Krishna and Rekha make their way through a construction worker community to remind a mother to bring her children for immunization. (Photo credit: WHO SEARO / C. McNab)
This area is different. Here, a searing sun reflects off the roofs of dozens of low tin sheds. Only a few tall trees provide shade. New construction surrounds this shanty village -– the skeletons of high rises emerging from former farms and village squares.
Dr Bindu Yadav gestures to the tin sheds. “The people who live here are the workers who build the high rises.” They arrive with their families from all over India. New construction sites and new communities spring up all the time.
“Many weren’t on any map,” says Dr Bindu, a Surveillance Medical Officer for the WHO’s India Office. “They may be here for months or years. You never know for sure.”
Labourers work to straighten rebar at one of the many building sites in Badshahpur. While the men work, women are generally home with the children in shanty communities. People come from all over India to work here and may stay just a few months. (Photo credit: WHO SEARO / C. McNab)
“It’s these people we have to work very hard to reach with primary health services including immunization,” she says. “It’s not easy, but the health teams are doing it.”
Up a dusty road, the community health workers have found Renu. She lives in a tin shed that doubles as a shop selling snacks and basic provisions. She emerges from the house carrying Raza – her baby boy of eight months.
The women chat. Renu explains that she’s recently arrived from the state of Uttar Pradesh – and that she and her family travel back and forth between states regularly, depending on where her husband finds work. The community health workers ask Renu about Raza’s immunization record.
They tell Renu not to worry too much if she doesn’t have his record- they would understand given how much she travels. But Renu dashes back into the house, and within moments she is back with the record. It shows that Raza is up to date with all his vaccines.
Krishna reminds Renu to bring him to an immunization session at nine months, when he’ll be vaccinated against measles and rubella. Renu says she knows - she’ll be sure to be there, and she thanks Krishna for the reminder.
Krishna, an Accredited Social Health Activist (ASHA) talks with Renu about her son Raza’s immunization record. (Photo credit: WHO SEARO / C. McNab)
A few years ago, very few children like Raza would have been up to date on their vaccines. A survey of Gurugram district in 2015 showed fewer than one in four children had received all scheduled vaccines1.
Now, more than 80% are fully vaccinated – a huge increase. Dr. Bindu attributes the success to “Mission Indradhanush” – a painstaking effort that has put these transient families on the map for primary health services.
Community health workers making a connection
Dr Rashmi Batra talks through routine immunization session planning with the Badshahpur health team. Dr Bindu Yadav (on the left in cream) is the WHO Surveillance Medical Officer who supports government teams with technical advice on their planning and monitoring. (Photo credit: WHO SEARO / C. McNab)
Mission Indradhanush translates as “Mission Rainbow”. Encouraged by India’s massive success eliminating polio, the Prime Minister launched the plan in 2014, aiming to fully immunize 90% of India’s young children. In October of 2017 an “Intensified” Mission Indradhanush (IMI) was launched, doubling the effort to reach the ambitious immunization goal in 201 high-risk districts in particular.
“A major issue was missing children who lived in migrant families,” explains Dr Rashmi Batra, a dental surgeon who oversees the work at the Badshahpur Primary Health Centre. She’s responsible for about 67,000 people who live year-round in the area – together with the additional 45,000 migrant workers who come and go here as well. Their children can be overlooked by a system that traditionally planned services for the “fixed” population. “Here in Badshahpur we worked for days on end, through Sundays and holidays, to map out the migrant worker communities,” says Dr Batra.
The team mapped new or previously left-out communities. They talked to workers and labour foremen. Community workers – including ASHAs and Anganwandi workers went door to door to conduct a head count survey of every person living in the household. The government added compensation for their work and included financial incentives for the surveys and for ensuring children were fully immunized.
A pregnant woman holds iron and folic acid supplements she received at a routine immunization session in her community of migrant workers. A few years ago, she may not have received any antenatal care at all, but Mission Indradhanush has put her community on the map for primary health services. (Photo credit: WHO SEARO / C. McNab)
Health workers had reliable access to all the commodities they needed – vaccines, oral rehydration salts, vitamin A, weigh scales, iron and folic acid supplements for pregnant women. They also provide paracetamol routinely and instruct parents to give children tablets if they run a fever – a fairly common occurrence after vaccination.
