Monitoring one of the largest full immunization programmes of the world

About Mission Indradhanush

The Ministry of Health and Family Welfare,Government of India has launched Mission Indradhanush on 25 December, 2014 as a special nationwide initiative to vaccinate all unvaccinated and partially vaccinated children under the Universal Immunization Programme by 2020.             The Mission focuses on interventions to expand full immunization coverage in India from 65% in 2013 to at least 90% children in the next five years. The programme provides immunization against seven life-threatening diseases (diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B) in the entire country. In addition, vaccination against Haemophilus influenza type B and Japanese Encephalitis is provided in select districts/states.

This will be done through special catch-up campaigns to rapidly increase full immunization coverage of children by 5% and more annually.

            Under Mission Indradhanush, the Health Ministry has identified 201 high focus districts across the country that have the highest number of partially vaccinated and unvaccinated children. Nearly 50% of all unvaccinated or partially vaccinated children are in these 201 districts. Of the 201 districts, 82 districts are concentrated in the four states of Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan and nearly 25% of the unvaccinated or partially vaccinated children of India are in these 82 districts of these four states. These districts will be targeted for intensive efforts to improve the routine immunization coverage in the country.   The ultimate goal is to protect all children and pregnant women against vaccine preventable diseases in India

AREAS UNDER FOCUS

            Mission Indradhanush will target 201 high priority districts in the first phase and 297 districts for the second phase in the year 2015. The implementation of the first phase of the Mission in 201 high focus districts will commence from 7^th April 2015, World Health Day

Within the districts, the Mission will focus on the 400,000 high risk settlements identified by the polio eradication programme. These are the pockets with low coverage due to geographic, demographic, ethnic and other operational challenges. Evidence has shown that most of the unvaccinated and partially vaccinated children are concentrated in these areas.             The following areas will be targeted through special immunization campaigns: ·      High risk areas identified by the polio eradication programme. These include populations living in areas such as: o    Urban slums with migration o    Nomads o    Brick kilns o    Construction sites o    Other migrants (fisherman villages, riverine areas with shifting populations etc.) and o    Underserved and hard to reach populations (forested and tribal populations etc.)

·      Areas with low routine immunization (RI) coverage (pockets with Measles/vaccine preventable disease (VPD) outbreaks).

·       Areas with vacant sub-centers: No ANM posted for more than three months.

·      Areas with missed Routine Immunisation (RI) sessions: ANMs on long leave and similar reasons

·      Small villages, hamlets, dhanis or purbas clubbed with another village for RI sessions and not having independent RI sessions.

