Comprehensive Multi Year Plan - UIP in India

Multi-Year Strategic Plan
2013-17
Universal Immunization Program
REACHING EVERY CHILD
Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1
UIP as a component of Reproductive, Maternal, Newborn, Child and Adolescent
health (RMNCH+A) in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2
Purpose of cYMP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.3
Planning Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.4
Immunization global priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
NATIONAL CONTEXT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1
History of immunization program in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2
National Rural Health Mission (NRHM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3
Burden of vaccine preventable diseases (VPDs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4
Status of vaccine coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4.1
Vaccine coverage and equity issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5
Current structure for service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5.1
Other stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
2.5.2
Current UIP Schedule in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.6
UIP successes as a child survival strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.7
Barriers for effective programming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
5
5
6
7
8
10
11
12
13
14
3.
GUIDING PRINCIPLES OF UIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.
UIP STRATEGIC PLAN: 2013-17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.1
UIP strategic plan framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2
Impact indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3
Target population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.
1
2
2
3
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21
22
22
M U LT I -Y E A R S T R AT E G I C P L A N 2 0 1 3 - 1 7
5.
NATIONAL MONITORING AND EVALUATION PLAN FOR UIP . . . . . . . . . . . . . . . . . . .

5.1
Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2
Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.4
Components of National M & E Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
5.5
Process for National M & E Plan development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51
51
51
51
52
52
6.
ANNEXURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANNEX 1: List of states showing good performance on immunization coverage and other
parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANNEX 2: List of States showing poor performance on immunization coverage and other
parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANNEX 3: NCCVMRC concept approved by MoHFW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANNEX 4: Key Recommendations from Effective Vaccine Management Assessment Report
2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANNEX 5: National Open Vial Policy 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANNEX 6: Monitoring Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANNEX 7: Emergency Preparedness and Response Plan 2011 . . . . . . . . . . . . . . . . . . . . . . . . . .
53
7.
COSTING AND FINANCIAL SUSTAINABILITY OF THE UNIVERSAL

IMMUNIZATION PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.
Summary of Findings on Baseline Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.
Details of Baseline Program Cost and Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.
Recurrent Costs - Structure and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1
Demographic projections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2
Vaccine and injection supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3
Personnel Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4
Training, Program Management, Disease Surveillance, Social Mobilization, Advocacy
and Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.5
Cold Chain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.0.
Future Resource Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.0.
Future Financing and funding gap analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
55
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59
62
65
74
83
85
85
86
90
90
91
94
94
97
98
99
iii
Acknowledgment
The comprehensive Multi Year plan (2013-17) was commissioned by the Ministry of Health and
Family Welfare and its development was carried out under the leadership of Ms. Anuradha Gupta,
Additional Secretary and Mission Director NRHM and Dr Rakesh Kumar, Joint Secretary.
We wish to acknowledge the contribution of the following from National Immunization Division,
MoHFW for providing regular guidance and inputs into the document Dr Ajay Khera, Deputy
Commissioner Child Health and Immunization; Dr M.K. Agarwal, Deputy Commissioner UIP and
Immunization; and Dr Pradeep Haldar, Deputy Commissioner Immunization.
Immunization Technical Support Unit (ITSU) maintained an oversight and coordinated the
development of the plan by a team comprising of Dr Manish Pant, Dr Susmita Chatterjee, Dr Rajeev
Gera, Ms Susmita Roy. Dr Shrihari Dutta from UNICEF India office provided technical inputs on a
regular basis to this team.
Professor Ramanan Laxminarayan, Public Health Foundation of India and Dr Vijay Moses,
Director ITSU were a constant source of support for the ITSU team while drafting the plan.
We are grateful to the following individuals for contributing their time and inputs in preparing this
document.
Dr Brighu Kapuria ITSU
Dr Jyoti Joshi Jain ITSU
Ms. Monica Chaturvedi ITSU
Ms Chaitali Mukherjee ITSU
Dr Prem Singh ITSU
Ms. Amruta Bahulekar ITSU
Mr Nithiyananthan Muthusamy ITSU
Ms Apoorva Sharan ITSU
Mr Arup Deb Roy ITSU
Mr Rajat Jain ITSU
Dr Raveesha R. Mugali, UNICEF India
Dr Satish Gupta UNICEF India
Dr Chandrakant Lahariya WHO India
Dr Pankaj Bhatnagar WHO India
Dr Balwinder Singh WHO India
Dr Satyabrata Routray WHO India
Abbreviations
AEFI
Adverse Events Following Immunization
AES
Acute Encephalitis Syndrome
AFP
Acute Flaccid Paralysis
ASHA
Accredited Social Health Activist
AVD
Alternate Vaccine Delivery
AWW
Anganwadi Worker
BCG
Bacillus CalmetteGurin
bOPV
Bivalent Oral Polio Vaccine
CBHI
Central Bureau of Health Intelligence
CCE
Cold Chain Equipment
CCL
Cold Chain and Logistics
CFC
Chloroflurocarbon
cMYP
Comprehensive Multi-year Plan
CRM
Common Review Mission
CSO
Civil Society Organization
CSSM
Child Survival and Safe Motherhood
DF
Deep Freezer
DIR
Detailed Investigation Report
DPT
Diphtheria Pertussis Tetanus
DTFI
District Task Force on Immunization
E2P
Evidence to Policy
EPC
Empowered Program Committee
EPRP
Emergency Preparedness and Response Plan
eVIN
electronic Vaccine Intelligence Network
EVM
Effective Vaccine Management
FHW
Frontline Health Worker
FIR
First Information Report
FMG
Financial Management Group
................................
vii
GMSD
Government Medical Store Depot
GoI
Government of India
HepB
Hepatitis B
HiB
Haemophilus influenzae B
HMIS
Health Management Information system
HR
Human Resources
ICDS
Integrated Child Development Services
IDH
Infectious Diseases Hospital
IEC
Information, Education and Communication
ILR
Ice-Lined Refrigerator
IMNCI
Integrated Management of Neonatal and Childhood Illnesses
IMR
Infant Mortality Rate
IPC
Inter-personal Communication
IPC
Indian Pharmacopoeia Commission
IPHS
Indian Public Health Standards
ISP
Immunization Strengthening Project
ITSU
Immunization Technical Support Unit
IUCD
Intra-Uterine Contraceptive Device
JE
Japanese Encephalitis
JRM
Joint Review Mission
JSSK
Janani Shishu Suraksha Karyakram
JSY
Janani SurakshaYojna
KO
Key Objective
LHV
Lady Health Visitor
MCTS
Mother and Child Tracking System
MCV
Measles Containing Vaccine
MDG
Millennium Development Goal
MDVP
Multi Dose Vial Policy
MIS
Management Information System
MMR
Maternal Mortality Rate
MoHFW
Ministry of Health and Family Welfare
MSG
Mission Steering Group
NBSU
Newborn Stabilization Unit
NCCA
National Cold Chain Assessment
NCCMIS
National Cold Chain Management Information System
NCCTC
National Cold Chain Training Center
NCCVMRC
National Cold Chain Vaccine Management Resource Center
viii
A B B R E V I AT I O N S
NGO
Non-Governmental Organization
NIHFW
National Institute of Health and Family Welfare
NNT
Neonatal Tetanus
NRC
Nutrition Rehabilitation Center
NRHM
National Rural Health Mission
NTAGI
National Technical Advisory Group on Immunization
OCP
Oral Contraceptive Pill
OPV
Oral Polio Vaccine
ORS
Oral Rehydration Salt
OVP
Open Vial Policy
PIP
Program Implementation Plan
PIR
Preliminary Investigation Report
RCH
Reproductive and Child Health
RI
Routine Immunization
RMNCH+A
Reproductive, Maternal, Newborn, Child & Adolescent Health
RRT
Rapid Response Team
RTI
Reproductive Tract Infection
SBHI
State Bureau of Health Intelligence
SHTO
State Health Transport Organization
SIA
Supplementary Immunization Activity
SMS
Short Message Text
SNCU
Sick Newborn Care Unit
STI
Sexually Transmitted Infection
STSC
Standing Technical Sub-Committee
TFR
Total Fertility Rate
tOPV
Trivalent Oral Polio Vaccine
TT
Tetanus Toxoid
UIP
Universal Immunization Program
UNICEF
United Nations Children's Fund
UT
Union Territory
VHND
Village Health and Nutrition Day
VLM
Vaccines Logistics Management
VMAT
Vaccine Management Assessment Tool
VPD
Vaccine Preventable Disease
WHO
World Health Organization
WIC
Walk-in Cooler
WIF
Walk-in Freezer
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1
Introduction
1.1 UIP as a component of
Reproductive, Maternal, Newborn,
Child and Adolescent Health in
India
There is a growing acknowledgment that over
the years various service packages have been
developed around the Reproductive and Child
Health program that have tended to function
independently. To bring about a greater impact
of the program there is a need to build synergies
between these various packages since they
address different stages of the life cycle. The

