**3. Success of Routine Immunization in India**

Two critical components for addressing equity and moving towards assured immunization program sustainability are the commitment and incorporation of local resources (particularly at subnational levels), and engagement and partnerships with civil society. India provides an interesting case study.

India's routine immunization program success to date can be summarized around six major milestones:

India's Universal Immunization Program (UIP) was launched in 1985 by the Indian Government, with prioritized (and annually budgeted and planned) local financial and logistics resources from federal, state, and district levels. This established the system for delivering essential vaccines (such as those preventing diphtheria, pertussis, tetanus, polio, and measles) to infants around the country and tetanus vaccine to pregnant women to prevent neonatal tetanus. Over the years, system strengthening has also increased focus on the following: supply chain to ensure availability of quality vaccines at every level; vaccine safety by augmenting adverse events following immunization (AEFI) surveillance; and data quality and accessibility. Two-way communication between the service provider and the beneficiaries also must be augmented through digital web-based platforms like the Mother Child Tracking System and availability and use of Maternal and Child Health cards that include all antigens and reminder dates. Additionally, particularly in the last 10 years, UIP has collaborated with Gavi, the Vaccine Alliance, and partners to augment skills of health workers and front-line program managers, such as via initiatives like Routine Immunization Skills Enhancement [10].

In 1995, India launched the nationwide pulse polio immunization program, including National Immunization Days for supplemental polio vaccination. These efforts, linked with routine vaccination that also emphasized birth dose polio vaccination, encouraged multi-stakeholder coordination, program innovation, and community mobilization and engagement at every level of program planning and implementation. This included important collaboration with civil society partners, such as Rotary and the multi-partner Social Mobilization Network led by UNICEF and the Core Group Polio Partners [11]. India's recognition of being polio free in 2014 also elevated the value of vaccination and contributed to a shift in focus on routine immunization [12].

To further address equity in reaching often missed or underserved communities, India launched the National Health Mission in 2013 [13]. The National Health Mission was a bold step towards integration of immunization with other program deliverables in Primary Health Care. The program also integrated two previously vertical and siloed initiatives that began in 2006: National Rural Health Mission and National Urban Health Mission.

The Mission Indradhanush (MI) Program, launched in 2014, and the subsequent launch of Intensified Mission Indradhanush (IMI), launched in 2017, were designed to address vaccine inequity in a subset of districts and facility clusters across geography and gender, based on evidence from data collected from districts. Important within both initiatives is the role of civil society as key partners, including engaging the accredited social health activist (ASHA) program for linking missed communities with immunization services [14]. These initiatives have also contributed to surveyed fully immunized coverage (FIC) increases, as shown in Figure 1 and Table 1, with national FIC coverage at 76.4% for 12–23-month-olds from the most recent NFHS-5, 2019–2021 [15].

**Table 1.** India fully immunized coverage (12–23-month-olds, card and maternal recall) by state from National Family Health Surveys.


In recent years, the UIP has expanded to include rotavirus vaccine, pneumococcal conjugate vaccine, inactivated polio vaccine, measles-rubella vaccine, and the Japanese Encephalitis vaccine (for adults). Political and bureaucratic administrator interest has been high at all levels, including from the Prime Minister. UIP and several donor and resource partners supported these introductions at a national scale through sophisticated epidemiology, investment evidence and technical support, and civil society partner engagement for communications and confidence and trust building. For example, donors, such as the Bill and Melinda Gates Foundation, Gavi, and the Vaccine Alliance, provided complementary support for the vaccine rollouts, including additional technical assistance via the Immunization Technical Support Unit and partners, such as UNDP, UNICEF, WHO, John Snow Inc/India, Clinton Health Access Initiative, and others. Additionally, the program was emboldened by domestic manufacturing of the vaccines and a committed supply for scale up. The new vaccine rollouts also provided opportunity for strengthening health systems with technologies, such as the electronic Vaccine Intelligence Network (eVIN), Vaccine Safety Monitoring, and the National Cold Chain Management Information System (NCCMIS) for real time cold chain monitoring and management decisions.

COVID-19 vaccination necessitated rapid, wide-scale digital technology to facilitate vaccine access across the majority of India's population. The COVID-19 vaccination tracking software, known as CoWIN, enabled citizens to choose their vaccination place and time at their convenience with strong community acceptance as evidenced in the high COVID-19 vaccination rates in India [16]. Expansion of the tool with Indian resources is anticipated to benefit routine immunization equity and coverage, enabling health workers and citizens to track routine immunization through the digital application known as UWIN.

As the COVID-19 pandemic response shifts, India is reviving and sustaining its routine immunization coverage improvement program with experience, equity, evidence, and empowerment.

India has gained extensive experience from large scale polio and measles vaccination campaigns and conducting the world's largest routine immunization program (Universal Immunization Program) to reach approximately 26 million infants and 30 million pregnant women. As noted, Intensified Mission Indradhanush and COVID-19 vaccination have also contributed to equity in previously under-served communities and populations. The experiences gained from these programs cut across vaccine supply, access, and community mobilization and have been institutionalized in India's immunization and health systems. A few examples of this institutionalization include vaccination microplans that are part of annual health performance implementation planning, alternate vaccine delivery systems, house-to-house immunization campaigns, and community radio for peer-to-peer conversation in the community.

To address the equity gap, India is tailoring efforts across geographies, gender, and socio-economic strata. During COVID-19 waves in India, some of the most heavily disrupted populations were remote, economically challenged people with specific needs (such as the differently-abled), the transgender community, and populations that migrated from their workplaces. These populations also deserve attention as primary health care programs, such as immunization, adjust in the post COVID-19 phase. States are partnering with community-based organizations and civil societies to tailor services that will enable better access to populations with specific and special needs. Examples of such initiatives are the iHEAR project of Sangath that generated evidence around challenges faced by the disabled and transgender communities during COVID-19 vaccination and the Vaccine on Wheels project of Jivika that provided doctor-supervised mobile medical units for immunization.

To inform and mobilize evidence-based action by generating high-quality digital data, India is strengthening its laboratory-supported Vaccine Preventable Disease (VPD) surveillance with the help of domestic institutions, such as the National Centre for Communicable Diseases and the National Public Health Support Program of the World Health Organization, India Country Office. The data generated from an empowered VPD Surveillance will, in turn, help health workers to take strategic, timely action to address coverage inequity and improve the quality of immunization services.

A key lesson from COVID-19 vaccination was the ability to integrate the use of digital technology, such as via CoWIN and its mobile app, for empowering clients with vaccination information and records. CoWIN generated high-quality real-time data for communities to make informed choices about where and when to organize and receive services; for health workers to track, record, and report vaccination; and for health authorities to take timely action. With lessons from the wide acceptance of CoWIN by the community for COVID-19 vaccination, India is planning to empower its communities with digital UWIN technology. The technology will empower service providers with digitalization of immunization records for tracking, recording, and reporting immunization coverage. For the community, the application will provide flexibility by allowing them to choose the location where they want to receive vaccination services and to have a digital record of their data and vaccination history that can be downloaded and saved. The digital record of citizens will be directly linked to their Ayushman Bharat Health Account (ABHA). The ABHA account will uniquely identify every registered individual as a participant in India's digital healthcare system.