“For these migrant labour communities, missing one day of work is one day of lost wages, so families wouldn’t bring their children for immunization for fear of them getting sick afterwards,” explains Dr Bindu. “Paracetamol is one way to help stem this fear.”
Beloved Indian actor Amitabh Bachchan has lent his image and provides messages to encourage immunization in India. (Photo credit: WHO SEARO / C. McNab)
So is basic awareness. A survey published in the British Medical Journal showed that about 45% of parents who didn’t immunize their children in India were simply unaware of immunization services 2. Mission Indradhanush included communication in the programming so that people were more likely to hear about immunization on the radio, or on community billboards. The actor Amitabh Bachchan, whose image is inimitably linked to polio eradication and immunization, lent his image and messages to posters and advertisement for routine immunization.
Intense action leads to long-term benefits
Mission Indradhanush was initiated as a push to map communities and intensify immunization sessions for those people who were missing out. In Gurugram district, the outcome result is dramatic. A coverage evaluation survey of the Intensified Mission Indradhanush in Gurugram shows that coverage increased from just 23.6% of children in the district to 83.8% by December 2018.3 This is a 60% increase – one of the most striking results in all of India.
The short-term impact of the campaign is the protection of children and women against vaccine-preventable disease, and healthier pregnancies for women. In the longer term, a key change is the inclusion of communities that were once neglected onto the routine immunization outreach schedule.
“Here in Badshahpur we had 74 regular vaccination sites before,” explains Dr Batra. “Now we’ve added 63 sites into our regular outreach.” That’s 63 new sites where community members can attend regularly scheduled outreach services where there were none before. “The fact these services are regularly scheduled helps a lot,” says Dr Batra. “People know they can count on us.”
Mothers and children wait for immunization and other primary health services, at an outreach session in their community. A few years ago, this community would not have had access to these services. (Photo credit: WHO SEARO / C. McNab)
Under the shade of the few tall trees in this Badshahpur community, mothers and children are gathering for immunization services. An auxiliary nurse midwife records their information into her register while her colleague prepares the vaccines.
Amongst those waiting is Sushanti, a 19-year old mother of Karishini, who is just one. She arrived in the community only a week ago from Jharkhand state in eastern India. Like most women here, her husband works as a construction worker on a building site. Sushanti found out about today’s immunization session from her ASHA, who personally went to see her at her home and invite her to the session.
Little Karishini should be fully vaccinated by now, but according to Sushanti, she’s had just the tuberculosis vaccine (known as BCG) and maybe one dose of pentavalent vaccine containing diptheria, tetanus, pertussis, hepatitis B and haemophilus influenzae type B vaccine. She should have had three by 14 weeks of age. Today, she’ll have several different vaccine doses including another pentavalent injection, oral polio vaccine and one to protect her from measles and rubella, together with a small spoon of vitamin A to boost her immunity.
Karishini isn’t thrilled to be receiving so many shots at once, but once it’s all over, she brightens and smiles together with her mother.
Sushanti, from Jharkhand state, has lived in this community for only a week. Her one-year old daughter Karishini was behind in her vaccines but started to catch up during this vaccination session in her community. (Photo credit: WHO SEARO / C. McNab)
“People coming and going are hard to track,” says Dr Bindu of WHO. “Thanks to the ASHA we knew about Sushanti and her baby. And thanks to Mission Indradhanush, we know about this community.
“People will come and go here, but we will come back and offer services to anyone living here whether for a few weeks, months or years.”
[1] Intensified Mission Indradhanush Coverage Evaluation Survey 2018, Ministry of Health and Family Welfare, Government of India. January 1 2019.
[2] BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4782
[3] Intensified Mission Indradhanush Coverage Evaluation Survey 2018, Ministry of Health and Family Welfare, Government of India. January 1 2019.