'Continuum of Care' approach includes two
dimensions stages of life cycle and places
where care is provided. This approach
underpins the RMNCH+A strategy that seeks
to provide an integrated set of interventions
through a large cadre of community-based
ASHAs and a three-tiered health system. The
key components of the RMNCH+A
interventions as a 'continuum of care' are given
in Table 1. Immunization is one of the key
elements in this strategy.1
Family & Community Outreach/Sub centre
Clinical
Table 1: RMNCH+A continuum of care across life cycle and different levels of healthcare
Reproductive care
Pregnancy and child birth care
Comprehensive abortion
care
RTI/STI case management,
Postpartum IUCD and
sterilisation; interval IUCD
procedures
Adolescent friendly health
services
Skilled obstetric care and

immediate newborn care
and resuscitation
Emergency obstetric care
Preventing Parent to Child
Transmission (PPTCT) of
HIV
Postpartum sterilisation
Reproductive health care
Antenatal care
Family planning (including

IUCD insertion, OCP &
condoms)
Prevention and
management of STIs
Peri-conception Folic acid
supplenentation
Weekly IFA
supplementation
Information and counselling
on sexual reproductive
health and family planning
Community based
promotion and delivery of
contraceptives
Menstrual hygiene
Full antenatal care

package
PPTCT
Newborn and childcare
Essential newborn care

Care of sick newborn (SNCU, NBSU)
Facility-based care of childhood illnesses (IMNCI)
Care of children with severe acute malnutrition
(NRC)
Immunisation
Postnatal care
Early detection and
management of
illnesses in mother and
newborn
Immunisation
Counselling and
preparation for newborn
care, breast feeding, birth
preparedness
Demand generation for
pregnancy care and
institutional delivery (JSY,
JSSK)
Child health care

First level assessment
and care for newborn
and childhood illnesses
Immunisation
Micro-nutrient
supplementation
Home-based newborn care and prompt referral

(HBNC scheme)
Antibiotic for suspected case of newborn sepsis
Infant and Young Child Feeding (IYCF), including
exclusive breast feeding and complementary feeding,
Child health screening and early intervention services
(0-18 years)
Early childhood development
Danger sign recognition and care-seeking for illness
Use of ORS and Zinc in case of diarrhoea
Intersectoral: Water, sanitation, hygiene, nutrition, education, education, empowerment

Adolescence/ Pre-pregnancy
Pregnancy
Birth
Newborn / postnatal
Childhood
A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health in India:
For Healthy Mother and Child. MoHFW, Government of India, 2013.
................................
01
02
Immunization is one of the most cost-effective

interventions that prevent needless suffering
through sickness, disability and death. The
benefits of immunization are not restricted to
improvement in health and life expectancy but
also have social and economic impact at both
community and national levels. Moreover, an
effective, equitable immunization program and
its impact on reducing the burden of vaccinepreventable diseases will greatly contribute to
achieving the Millennium Development Goal
4 (MDG4) that envisages a two-third reduction
in child mortality by 2015.
In the last three decades, India has made
significant progress on sustainable and
inclusive growth. There is now a greater sense
of awareness and expectations from the people
as the country makes further social and
economic progress. Investments on the social
determinants of health have improved
availability and access to health services
though there still remain challenges of inequity
and affordability.
1.2 Purpose of cMYP

This multi-year strategic plan (201317) has
evolved from its first iteration (cMYP 200510)
and is underpinned by the Government of
India RMNCH+A 2013 strategy and the
National Vaccine Policy, 2011. The document
mainly seeks to:
a. Provide a broad framework of objectives,
expected results and strategies that cover the
different aspects of Routine Immunization
p r o g r a m s e r v i c e d e l ive r y, s y s t e m
strengthening, social mobilization and
demand generation, newer vaccines and
technology, epidemiology of vaccinepreventable diseases and management of
adverse events following immunization.
b. Identify costing and financing requirement
as part of the planning cycle.
c. Propose monitoring and accountability
tracking mechanisms that should lead to
improved program efficiency
d. Explore and expand opportunities to
integrate other maternal and child health

interventions such as breast feeding,
Vitamin A supplementation and ORS
through UIP.
1.3 Planning process

The strategic plan had been prepared through a
close collaborative and iterative process
involving national program managers, state
o f f i c i a l s, p r o f e s s i o n a l a s s o c i a t i o n s,
development partners and implementing
agencies, which provide the goals, objectives,
indicators, strategies and costs. As cMYP
(200510) was completing its life in March
2010, a supplement to extend it till March 2012
was prepared. Initially, a framework for revised
cMYP was agreed upon by a working group of
national immunization program managers and
development partners where attention was
paid to new developments and initiatives that
had taken place since 2005. These initiatives
included those that have been enacted under
the National Rural Health Mission (NRHM)
and the recommendations of NTAGI in the
recent years. Two regional consultations were
held in New Delhi and Kolkata. These
consultations were attended by senior officials
in the Ministry of Health and Family Welfare
(MoHFW), program managers from the
national immunization division; state, district
and block level immunization officials, and by
representatives of development partners and
other professional organizations and NonGovernment Organizations.
In April 2013, under the guidance of national
immunization division, ITSU facilitated the
process of drafting the next cMYP (201317)
and set up a core committee to draft the plan,
comprising of representatives from ITSU,
WHO and UNICEF. The members of the core
committee met and communicated on a regular
basis among themselves to continually refine
the draft plan. Inputs on key objectives and
strategies came through the national
immunization division through regular
meetings with the drafting team. The current
cMYP document went through several
iterations before it was sent to NTAGI for
comments, which were subsequently
03
incorporated. In addition to the main strategic

component of cMYP, the core committee also
worked on the detailed costing of the program
under the guidance of national immunization
division.
1.4 Global Priorities on immunization