Mission Indradhanush - 201 Focus Districts

S.NO	STATE	S.NO	DISTRICT	S.NO	DISTRICT
1	ANDHRA PRADESH	1	EAST GODAVARI	2	GUNTUR
		3	KRISHNA	4	KURNOOL
		5	VISAKHAPATNAM
2	ARUNACHAL PRADESH	1	CHANGLONG	2	EAST KAMENG
		3	EAST SIANG	4	LOHIT
		5	UPPER SIANG
3	ASSAM	1	BONGAIGAON	2	DARRANG
		3	DHUBRI	4	GOALPARA
		5	HAILAKANDI	6	KARIMGANJ
		7	KOKRAJHAR	8	NAGAON
4	BIHAR	1	ARARIA	2	BEGUSARAI
		3	CHAMPARAN EAST	4	CHAMPARAN WEST
		5	DARBHANGA	6	GAYA
		7	JAMUI	8	KATIHAR
		9	KISHANGANJ	10	MUZAFFARPUR
		11	PATNA	12	SAHARSA
		13	SAMASTIPUR	14	SITAMARHI
5	CHHATTISGARH	1	BALODABAZAAR BHATAPARA	2	BIJAAPUR
		3	BILASPUR	4	DANTEWADA
		5	JASHPUR	6	KORBA
		7	RAIPUR	8	SARGUJA
6	DELHI	1	NORTH-EAST	2	NORTH-WEST
7	GUJARAT	1	AHMEDABAD	2	AHMEDABAD CORPN.
		3	BANASKANTHA	4	DAHOD
		5	DANGS	6	KUTCH
		7	PANCHMAHALS	8	SABARKANTHA
		9	VALSAD
8	HARYANA	1	FARIDABAD	2	GURGAON
		3	MEWAT	4	PALWAL
		5	PANIPAT
9	JAMMU & KASHMIR	1	DODA	2	KISHTWAR
		3	PUNCH	4	RAJAURI
		5	RAMBAN
10	JHARKHAND	1	DEOGHAR	2	DHANBAD
		3	GIRIDIH	4	GODDA
		5	PAKUR	6	SAHIBGANJ
11	KARNATAKA	1	BANGALORE (U)	2	BELLARY
		3	GULBARGA	4	KOPPAL
		5	RAICHUR	6	YADGIR
12	KERALA	1	KASARAGOD	2	MALAPPURAM
13	MADHYA PRADESH	1	ALIRAJPUR	2	ANUPPUR
		3	CHHATARPUR	4	DAMOH
		5	JHABUA	6	MANDLA
		7	PANNA	8	RAISEN
		9	REWA	10	SAGAR
		11	SATANA	12	SHADOL
		13	TIKAMGARH	14	UMARIYA
		15	VIDISHA
14	MAHARASHTRA	1	BEED	2	DHULE
		3	HINGOLI	4	JALGAON
		5	NANDED	6	NASIK
		7	THANE
15	MANIPUR	1	CHURACHANDPUR	2	SENAPATI
		3	TAMENGLONG	4	UKHRUL
16	MEGHALAYA	1	EAST KHASI HILL	2	WEST GARO HILLS
		3	WEST KHASI HILL
17	MIZORAM	1	LAWNGTLAI	2	LUNGLEI
		3	MAMIT	4	SAIHA
18	NAGALAND	1	DIMAPUR	2	KIPHIRE
		3	KOHIMA	4	MON
		5	TUENSANG	6	WOKHA
19	ODISHA	1	BOUDH	2	GAJAPATI
		3	GANJAM	4	KANDHAMAL
		5	KHURDA	6	KORAPUT
		7	MALAKANGIRI	8	NABARANGPUR
		9	NUAPADA	10	RAYAGADA
20	PONDICHERRY	1	YANAM
21	PUNJAB	1	GURDASPUR	2	LUDHIANA
		3	MUKTSAR
22	RAJASTHAN	1	ALWAR	2	BARMER
		3	BUNDI	4	DHAULPUR
		5	JAIPUR	6	JODHPUR
		7	KARAULI	8	SAWAI MADHOPUR
		9	TONK
23	TAMIL NADU	1	COIMBATORE	2	KANCHEEPURAM
		3	MADURAI	4	THIRUVALLUR
		5	TIRUCHIRAPALLI	6	TIRUNELVELI
		7	VELLORE	8	VIRUDHUNAGER
24	TELANGANA	1	ADILABAD	2	MAHBUBNAGAR
25	TRIPURA	1	DHALAI	2	TRIPURA NORTH
		3	TRIPURA WEST
26	UTTAR PRADESH	1	AGRA	2	ALIGARH
		3	ALLAHABAD	4	AMETHI
		5	AMROHA	6	AURAIYA
		7	AZAMGARH	8	BADAUN
		9	BADOHI	10	BAHRAICH
		11	BALRAMPUR	12	BANDA
		13	BARABANKI	14	BAREILLY
		15	BULANDSHAHAR	16	CHITRAKOOT
		17	ETAH	18	ETAWAH
		19	FARRUKHABAD	20	FEROZABAD
		21	GHAZIABAD	22	GONDA
		23	HAPUR	24	HARDOI
		25	HATHRAS	26	KANNAUJ
		27	KASGANJ	28	KAUSHAMBI
		29	KHERI	30	MAINPURI
		31	MATHURA	32	MEERUT
		33	MIRZAPUR	34	MORADABAD
		35	MUZAFFARNAGAR	36	PILIBHIT
		37	SAMBHAL	38	SHAHJAHANPUR
		39	SHAMLI	40	SIDDHARTHNAGAR
		41	SITAPUR	42	SONBHADRA
		43	SRAWASTI	44	SULTANPUR
27	UTTARAKHAND	1	HARDWAR
28	WEST BENGAL	1	24-PARGANAS NORTH	2	24-PARGANAS SOUTH
		3	BARDHAMAN	4	BIRBHUM
		5	MURSHIDABAD	6	UTTAR DINAJPUR

STRATEGY FOR MISSION INDRADHANUSH

            Mission Indradhanush will be a national immunization drive to strengthen the key functional areas of immunization for ensuring high coverage throughout the country with special attention to districts with low immunization coverage.

