers' older than 28 years.
Antenatal care during pregnancy:
Antenatal care during pregnancy has a strong positive direct effect on vaccination. The chances of immunization are a mere 18 percent for the children of mothers with no antenatal care during pregnancy and 57 percent for the children of mothers with some antenatal care.
Chance of immunization varies with religion also. The likelihood of being fully immunized is 42 percent for children from Hindu household, 33 percent for children from Muslim household and 64 percent for children from Christian and other minority community household.
Living standard index:
Chance of immunization increases with standard of living index of children's household and also depeneds on the household income.
Mother's awareness about immunization also has significantly strong positive effect on vaccination.
Electronic mass media & Electricity:
Electricity also has significant effect on full immunization in India. It shows that electricity has significantly strong positive effect on immunization possibly through electronic mass media. Islam et al (1996) also noted such a positive relationship.
These are the few determinants take into consideration which majorly effected the implementation of the policy of immunisation and major hinderances for the acheivement of the targets.
A CRITICAL REVIEW OF UIP EXPERIENCE IN INDIA
Various survey results bear the testimony to the glaring gap between the goals aspired for and the targets reached. National Review mentioned some supply side bottlenecks that may hinder the UIP to achieve its goals. Public health should not be treated as the sole responsibility of The health sector. Policies and programmes in other sectors such as environment, education, welfare, industry, labour, information, etc, have also be informed and influenced by public health considerations (Gopalan, 1994). No matter how noble the idea of UIP, a 'non-controversial'
Programme of GoI, it faces severe criticism from many scholars. As Banerjee (1986, 1993) pointed out that it is a part of 'ill conceived and unimaginative global venture' and '... revealed many serious flaws in the programme itself. The most outstanding among them was that a massive, expensive and a very complicated programme had been recommended for launching without even finding out what the problem was, leave alone the other important epidemiological considerations, such as incidence rates under different ecological conditions and time trends of the chosen diseases'. Banerjee (1992) mentions that 'the Union Department of Family Welfare did not have most basic epidemiological data concerning the extent of the problems, leave asidetheir significance in relation to other health problems of the country'. Madhavi (2003) also noted strong indications of immunization policy in India, instead of being determined by disease burden and demand, is increasingly driven by supply push, generated by industry and mediated by international organizations.
The need of the hour is an equitable, participatory and intersectoral approach to health and health care. Provision of vaccination should not be treated as the sole responsibility of the health sector. Policies and programmes in other sectors such as education, welfare, industry, labour, information, environment, etc. have also to be informed and influenced by public health considerations.
To reach the goal of UIP in India, the policy managers should also try to:
- Enhance (female) education through Education for All and incorporate primary health information in the curricula.
- Generate enough employment opportunity supported by the Government (e.g., some kind of Employment Guarantee Programme).
- Increase infrastructure to provide antenatal care universally.
- Spread more and more basic information regarding vaccination through electronic mass media.
- Enhance coverage in EAG and North-eastern states by organizing more sub-national immunization days (SNIDs).
- Spread news to break religious misbeliefs against vaccination.
- Raise number of health personnel to improve mother's awareness.
- Provide urban facilities in rural areas if possible with the help of corporate social responsibility.
- Provide electricity to every village if possible through nonconventional energy resources.
- Promote small family norm and discourage early marriage.
Some supply-side facility enhancement can also improve demand for vaccination. For example, the government should recognise the shortage of supply of these vaccines and try to develop the resources by own instead of waiting for the international organisations. The main set back of the achievement of the goals of the policy is total dependence on the supply of the vaccines and untimely deliverance of the programme. But as immunization is a long term process, one should give thrust to improve its demand given the meagre Central as well as State budgetary allocation on health sector as a whole for decades and evaporating aids and soft loans from international organizations.
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