A c c o r d i n g t o W H O, i m mu n i z a t i o n
interventions have proven to be a success across
the globe and today reach out to over 100
million children and prevent 2.5 million deaths
per year. As new global health paradigms
emerge, fresh perspectives and priorities are
emerging in immunization as well. Universal
immunization coverage is an important
element of universal health coverage to achieve
the MDGs by 2015. Despite improved
vaccination coverage there are rising inequities
among different population groups that need to
be addressed for a more meaningful success.
There are at least ten new antigens now
available that can be added to the traditional
EPI interventions including vaccines against
Hepatitis B, Rota virus, Japanese Encephalitis,
and Human Papilloma Virus. Several countries
are now moving beyond the traditional target
population of infants and pregnant women to
include adolescents and adults. WHO expects
that by 2015 immunization should contribute
2
3
I N T R O D U C T I O N
to reducing approximately 25 percent to the

reduction in child mortality.2
WHO has identified priority areas in
immunization for the future to sustain the
momentum on immunization. 3
These
priorities, which are also reflected in the
national cMYP, include the following:
strengthening the Routine Immunization
program,
accelerating measles control activities,
introducing newer vaccines through

evidence-based policies,
increasing access to immunization services

through system strengthening.
As the current set of MDGs reach their end in

2015, new global health paradigms will emerge
that will focus on universal health coverage and
sustainable development. A well-functioning
UIP that aims to reach out to every child will
contribute to universal health coverage and
healthier future generation. To achieve this,
UIP will need strong underpinning of good
governance and accountability at all levels.
This will necessarily lead to improved program
efficiency and more children will get
immunized.
WHO Strategic Plan 201015. Department of Immunization, Vaccines and Biologicals

Global Action Vaccine Plan 20112020. World Health Organization
................................
2
National Context
2.1 History of immunization
program in India
The success of smallpox eradication in the 70s
brought attention to the immunization
program globally as well as in India. The
Expanded Program on Immunization (EPI), a
national policy of immunizing all children
during the first year of life with DPT, OPV,
BCG and typhoidparatyphoid fever vaccines
was launched in 1978. Immunization of
pregnant mothers with TT vaccine was
introduced in 1983. In 1985, the name of EPI
was changed to the Universal Immunization
Program (UIP) with activities phased in to the
entire country by 1990. The stated objectives of
UIP are:
To rapidly increase immunization coverage
To improve the quality of services
To establish a reliable cold chain system to

the health facility level
To introduce a district-wise system for

monitoring of performance
To achieve self-sufficiency in vaccine

production
UIP was given the status of a one of the five

'National Technology Missions' in 1986.
Subsequently in 1992, UIP became a part of
Child Survival and Safe Motherhood (CSSM)
program and then of Reproductive and Child
Health (RCH) program in 1997. A specific
Immunization Strengthening Project (ISP) was
designed to run from 2000 to 2003, which
included the following main components:
polio eradication
l
strengthening routine immunization
l
strategic framework for development.
l
2.2 National Rural Health Mission

(NRHM)
Immunization is a critical component of the
Government of India's child survival strategy.
In 1997 the MoHFW launched a Reproductive
and Child Health (RCH) program to reduce
IMR, MMR, TFR and to increase
immunization coverage, especially in rural
areas. The second phase of the RCH program
(200510) focused on minimizing regional
variations through provision of assured,
equitable, and responsive quality services.
With a view to strengthen public health system
in rural areas, the Government of India
launched the National Rural Health Mission in
2005. The NRHM was established as a single
platform to bring together all of the national
health efforts, including RCH.4 The goal of the
NRHM is to address gaps in the provision of
effective health care to rural population with a
special focus on 18 states, which have weak
public health infrastructure.5 To achieve this
goal the NRHM envisions a shift away from the
vertical health and family welfare programs to
a new architecture in which societies under
different programs are merged and resources
pooled at the district level. NRHM also
provides states with flexibility in making their
own plans in delivering RI interventions. It also
seeks to strengthen local public health
provision with infrastructure and manpower
and facilitate the participation of the not-forprofit and for-profit sectors in achieving
Ministry of Health and Family Welfare (2005): National Rural Health Mission, Framework for Implementation (2005-12)
The 18 states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu &
Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Odisha, Rajasthan, Sikkim,
Tripura, Uttaranchal and Uttar Pradesh.
5
................................
05
06
desirable health outcomes. In the 12th FYP the

Government of India has proposed a National
Health Mission for improving healthcare in
rural as well as urban areas. UIP is an integral
component of NRHM.
At the national level, the NRHM has a Mission
Steering Group (MSG) headed by the Union
Minister for Health & Family Welfare and an
Empowered Program Committee (EPC)
headed by the Union Secretary for Health &
Family Welfare. EPC implements the Mission
under the overall guidance of the MSG.6
At the state level, the mission functions under
the overall guidance of the State Health
Mission headed by the Chief Minister of the
state and provides oversight to the functioning

of the health system and NRHM activities,
policy inputs for health sector, conducts
intersectoral coordination and advocacy. The
functions under the mission are carried out
through the State Health & Family Welfare
Society led by the Mission Director. Under
NRHM, states have set up State Health
Societies to strengthen health service delivery
infrastr ucture, financial management,
coordination with NGOs/CSOs/donors and
monitoring of various national programs.
The State Mission and State Society are
interlinked in terms of a common secretariat as
shown in Figure 1 below.
Figure 1: Composite organogram of the State Mission and the State Society
State Health Mission

Governing Body, State Health Society
Executive Committee, State Health Society
SPMSU
(Headed by Executive
Director/Mission
Director)
2.3 Burden of vaccine-preventable

diseases (VPDs)
Over the past 20 years, the reported cases of the
main VPDshave declined. However, in recent
yearsthere has been an increasing trend in the
number of reported measles, diphtheria and
pertussis cases as shown in Figure 2. This
increasing trend may be due to an actual
6
Source: www.nrhm.gov.in
Program Committees
(Headed by Director/
Director General)
(Optional)
increase in number of cases or can be attributed

to improvements in case detection and the
overall surveillance system strengthening. To
minimize this inconsistency and to stabilize the
reporting trends, improving the surveillance of
VPDs in the countryis urgently needed.It is
estimated that approximately 80,000 children
die annually from measles and associated
complications. Although this figure has
07
N AT I O N A L C O N T E X T
decreased over the years with improvements in

routine vaccination coverage rates, measles
mortality still remains high. In 2010, the
Government of India decided to introduce a
second dose of measles containing vaccine
(MCV2) in UIP. In 21 states with measles 1st
dose coverage more than 80 percent, MCV2
was introduced directly in their routine
immunization whereas, 14 states were taken up
for measles Supplementary Immunization
Activity (SIA) followed by introduction of
MCV2 six months following the completion of

the campaign. Delhi, Sikkim, Goa and
Puducherry took initiative themselves and
introduced 2nd measles dose through MMR.In
September 2013, India committed to
eliminating measles and controlling
rubella/congenital rubella syndrome (CRS) by
2020 as part of the resolution that was
approved by SEARO's 66th regional
committee.
Figure 2: Trends in the reported cases of Measles and Pertussis from 19902010 (Source CBHI)
120000
Burden of VPDs
Cases
100000
80000
60000
40000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
20000
Measles
2.4 Status of vaccine coverage

Though the reported vaccination coverage for
all vaccines has always been higher than
evaluated coverage, the average vaccination
coverage has shown a consistent increase over
the last two decades as shown in Figure 3
below.
However these averages mask the disparities
Pertussls
between geographies and population groups.