            The broad strategy, based on evidence and best practices, will include four basic elements-

1.    Meticulous planning of campaigns/sessions at all levels: Ensure revision of microplans in all blocks and urban areas in each district to ensure availability of sufficient vaccinators and all vaccines during routine immunization sessions. Develop special plans to reach the unreached children in more than 400,000 high risk settlements such as urban slums, construction sites, brick kilns, nomadic sites and hard-to-reach areas.

2.    Effective communication and social mobilization efforts: Generate awareness and demand for immunization services through need-based communication strategies and social mobilization activities to enhance participation of the community in the routine immunization programme through mass media, mid media, interpersonal communication (IPC), school and youth networks and corporates.

3.    Intensive training of the health officials and frontline workers: Build the capacity of health officials and workers in routine immunization activities for quality immunization services.

4.    Establish accountability framework through task forces: Enhance involvement and accountability/ownership of the district administrative and health machinery by strengthening the district task forces for immunization in all districts of India and ensuring the use of concurrent session monitoring data to plug the gaps in implementation on a real time basis.

The Ministry of Health and Family Welfare will establish collaboration with other Ministries, ongoing programmes and international partners to promote a coordinated and synergistic approach to improve routine immunization coverage in the country.

Monitoring of Operational Activities

            The Ministry of Health & Family Welfare has put in place a massive framework for rigorous monitoring of one of the largest immunization programmes of the world. The multi-level structure has been carefully designed to supervise and monitor the operations at the state, district and block levels through an army of health experts, officials and various partners.

            WHO Country Office for India is collating preparedness status for Mission Indradhanush from 28 states and 201 high focus districts. Critical information on preparedness, including quality of task forces for Immunization, deputation of senior officials to priority areas for monitoring, status of trainings at state, district and block levels and status of microplanning activities is being collated by WHO-NPSP Surveillance Medical Officers and field monitors, and information generated is being shared on a weekly basis with the Ministry of Health and Family Welfare, Government of India on a weekly basis.

            A total of more than 225 field Medical Officers, nearly 900 field monitors and more than 1000 external monitors have been deployed by the WHO Country Office for India to monitor the operational components of Mission Indradhanush at session site and at community level. In addition, sub regional and regional team leaders will also be monitoring the implementation besides the national monitors from the WHO Country Office. A standard set of formats for session site monitoring and house to house monitoring have been developed for concurrent monitoring in the field by the monitors, who will also be supported by available monitors from partner agencies such as UNICEF and CORE that are already involved with monitoring operational components of routine immunization.

            All monitors, including field monitors, external monitors will be deployed by WHO NPSP for duration of at least 8 days (7-14 April). All available monitors including those from partner agencies will undergo a briefing at district level, to be conducted by the Surveillance Medical Officers. The SMO of WHO NPSP will also prepare a monitoring plan for all monitors.

            Each monitor will be expected to monitor 4–5 session sites on day 1, and from day 2 onwards, monitor 2–4 sessions per day. In addition, each monitor will conduct house-to-house monitoring from the second day of the Mission Indradhanush drive. House-to-house monitoring will be done only in those areas where immunization sessions have already been held as per microplans during the Mission Indradhanush drive. A monitor should be able to monitor 2–4 areas that have been covered in previous days for house-to-house monitoring. Areas where immunization sessions have been held on the last day of Mission Indradhanush drive will be monitored over the next 1–2 days.  

Information generated from concurrent monitoring will be utilized at local level during evening debriefing meetings at block and district level to ensure mid-course corrective actions. Data generated from the monitoring formats will be collated in a data tool to generate key indicators that will be shared at all levels with the Government.

Communication Monitoring

            To meet and sustain coverage goals under Mission Indradhanush, a well-carved strategic communication plan needs to be in place, reaching out to communities and hard-to-reach populations and building trust in health care services. Multi-pronged communication approach is crucial for the success of the mission. Therefore, it becomes imperative that the communication efforts are monitored closely.

