Immunising 25 million infants every year

by Rolf Carriere

In 1981 I had rejoined UNICEF, in New Delhi, after a 3-year stint with the World Bank in Washington DC during which I had been working on the design of a large-scale nutrition project in Tamil Nadu. David Haxton, newly appointed as Regional Director, had me first work for about two years as Regional Officer (which included Bhutan), but then asked me to head up the Health & Nutrition Section of the India office. One of the important health interventions then already underway in India (since 1978) was the Expanded Programme on Immunization which aimed to protect children against six diseases: measles, diphtheria, whooping cough, tetanus, tuberculosis and polio. A good start had been made (initially without measles), but, due to supply and demand constraints, coverage had stalled at around 20 percent, and so had energy and enthusiasm, even though the agreed global goal was to achieve 80 percent by 1990. A daunting task. I recall being invited for a week’s training at WHO Geneva for ‘senior managers’ conducted by the inspiring Rafe Henderson, and returning to Delhi as a convert.

At the global level, with a visionary but impatient Jim Grant as Executive Director searching for ‘doable’ interventions to save children’s lives, immunization soon became the ‘I’ in his GOBI strategy of selective Primary Health Care, and thus a super-high corporate priority—in particular for India, because ‘if India doesn’t achieve the target, the world wouldn’t! ‘ Haxton transmitted that unmistakable sense of urgency fiercely and enabled us to put together a small but great team of professionals to help create demand (‘going public’, he called it, a mix of high-level advocacy, information campaigns and social marketing) and to help strengthen India’s delivery capability, (‘going to scale’ was the term we used, a deviation from UNICEF’s traditional role of supporting only modest-sized projects, leaving infrastructural investments to bigger donors). So, this Universal Child Immunization (UCI) programme was to be different: the plan was to immunize all infants, not just those that could be reached with UNICEF’s limited funding available.

The challenge was huge and complex: (i) to deliver potent vaccines, locally produced or imported, to 25 million new-borns each year 5 times before their first birthday; as well as (ii) for parents (and everybody else) to want these babies to be immunized. That required strong political support from the country’s top leadership. That started with the Prime Minister, Mrs Indira Gandhi, to whom Dave Haxton and Jim Grant had good access, but also included India’s powerful civil service, the Indian Administrative Service (IAS). The UNICEF team offered executive briefings for the IAS in their Mussoorie training college, as well as for State Health Secretaries, together with selected District Collectors, Joint, Additional Secretaries and Secretary of the GOI who were invited, in small groups, to comfortable hotels for three-day seminars on ‘doable’ child survival strategies. Those seminars aimed as much at personal enrolment as at professional engagement, institutional commitment and political buy-in. Jon Rohde always kicked off the first session entitled Who Dies of What and Why—and What Can Be Done About That? And Sharad Sapra led the session on District Planning, an elaboration of the EPI training package that also included beneficiary enumeration, micro-planning and social mobilization to ‘make immunization everybody’s business’. Early days and high stakes!

Some events from the 1980’s stand out in my memory.
  • The decision to make districts (rather than states or blocks) the primary, manageable unit of planning and implementation. To learn the ropes and iron out problems, we started with 30 demonstration districts (out of some 600 districts, each of 1-2 million population).
  • UNICEF’s daring challenge, in the presence of Mrs. Gandhi, to expose GOI’s inflated coverage statistics. This became known as the ‘numerator/denominator controversy’ in which all vaccinated under-fives were included in the numerator, instead of only the under-ones.
  • UNICEF’s choice of investment in tinplate posters, after Rina Gill had found the lifespan of paper posters sometimes to be less than an hour. A survey had also discovered that parents, surprisingly, considered polio lameness as more frightening than measles death or diphtheria—an insight that informed our Recognize the Disease campaign to help create a felt need.
  • UNICEF’s contracting of several large advertising agencies to help professionalize GOI’s health education and communications.
  • The high-stakes advocacy slide-sound presentations for high-level audiences (forerunners of today’s PowerPoint). These presentations were always nerve-wracking because technical hitches could easily derail an otherwise compelling, captivating message.
  • The ex-gratia payment was instituted to compensate parents whose babies had actually gotten polio after vaccination (a risk of one in a million!).
  • The brilliant WHO 30-cluster surveys that provided instant feedback on EPI coverage—and Sapra’s equally brilliant extension thereof with several more public health indicators.
  • UNICEF’s proposal to make EPI a ‘living memorial to Mrs Gandhi’, and, later on, the idea to elevate the now renamed Universal Immunization Programme (UIP) to one of the few top-priority GOI Missions led by Rajiv Gandhi and Sam Pitroda. The poster with Rajiv administering polio drops to a child was very popular.
  • The ‘total mobilization’ of UNICEF State Offices led by Monica Sharma to achieve the 1990 UIP targets.
  • The generosity and trust of donors like Canada, Sweden, Denmark and USA to channel their aid resources through UNICEF. We had submitted UNICEF’s largest-ever proposal for supplementary funding, and it got fully funded within 6 months!
  • The Rotary Foundation’s $20 million offer to buy vaccines for UIP—and UNICEF’s counter proposal that Rotary India retain $1 million for the purpose of social mobilization of their own influential network of 1400+ Rotary Clubs, each taking on a city where coverage was particularly low (rather than a village, as was previously done). This made a huge difference in logistics and promotion to attain, and sustain, higher coverage.
  • UNICEF’s support to cold chain and transport components with Karl-Gustav Forsmark, Naseem Ahmed and Mogens Munck.
  • UNICEF provided early support to the Serum Institute to boost domestic vaccine production, aimed at import substitution. This led eventually to the Serum Institute becoming the largest vaccine producer in the entire world.
  • The productive working relationship with several GOI Joint Secretaries and with WHO’s Bob Kim-Farley.
UIP was among the first large-scale PHC programmes with time-bound goals which, in many ways, justified the convening of the first-ever World Summit for Children at the UN in September 1990 to celebrate UCI and to call for a further 26 global goals to be achieved for children within a decade. That, in turn, served as a model of the MDG-2015 and SDG-2030 programmes that followed two decades later. Moreover, UIP helped create a basic infrastructure that, in due course, allowed new vaccines to be added and delivered—including the COVID-19 vaccines. The latter has brought to light both old and new challenges of feeble global leadership, vaccine hesitancy, misinformation, inequitable distribution, and protection of pharmaceutical corporate economic interests which are now to be addressed as the world moves to Immunization Agenda 2030.

But now, the scale and stakes have only increased.



Comments

Post a Comment