These inequities represent gaps in service
delivery that leaves certain groups of children
at a high risk of remaining unvaccinated. As
per NHFS-3 data, nine states are below the
national average for vaccination coverage
including Madhya Pradesh, Uttar Pradesh,
Bihar and Jharkhand. Even within states there
exists a difference in total coverage between
different districts as shown in Figure 4.7
NFHS-3 data
................................
08
Figure 3: Trends in vaccination coverage over the last twenty years as shown in different surveys
Vaccine coverage
70.0%
61.4%
60.0%
54.2%
50.0%
42.0%
40.0%
53.5%
45.9%
43.5%
35.4%
30.0%
20.0%
10.0%
0.0%
NFHS-1 NFHS-2 NFHS-3
(1992-93) (1998-99) (2005-06)
DLHS-1 DLHS-2 DLHS-3

(1998-99) (2002-04) (2007-08)
CES
(2009-10)
Figure 4: District level coverage of fully immunized children between 12 and 23 months of age.
(Source: DLHS 200708)
Below 30
30 to 50
50 to 70
70 to 90
Above 90
2.4.1 Vaccine coverage and equity

issues
While vaccines under UIP are provided free of
cost through all the public health facilities
across the countries, disparities in coverage
exist for different population groups that need
to be addressed. There are significant inequities
in vaccination coverage in different states based
on various factors related to individual (gender,
birth order), family (area of residence,
wealth,parental education), demography
8
(religion, caste) and the society (access to

health care, community literacy level)
characteristics.8
There is a clear gender coverage differential as
reported by different surveys. Boys generally
have a higher vaccination coverage than girls as
reported by most surveys conducted across the
country (Figure 5).
The gap between genders also exists for
individual vaccines such as BCG, DPT and
measles.
Joseph L Mathew (2012): Inequity in Childhood Immunization in India: A Systematic Review, Indian Pediatrics,
Volume 69, March 16, 2012.
09
Vaccination coverage is also lower amongst

infants coming from scheduled caste (SC),
scheduled tribes (ST) and other backward
castes (see Figure 6).
Urban areas have higher vaccination coverage

as compared to rural areas and this gap exists
for all vaccines. Within urban areas, slum
populations have a lower coverage. Migrants
coming to urban areas to have a lower coverage
level as compared to the resident population.
Urban and rural poor populations have a lower
coverage as compared to the wealthier one.
A comparison of states showing good and poor

performance on immunization coverage is
given in Annex 1 and Annex 2 respectively.
Figure 5: Gender differential in vaccine coverage (Source: HMIS)

13000000
Fully Immunized Children
12500000
12000000
11500000
11000000
10500000
10000000
9500000
9000000
2008-09
2009-10
Male
2010-11
2011-12
2012-13
Female
Figure 6: Differentials in vaccine coverage across geography, caste and wealth status
(Source: UNICEF CES 2009)
Percentage of children age 12-23 mfully immunized

75.5
67.4
66.3
58.5
60.6
58.9
49.8
Urban Rural
Others OBC
SC
ST
47.3
Richest Poorest
Quintile Quintile
................................
10
2.5 Current structure for

immunization service delivery in
the country
The implementation of the UIP is a joint
responsibility of government at all levels,
namely Central, State and Union Territory
Districts and Sub-Districts. The relationships
between central and state immunization
departments and between state and district
immunization officers are critical for efficient
and effective service delivery.
National: The MoHFW comprises of four
departments, each of which is led by a
Secretary to the Government of India. These
include:
Department of Health & Family Welfare;
Department of Ayur veda, Yoga &

N a t u r o p a t hy, U n a n i , S i d d h a a n d
Homoeopathy;
Department of Health Research; and
Immunization Division at MoHFW has set up

an Immunization Technical Support Unit
(ITSU). The ITSU is staffed with technical
officers to support various functions of UIP
under six different pillars:
Strategic planning and system design,
Monitoring and evaluation,
Va c c i n e l o g i s t i c s a n d c o l d c h a i n
management,
Adverse events following immunization

(AEFI) management and vaccine quality
and safety,
Translation of evidence to policy, and
Strategic communication.
Through ITSU,the ministry will facilitate to

harmonize various initiatives being piloted or
implemented in different states by all
immunization partners and provide a single
platform for discussions, development of
strategies and coordination with partners for
scaling up the successful models.
Department of AIDS Control.
The MoHFW is responsible for implementing

various national health programs in all states of
India. The Directorate General of Health
Services renders technical advice on all
medical and public health matters and is
involved in the monitoring of implementation
of various health services. The MoHFW is
responsible for funding of various national
programs including immunization program,
providing technical assistance and policy
guidance to the states, and for monitoring and
evaluation. Funding for extra staff and other
health system resources at the state level is
provided by the NRHM, a flexible mechanism
that allows for integration of funds for all the
national schemes while allowing for states to
flexibly allocate funds for system improvement
in a manner that is consistent with their needs
and challenges. All states are required to
submit in advance a Program Implementation
Plan (PIP) for a financial year, along with
complete projections of funds required to
implement the PIP.
To augment technical and managerial support
under UIP for strengthening, revitalization and
successful implementation of RI, the
State: At the state level, the Secretary of Health

is responsible for all health-related efforts. The
State Department of Health and Family
Welfare is led by a Director of Health Services
under which the State Directorate of Health
Services serves as the technical wing. Large
states such as Bihar, Madhya Pradesh, Uttar
Pradesh, Andhra Pradesh, and Karnataka have
additional zonal or regional or divisions set-up
between the State Directorate of Health
Services and the District Health
Administration. Most of the states have a
dedicated State EPI Officer; however, at places
Deputy Director-HFW has additional
responsibility of being EPI Officer. Additional
support for UIP at the state level is provided by
a cold chain officer and by data and
administrative support staff. State governments
are responsible for implementation and
supervision of the various programs and for
provision of relevant infrastructure and
curative services in the states including village
outreach sessions for immunization.
District: In the district, under the overall
supervision of Chief Medical and Health
Officer (CMHO) or Civil Surgeon (CS), the
District Immunization Officer (DIO)
11
coordinates all the immunization-related

efforts. The responsibility for immunization
also lies with Block Medical Officers and PHC
Medical Officers. The Auxiliary Nurse
Midwife (ANM) delivers the immunization
services to the community.
Immunization services are provided through
the following:
sub-centers, primary health centers, and
community health centers,
health service delivery and identify practical

and political challenges that must be overcome
to improve the health of citizens. CSOs
therefore play a crucial role to advocate for
policy changes, generate greater transparency
and hold governments and other healthcare
stakeholders to account. At the country level,
Civil Society encompasses a diverse array of
actors, including the following:
patient groups, health workers, medical or
health unions and associations,
sub-divisional/taluk/speciality hospitals,
tertiary hospitals,
l
l
urban health ser vices provided by

municipalities,
faith-based organizations,
non-governmental organizations,
community-based organizations,
academic institutions,
hospitals and dispensaries run by railways,

defense, and public sector undertakings,
Employees State Insurance Scheme

hospitals
dispensaries funded by the government

(State and Centre).
Private health sector also provides an estimated

1520 percent of immunization services.
The Indian Public Health Standards (IPHS) for
immunization has been drafted to improve the
quality of the service and NRHM supports
efforts to improve the quality of service by
strengthening sub-centers and primary health
centers. The funding mechanism for
immunization has also been simplified and
made flexible along with adoption of the
bottom-up planning approach through district
and state Project Implementation Plans (PIPs).
Immunization service delivery in many areas
within a district, i.e. urban areas, especially
slums and peri-urban areas, where migrant
families live; areas in semi-legal situations due
to weak infrastructure; areas which are
managed by different local bodies such as
railways and cantonment have been, and are
still, a major concern.
2.5.1 Other stakeholders