            This monitoring system will be used to take immediate corrective action for improvement and for evidence based and focused implementation of communication plan for the Mission Indradhanush. Communication monitoring will measure progress of various IEC/BCC activities at a particular time and at a particular implementation level. UNICEF will be overall in-charge and lead for this IEC/BCC Monitoring, with support of Immunisation Technical Support Unit (ITSU) and other partners.

            As per the updated partner monitoring mapping, Lead RMNCH+ partners and UNICEF covers all 201 districts, and together have 1091 staff/consultants for the 1908 blocks under Mission Indradhanush. UNICEF covers 187 districts, 812 blocks in 21 states (15 UNICEF states + 6 North East states). Rest of the districts and blocks are covered by lead partners.

            All blocks will be monitored with support of UNICEF in six high priority states (Rajasthan, Madhya Pradesh, Uttar Pradesh, Bihar, West Bengal and Jharkhand) with maximum number of partially and unimmunized children. To cover all districts and Blocks in these high priority states, UNICEF will be deploying their extra staff from UP & Bihar to other high priority states like Madhya Pradesh and Rajasthan. UNICEF is also hiring additional monitors to monitor MI communication activities in West Bengal.

There are three formats for monitoring:

• District level monitoring format
• Monitoring to be done once for Mission Indradhanush drive (preferably on first day of Mission Indradhanush drive)
• Aim to measure district preparedness and status of implementation
• PHC/Planning Unit level monitoring format
• Monitoring to be done once for MI drive (preferably on first day of Mission Indradhanush drive)
• Aim to measure PHC/ Planning unit level preparedness and status of implementation
• Session site monitoring format
• 2-4 sessions for each Mission Indradhanush day
• To measure output and outcome of communication activities

Simple excel based data-entry tools (for each format) is also developed for analysis and sharing of data. This analysed data and monitoring feedback will be shared with all the concerned officials for action. It will be shared during evening block meeting and during District Task Force for Immunisation (DTFI) and State Task Force for Immunisation (STFI) for evidence based adjustments to the roll out of the campaign. 

            UNICEF officials ad partners will ensure entry of all the monitoring data from their districts or blocks in simple excel based data entry tool and send this compiled district excel sheet along with filled monitoring format to Health Specialist, UNICEF at 15 UNICEF state offices and for remaining states data entry tools and filled formats will be send to ITSU for compilation and analysis.

Data Flow figure

The compiled data from all the states will be analysed at UNICEF country office and will be shared with MoHFW.

National Level Monitoring

            A control room has been established at ITSU for coordinating with State Nodal Officers and National Level Monitors regarding daily reporting of the progress of Mission Indradhanush activities. The control room will also collect, compile and analyze their filled assessment checklists data. The details of contact persons from ITSU control room has been shared with states and will be shared with national level monitors also.

For the monitoring of Mission Indradhanush, national level monitors have also been assigned one for each district, placing 201 monitors for 201 districts. These monitors have been pooled from various partner agencies viz, Ministry of Health and Family Welfare, National Health System Resource Center, National Institute of Health and Family Welfare, CORE, UNDP, ITSU, DELOITTE, BMGF, JSI, IPE Global, Rotary, UNICEF, WHO-NPSP.

            They will reach the assigned districts one day prior to the start of the activity and will check the preparedness of the district for Mission Indradhanush. During their visit to the district, monitors will also meet district level officials and will give them feedback about their observations on daily basis. After monitoring at district headquarter, they will also visit blocks of the same district on subsequent days for monitoring the preparedness at block level. During their visit, they are also expected to visit session sites and monitor sessions on standard session site monitoring format to assess the quality of implementation of activities. The national level monitors will stay in the assigned district for at-least 4 days and will visit minimum 3-4 blocks of the districts during the whole monitoring period. The national level monitors will be using two checklists i.e. District Assessment Checklist and Block / Urban area Assessment Checklist and a monitoring tool for session site.

            The data entry excel sheet tool based on the filled checklists will be submitted by monitors to Immunization Technical Support Unit (ITSU) by email on daily basis, and will be compiled by ITSU for feedback. The hard copies of all the formats will be submitted to ITSU immediately after monitor returns from the assigned district. The session site monitoring formats filled by the national level monitors will be handed over to local WHO-NPSP office in the district itself.

Ms. Manisha Verma is Director (M & C), Ministry of Health & Family Welfare.

Courtesy: pib.nic.in