Civil Society Civil Society Organizations
(CSOs): These organizations offer a wide
range of experience and knowledge essential
for UIP. They can provide insight into gaps in
media,
advocacy groups,
migrants, women, youth and other neglected

or vulnerable groups.
Civil society groups of particular importance

to ensuring that UIP achieves its intended
results are those with expertise in maternal
health, child health, immunizations, nutrition,
health systems and services, monitoring and
evaluation. The MOHFW will engage more
proactively with academia, professional
societies, and other national agencies and
committees and networks like the development
partners forum to ensure a cohesive and
coordinated approach to achieving national
immunization priorities.
Private hospitals and clinics: Private health
sector plays an important role in providing
immunization services and fill gaps in delivery
of RI services through public system. Studies in
India have shown that private sector does
enable increased access to traditional EPI
vaccines for those who can afford to pay.9
Private sector also plays a role in introducing
newer and underutilized vaccines prior to their
induction in the public program. Private sector
also has a key role to play in supporting the
surveillance system for vaccine-preventable
diseases and adverse events following
immunization by reporting cases that may have
been missed out by the public surveillance
system.
Howard D, Roy K. Private care and public health: do vaccination and prenatal care rates differ between users of private vs.
public sector care in India? Health Services Research 2004;49:2013-26
................................
12
2.5.2 Current UIP Schedule in India
pregnant women, infants, children and

adolescents as shown in Table 2 below.
The current UIP vaccination schedule caters to

Table 2: Vaccination schedule under UIP in India
When to give
Dose
Route
Site
TT-1
Early in pregnancy
0.5 ml
Intra-muscular
Upper Arm
TT-2
4 weeks after TT-1*
0.5 ml
Intra-muscular
Upper Arm
TT- Booster
If received 2 TT doses in a
pregnancy within the last 3 years
0.5 ml
Intra-muscular
Upper Arm
BCG
At birth or as early as possible till

one year of age
0.1ml
(0.05ml until 1
month of age)
Intra-dermal
Left Upper Arm
Hepatitis B
Birth dose
At birth or as early as possible

within 24 hours
0.5 ml
Intra-muscular
Antero-lateral side
of mid-thigh
OPV
Zero dose
At birth or as early as possible

within the first 15 days
2 drops
Oral
Oral
OPV 1,2 & 3
At 6 weeks, 10 weeks & 14 weeks 2 drops
Oral
Oral
Vaccine
For Pregnant Women
For Infants
DPT1,2 & 3
0.5 ml
Intra-muscular
Antero-lateral side
of mid-thigh
Hepatitis B
1,2 & 3
0.5 ml
Intra-muscular
Antero-lateral side
of mid-thigh
Hi Bcontaining
Pentavalent
1, 2 & 3**
0.5 ml
Intra-muscular
Antero-lateral side
of mid-thigh
0.5 ml
Sub-cutaneous Right upper Arm
9 completed months
For Children and Adolescents
0.5 ml
Sub-cutaneous Left Upper Arm
DPT 1st
booster
16-24 months
0.5 ml
Intra-muscular
Antero-lateral side
of mid-thigh
OPV Booster
16-24 months
2 drops
Oral
Oral
Measles
2nd dose
16-24 Months
0.5 ml
Sub-cutaneous Right upper Arm
JE 2nd dose
16-24 months with DPT/OPV

booster
0.5 ml
Sub-cutaneous Left Upper Arm
DPT
2ndBooster
5-6 years
0.5 ml.
Intra-muscular
Upper Arm
TT
10 years & 16 years
0.5 ml
Intra-muscular
Upper Arm
Measles 1st
dose
9 completed months-12 months.

(give up to 5 years if not received
at 9-12 months age)
JE 1st dose***
Vitamin A****
*Give TT-2 or Booster doses before 36 weeks of pregnancy. However, give these even if more than 36 weeks have passed. Give TT to a woman in labor, if she has not previously
received TT.
**Pentavalent vaccines contain a combination of DPT, HepB and HiB. In the states where it has been introduced, it will replace DPT 1,2& 3 and Hepatitis B 1, 2 & 3. Hepatitis B birth
dose and booster doses of DPT will continue as before.
*** JE Vaccine (SA 14-14-2) is given in select endemic districts, after the campaign is over in that district.
****The 2nd to 9th doses of Vitamin A can be administered to children 1-5 years old during biannual rounds, in collaboration with ICDS.
13
2.6 UIP successes as a child

survival strategy
The Universal Immunization Program (UIP)
in India is one of the largest of its kind in the
world, in terms of the following:
quantity of vaccines used,
number of beneficiaries reached out to,
number of immunization sessions

organized,
the geographical spread and diversity of

areas covered.
It caters to nearly 27 million infants and 30

million pregnant women annually free of cost.
There is a strong political commitment for
achieving universal immunization coverage in
the country along with the eradication and
elimination of the targeted diseases.
As a key element of the national child survival
strategy, UIP has contributed significantly to
reducing mortality and morbidity due to
vaccine-preventable diseases and the infant
mortality rate over the last decade. While
surveillance information for specific VPDs is
limited, the steady fall of IMR from 123 to 50
deaths per 1000 live-births does in part reflect
the impact of the UIP.10
Since its launch in 1995, the Pulse Polio
campaign aimed at eradicating polio from
India, has begun to show results. Governments
at the national and state levels are
implementing strategies on a scale and
intensity that is unprecedented in the history of
polio eradication. These efforts have brought
India closer to the goal of polio eradication and
there is currently no reported case since
January 2011.11 India has been declared polio
non-endemic country by World Health
Organization in early 2012. Neonatal Tetanus
cases have declined significantly as more
pregnant women received TT vaccine as part of
their ante-natal care. There has been an overall
reduction in the number of cases and deaths
due to diphtheria, pertussis and measles as
well.
Under National Rural Health Mission,

MoHFW has undertaken many initiatives to
improve health systems and immunization
outcomes. Districts have been provided with
more human as well as financial resources to
improve delivery of immunization and other
health services. Introduction of ASHA into the
system as a community link worker has
brought about a major improvement in
community mobilization. Districts have
strengthened their delivery systems and
developed micro-plans for improved efficiency.
The number of vaccine delivery points has
increased along with the cold chain points.
MoHFW also introduced a system for
Alternate Vaccine Delivery (AVD) to provide
vaccines at the outreach session sites.
Innovative technology like auto-disable
syringes are now in use in all states and union
territories. Immunization-related trainings
have led to an increased capacity of frontline
health workers to deliver vaccines at the village
level. Focus in the urban areas has led to an
improved immunization services in slums
areas, though more needs to be done in this
area.12 MoHFW has also initiated Mother and
Child Tracking System (MCTS) to enable the
entry of mother and child data into a central
database.
The year 201213 was declared by the
Government of India as the year of
Intensification of RI in India. In this context,
the MoHFW had put in place a few strategic
actions to improve immunization coverage.
These included
improving health systems,
promoting village health and nutrition day

(VHND),
launching Immunization Weeks,
launching of the Teeka Express for

delivery of vaccines to outreach sessions,
pilot-launching of the National Cold Chain

Management Information System
(NCCMIS) for real-time monitoring and
management of cold chain systems and
setting up of the Immunization Technical
10
SRS 2011
National Polio Surveillance Program. www.npspindia.org.
UIP Review 2004
11
12
................................
14
document called RMNCH+A. Strengthening

RI to increase coverage has been identified as a
key intervention in RMNCH+A. Many
different ministries, global and Indian experts,
goodwill ambassadors, private sector, civil
society, media, and faith-based organizations
have pledged to recommit themselves to the
Call to Action.
Support Unit (ITSU) to provide technical

and programmatic support for successful
implementation of the UIP.
India's 'Call to Action on Child Survival and
Development' announced in February 2013,
and led by the MoHFW, the Government of
India, calls for a concerted, convergent and
inter-sectorial approach to achieving the
country's child survival goals by 2017. Based
on composite indicators the Government of
India has identified strengthening efforts in the
184 high priority districts in the country. This
five-year ambitious target will heighten the
importance of 'continuum of care', ensuring
the tight linkage between maternal and
newborn health as outlined in the new strategic
2.7 Barriers for effective

programming
Overall immunization coverage levels are low
in the country. According to the CES 2009, the
reasons for low immunization coverage pertain
to issues on the demand and supply side as
given in Figure 7 below
Figure 7: Reasons for low immunization coverage in India (Source UNICEF CES 2009)
28.2
Did not feelneed

Not knowing about vaccines
Not knowing where to go for immunization
Time not convenint
Fear of side effects
Do not have time
Wrong advice by someone
Cannot afford the cost
Vaccine not available
Place not convenient
ANM absent
Long waiting time
Place too far
Service not available
26.3
10.8
8.9
8.1
Demand side
issues
6
3
1.2
6.2
3.8
3.9
Supply side
issues
2.1
2.1
2.1
Others
11.8
0
10
15
20
25
30
Percentage
The performance of immunization program in
India is regularly assessed through UIP review
meetings at national and state levels, Joint
Review Missions (JRM) and Common Review
Missions (CRM) sent by GoI. At least one
national review is conducted every year besides
additional state specific review as per the
program need. The common constraints in
immunization program are summarized

below:
a. Gaps in cold chain and vaccine logistics
management: There is limited cold chain
infrastructure and capacity in many states, even
for routine UIP vaccines. Systematic efforts to
identify gaps and address issues in cold chain
15
and VLM have been conducted in recent years.

In addition to the 2008 NCCA, a number of
vaccine and cold chain management
a s s e s s m e n t s ( Va c c i n e M a n a g e m e n t
Assessment Tool (VMAT)/EVM assessments)
have been conducted in 10 states and one
national UIP store (Government Medical Store
Depots (GMSD) Karnal) between 200711.13
A recent national-level assessment of EVM
conducted by the Government of India and
UNICEF in 10 states and four GMSDs along
with other studies including deep dive and
KPMG exercises by ITSU have identified the
following constraints:
the poor performing states and specifically at

the field level.
Monitoring and MIS issues such as lack of
realtime vaccine stock status, consumption
patterns, wastage rates, along with a
continuous temperature monitoring system
for cold chain, lack of cold chain inventory
and real-time NCCMIS, no regular review
of CCL system at the state and district level,
and poor documentation and MIS for
vaccine management (standardized
registers, records and procedures).
Vaccine procurement issues are significant

as delay in placement of procurement orders
and irregular supply of vaccines have a direct
impact on vaccine availability affecting
immunization coverage. Moreover, certified
vaccine suppliers are few, and since orders
are always given to the lowest bidder, the
supply of vaccines is often erratic.
Infrastr ucture issues include poor

infrastructure of vaccine stores and
transportation systems; a lack of standards
for vaccine stores at different levels and
insufficient temperature monitoring system
at all vaccine storage points from GMSDs to
last cold chain point level, state, and regional
stores. There exist difficulties in procuring
the right quality of cold chain equipment on
time with adequate after-sale support. There
is a paucity of repair kits and spares cold
chain technicians and inequitable cold chain
point (last vaccine storage site) distribution.
Cold chain equipment in many states in the
country is old and in many cases broken.
There is also a paucity of available data on
Vaccine Logistics and Cold Chain to devise
national plans and strategies to address
them. .
HR issues such as lack of a CCL support

unit with experts on cold chain for both the
immunization division of MoHFW and at
the state level; lack of induction training and
a regular educational program for staff
inducted in the Vaccine Logistics and Cold
Chain system; insufficient institutional
training capacity to manage cold chain and
logistics at all levels; shortage of trained
manpower and relevant job-aids for
managing cold chain at all levels (state,
division/regional and district levels); and
lack of HR with capacity for Vaccine
Logistics Management (VLM) at all levels
(national, GMSDs, state, district and
PHCs). The shortage of HR is more acute in
13
These constraints have led to high breakdown

rate of equipment, overstocking and stockouts, inadequate monitoring and supervision,
poor management, and the possibility of
AEFIs, thus hampering improved vaccine
coverage.
b. Poor social mobilization: Low levels of
awareness, communication and informationsharing amongst frontline workers as well as
poor HR capacity for BCC in government
institutions as a whole contributes to the
problem of high left-outs and dropouts. Studies
have shown that insufficient and ineffective
health communication along with lack of
promotion or follow-up of RIs are two of the
main health system constrains behind low
coverage in immunization, preventing parents
from initiating or following through with their
child's vaccination schedule. Given that the
actual rate of immunization is low, the high
dropout rate reduces the number of fully
immunized children in the country. Poor
populations and those with lower levels of
education are most vulnerable to impacts of
low levels of advocacy and communication.
Listed below are some of the system-related
constraints in advocacy and communication
National Cold Chain Assessment, India. July 2008. NRHM & UNICEF
................................
16
that lead to low levels of immunization

coverage.
There is weak capacity at the state level and
inadequate HR to generate evidence-based
communication strategies and effective BCC
campaigns
We a k c o m m u n i c a t i o n c a p a c i t i e s
(spokesperson system) within the
government machinery at national and state
levels in handling AEFIs.
Information dissemination is not timely and

often mixed messages are received by
beneficiaries
Weak counseling and interpersonal

communication (IPC) skills among health
workers and community mobilizers, which
adversely affects dissemination of
communication of messages.
Weak capacities and counseling skills of

service providers to ensure delivery of
quality care, especially in hard-to-reach
areas.
There is an urgent need to strategically

approach communication, aiming at behavior
change both at the service delivery level and at
the community level to generate demand
among the caregivers. Meeting the shortfall of
health professionals and building their
counseling and communication skills are
imperative to a sustained and holistic response
to the public health concerns in the country.
This requires health care to be addressed not
only from the scientific perspective of what
works, but also from the social and behavioral
perspective of who needs it the most. One also
needs to understand the social norms and
barriers that prevent them from accessing the
services and how to reach the unreached.
c. Poor data management and analysis for
evidence generation: A robust system for data
management and evidence generation is
crucial to support informed decision making
for the creation of realistic goals and strategies
for improvement of current coverage levels and
introduction of new antigens in UIP. Since the
inception of UIP, India has set up a reporting

mechanism from the health center to national
level. In last few years, the country has also
introduced electronic data systems like HMIS
and MCTS to improve reporting, analysis,
monitoring and planning at all levels. However,
there are big gaps in quality of data being
reported, its analysis and use for decision
making and thus leading to inadequate
information to support NTAGI and UIP to
design and implement strategies to improve
immunization quality and coverage. Some of
the main constraints in the area of data
management and evidence generation are
listed below:
Poor monitoring and evaluation for data
entry, resulting in errors in data entry and
inaccurate data. In recent years, partners'
support and networks have contributed to
increased monitoring and supportive
supervision with visible positive impact in
select states. However, there is a need to
build the capacity of government officials
and strengthen the system to improve
monitoring and supervision by government
officials.
Poor monitoring and evaluation results in

insufficient data quality and reporting rates.
A vast majority of states have wide gaps in
reported and evaluated coverage data. The
factors for this variation need to be identified
through regular data quality audits and
necessary corrective measures should be
taken.
Inadequate surveillance data quality and

reporting rates result in poor surveillance of
VPDs and AEFIs. While some attention has
been paid to strengthening VPD
surveillance, systemic deficiencies and
bottlenecks such as insufficient laboratory
capacity and limited trained manpower at
the district levels to carry out surveillance,
continue to exist. Inadequate VPDs
reporting results in the inability of UIP to
measure disease burden to make a decision
on the introduction of new antigens and
impact of vaccination on the disease. There
is a felt need for HR capacity building in
17
VPD surveillance, strengthening laboratory

capacity by improving infrastructure and
making reagents available, and building
system for timely reporting and actions.
Similarly surveillance of AEFI cases is poor
and a structured response to reported serious
cases of AEFI is lacking.
Limited focus on operational research for
immunization and finding locally suitable
solutions. Good quality research is needed
to provide an evidence base for a more
informed decision making and improving
performance.
The successful implementation of HMIS under

NRHM and MCTS under Mission Mode
Project provides a great opportunity to
strengthen data management and evidence
generation to inform decision making in UIP.
With the augmentation of human resource at
national level also provides an opportunity for
coordination between various reporting and
surveillance systems in the country as well as
putting up a system for using information for
decision making.
d. Weak human resource capacity: In a study
of HR needs assessment in UIP by Mavlankar
et al (IIM Ahmedabad)14 the following was
found:
There is limited technical and operational
human resource capacity and quality at
various levels in UIP.
Immunization cells at both the state and the

national level are small and inadequately
staffed.
The roles and responsibilities of officials at

the state immunization cells are not well
defined
State immunization officials have no

financial powers and their titles are not
commensurate with their responsibilities.
The lack of human resource capacity and

poorly defined roles and responsibilities at
various levels have a cascading effect on all
other areas of program performance, including
monitoring and evaluation, supply chain and
logistics management, and strategic
communications. Lower quality of monitoring
and supportive supervision of the program
leads to reduced efficiency and effectiveness of
interventions at all levels of programming and
needs to be addressed seriously.
While UIP is a part of a wider RMNCH+A
strategy of the government, there is a need to
increase the HR capacity and numbers of
immunization managers at all levels. The
Government of India has set up an
Immunization Technical Support Unit (ITSU)
to augment human resource capacity at
national level with focal persons assigned for
specific functions such as cold chain and
vaccine logistics, Evidence to Policy and
surveillance, Strategic Communication,
Monitoring and Evaluation and Adverse
Events Following Immunization (AEFI).
Training immunization staff on relevant topics
will improve program efficiency and
effectiveness as well.
Key personnel capacities are spread thin

across multiple areas in day-to-day
management with no focus on priorities.
They are not able to focus on developing
strategic solutions and to organize and
coordinate activities such as introducing
new vaccines, updating technology,
applying for international funding and
support, writing reports and analyzing data.
e. Need for a well delineated accountability

systems: A major problem is the lack of
institutionalized and uniform accountability
structures, focused on performance review at
each administrative level i.e. central, state and
district levels. The country has a Multi-Year
Strategic Plan for UIP but its implementation is
not monitored in absence of a monitoring and
accountability structure. Though, there are
review mechanisms in place at all levels, but
these are not followed consistently. Moreover,
in absence of a robust system for data analysis,
14
Universal Immunization Program in India: A Study on HR Needs Assessment at National and State Levels.
Dr D.V Mavalankar et al, IIM Ahmedabad. Study commissioned by HRD Committee on UIP constituted by GoI.
................................
interventions and follow up, these are not very

effective.
f. Evidence synthesis for informed policy
making: The NTAGI was formed in 2001 and
tasked with advising the MoHFW on issues
related to the prog ram, policy and
implementation of the national immunization
program. Since its inception the NTAGI has
recommended evidence-based
recommendations to the UIP, such as the
following:
introduction of the Hepatitis B, Pentavalent
and Japanese Encephalitis vaccine
use of VVM in government vaccine supplies
use of AD syringes
However, there is great scope for revision and

improvement in the decision-making process
for the introduction of new vaccines in the UIP.
In the light of the current advancements in the
field and the availability of several new
interventions, it is imperative to establish
scientific evidence-based protocols for making
immunization related decisions.
As India considers adding new antigens (e.g.,
rotavirus, pneumococcal, MMR, HPV,
IPV/hexavalent, cholera, typhoid, and JE) as
well as new immunization technologies (e.g.,
updated injection safety devices), the
immunization program also needs to keep
pace. NTAGI is an advisory body with clear
terms of reference for overall guidance but not
day-to-day operations. NTAGI needs a welldefined secretariat to conduct regular meetings
and a clear scope of work that maintains focus
on making a structured recommendation on
immunization. At the same time, there is an
ever increasing need to develop capacity to
identify and address critical gaps in evidence
base. The health system must be able to
evaluate new vaccines for safety, efficacy,
relevance and cost-effectiveness; accommodate
18
the new vaccines in its cold chain management

system and vaccine logistics; assess and
respond in real time to roll-out challenges; and
conduct post-marketing surveillance to ensure
that lessons learnt from the roll-out are
incorporated back into the system.
3
Guiding Principles of UIP
The services provided through the
UIP shall be guided by the following
principles
1. Universal immunization coverage:
Sustaining demand and ensuring that all
pregnant mothers, children and adolescents are
immunized as per national schedule in line
with the principles of universal health
coverage.
2. Equitable access: Ensuring that the
immunizations services reach out to the underserved, needy and most vulnerable populations
while addressing regional inequalities across
states.
3. High quality services and innovation:
Maintaining highest possible quality in vaccine
procurement, storage, distribution and delivery

services in an innovative and safe manner.
4. Sustainability and Partnerships:
Committing resources, financial, human and
technical, that sustain immunization benefits
to the people at all times and promoting
partnerships across different sectors and
organizations build synergies and expand the
overall coverage of the program.
5. Governance: Decentralized planning
through a bottoms up approach to improve
operational efficiency
6. M a n a g e m e n t e x c e l l e n c e
and
accountability: Implementation, oversight
and accountability of interventions that
optimize efficient use of resources
................................
19
4
UIP Strategic Plan: 2013-17
This comprehensive multi-year strategy plan
seizes on the opportunity to address geographic
and social inequities in immunization coverage
rates, and other immunization-related issues
highlighted in earlier sections. The plan aims to
strengthen immunization infrastructure within
the broader RCH program and offer a platform
for integrating other primary care interventions
and strengthening the public health system at
all levels. UIP offers universal immunization
coverage to all children in the country as per the
national immunization schedule.
4.1 UIP strategic plan framework

This plan derives its essence from the National
Vaccine Policy 2011 and is underpinned by the
goals ascribed in the National Health Policy
2002 and National Rural Health Mission 2005.
The plan framework consists of an overarching
Goal and a set of six Key Objectives (KO) that
cover different aspects of the immunization

program including - operational efficiency,
epidemiological support, health system
strengthening and demand generation(See Box
1). These Key Objectives are interlinked and
mutually reinforce each other, thus providing
greater focus, structure and flexibility for
developing context-specific strategies and
interventions. Each Key Objective has a set of
Expected Results to be achieved in the medium
term and a set of actionable strategies that can
be contextualized in the State and District
implementation plans. The framework
elements are designed to be simple, feasible,
flexible and relevant to the needs of the people.
As part of providing better governance for the
program, the UIP strategic plan has a
comprehensive monitoring and accountability
tracking framework which consists of a key
indicators, targets, source of information,
assigned responsibility and information
dissemination.
Box 1: UIP Goal and Key Objectives
GOAL
Reduce mortality and morbidity due to vaccine-preventable diseases through high quality
immunization services
KEY OBJECTIVES
KO 1: Improve program service delivery for equitable and efficient immunization services by
all districts
KO 2: Increase demand and reduce barriers for people to access immunization services
through improved advocacy at all levels and social mobilization
KO 3: Strengthen and maintain robust surveillance system for vaccine-preventable diseases
(VPDs) and adverse events following immunization (AEFI)
KO 4: Introduce and expand the use of new and underutilized vaccines and technology in UIP
KO 5: Strengthen health system for immunization program
KO 6: Contribute to global polio eradication, measles, maternal and neonatal tetanus
elimination
................................
21
22
4.2 Impact indicators

1. Reduction in infant mortality rate
2. Reduction in cases of vaccine-preventable
diseases
4.3 Target population

RI interventions will be targeted at reaching out
to all eligible children and pregnant women as
per the national schedule. Given the equity
issues, special efforts will be made to ensure
that immunization services reach out to
targeted beneficiaries belonging to the lower
socio-economic strata, those living in urban
slums, rural areas, tribal and other hard-toreach areas.
The following section elaborates on the
strategic framework further
KEY OBJECTIVE 1: Improve program

service delivery for equitable and
efficient immunization services by
all districts
Vaccine logistics management is one of the
critical elements in the immunization program
to ensure that all vaccines are available at the
last cold chain point for immunization
sessions. Similarly, a reliable and adequate cold
chain network is essential to ensure that
vaccines are stored within the recommended
temperature ranges, and safe and potent
vaccines are delivered to children. Various
recent studies like Effective Vaccine
Management (EVM 2013), Vaccine Wastage
Study (2008), ITSU deep dive study, KPMG
vaccine logistics study (2013), ICMR Freezing
Study etc. have pointed out issues related to the
existing vaccine logistics system up to the last
cold chain point, and the capacity,
functionality and maintenance of cold chain
equipment at all levels.
Key Performance Indicators (KPI)
immunization coverage
3. Number of States/UTs having less than 10%
dropout from DPT1-DPT3 (or Pentavalent)
The indicators will disaggregated by gender,
geography (urban slum, urban, rural) and
socio-economic parameters, where relevant.
Expected Result 1.1: Strengthen the national
cold chain management system:
Maintaining a strong cold chain system is
critical for maximizing the operational
efficiency of UIP. Strategies to achieve this will
focus on capacity building, hardware
management and innovative technology.
Strategies
1. Develop National Cold Chain
Management action plan:
A national plan for cold chain management is
essential for improving overall UIP program
efficiency. The national cold chain plan shall be
based on various situation analyses on cold
chain and vaccine logistics management in the
country. The major components of the plan
will include:
a) National Standards:
One of the major gaps in cold chain
management is the absence of standards
performance parameters. The national cold
chain plan will include standards for the
following:
Vaccine storage at all levels as per WHO
standards
Cold Chain point expansion guidelines
Cold Chain equipment plan for different

levels of vaccine stores
Quality maintenance of vaccines
Temperature monitoring of cold chain

system
1. Number of States/UTs where > 95%

sessions were held as planned
2 . % o f d i s t r i c t s h av i n g > 8 0 % f u l l
Human resource for cold chain and vaccine

logistics
CCE testing lab
23
b) Specification of equipment and accessories

A specification committee comprising
technical experts from the field, the National
Cold Chain Training Centre (NCCTC),
engineering colleges, IITs, and program experts
will be established to provide guidelines on the
technical specifications of cold chain
equipment and accessories.
c) Procurement guidelines for cold chain
equipment and accessories
Procurement guidelines for cold chain
equipment and accessories shall be developed,
and reviewed periodically by a technical
committee of experts convened by the
MoHFW. The guidelines shall provide
parameters for equipment procurement,
rationale for purchase, quantity, guidelines on
aging etc. The technical committee shall meet
at least once a year.
Stress will be placed on promoting indigenous
cold chain equipment which is contextualized
and adaptable to local needs and environment.
A Management Information System (MIS) for
tracking the working status of cold chain
equipment and spare parts will also be set up.
The plan will also focus on regular retiring of
old and sick cold chain equipment, regular
program reviews with cold chain officers, staff
trainings, maintenance and servicing of cold
chain equipment, implementation of MIS,
logistics and supply chain management.
d) Promote indigenous cold chain equipment
for immunization
To reduce costs and improve overall program
efficiency, the MOHFW will promote the use
of cold chain equipment that is locally
produced and serviced by Indian
manufacturers. NCCVMRC will organize
consultative meetings with engineering
colleges, industries, IITs, national physical
laboratories, DG S&D to determine the safety
standard, program need and scale of
requirement required to fulfill the needs of UIP.
U I P S T R AT E G I C P L A N F R A M E W O R K
2. Enhance the capacity of the National

Cold Chain Vaccine Management
Resource Centre (NCCVMRC) and the
National Cold Chain Training Center
(NCCTC) to better manage the Cold
Chain and Vaccine Logistics
Management (VLM) system.
The NCCVMRC has been set up in National
Institute of Health and Family Welfare
(NIHFW) to conduct training and capacity
building activities on cold chain equipment and
vaccine management, including preventive
maintenance and repair, at the state level. The
center provides supportive supervision to states
to promote smooth functioning of cold chain
and vaccine management systems. The center
also undertakes cold chain and vaccine
management assessments and reviews jointly
with the Immunization division MOHFW,
UNICEF, WHO and other partners. It
functions as an extended wing of the
Immunization division (MoHFW) for cold
chain and vaccine management. The
NCCVMRC's needs enhancement in terms of
human resources recruitment, infrastructure
and equipment to be able to function effectively
(See Annex 3).
The NCCTC, which has been set up at SHTO
Pune, is the country's only cold chain training
center. The NCCTC will have its capacity
strengthened to perform the following:
function as a testing lab of equipment
performance,
l
experiment with innovative technologies,
l
support the MoHFW for procurement by
producing evidence on the specifications of
equipment and their performance,
l
develop appropriate spare parts for all types
of cold chain equipment enabling local
repair,
l
develop a training module of Cold Chain
Equipment (CCE) repair and maintenance,
l
provide maintenance support to GMSDs.
l
The center will be run as an independent body
................................
24
with its own governance and management

structure reporting to the Director, NIHFW.
areas, keeping in mind factors such as distance

from and time to travel to session sites.
3. Conduct a nationwide rollout of cold

chain MIS
The National Cold Chain Management
Information System (NCCMIS), which is a
web-based system for tracking cold chain
equipment in real-time, shall be expanded to
cover all states. The system will be hosted on
NIHFW servers with helpline support
provided by NCCVMRC. Key objectives of the
NCCMIS are to provide guidance on:
cold chain infrastructure up to the lowest
level with performance indicators;
stock positions of cold chain equipment

spare parts at GMSDs and at the state level,
and specification for local procurement;
troubleshooting of cold chain equipment;
cold chain and vaccine management

practices as per national norms;
available trained HR in cold chain and

upcoming training programs; and
cold chain space requirements for

introduction of new vaccines.
4. Increase the number of cold chain

points closer to vaccination sites in
selected states and take up repairs and
maintenance work of the existing
equipment
Currently, there are over 27,000 cold chain
points across the country. All states need to
plan and ensure that one cold chain point caters
to a population of 30,000 in rural areas, up to
50,000 population in urban areas, and 1520,000 population in tribal and hard to reach
Table 4: Cold Chain equipment in the four GMSDs
WIC
WIF
Future needs (within plan period)
Kolkata
Need 2 more WIC and 2 more WIF
Chennai
GMSD
Karnal*
Mumbai
Need 8 WIC and 4 WIF

2
* Needs 100 percent replacement of cold chain equipment
25
In addition to the GMSDs, each of the 39 State

Vaccine Stores need to have 50 percent of their
existing cold chain equipment replaced within
the plan period. Each of these stores should
have at least four WICs and two WIFs of 40
cub mt. which shall be put in place within the
plan period.
Each of the 139 Divisional Vaccine Stores need
to have one WIC of 40 cub mt and one WIF of
20 cub mt, which shall be put in place within
the plan period.
Before the end of the plan period, each District
Vaccine Store should have the following:
one WIC and six DF in districts with a
population of more than 2 million ,
eight large ILR and four large DF in districts

with a population below 2 million.
Supplies of all non-electrical equipment

(vaccine carrier, ice boxes) and accessories15
shall be updated as per the needs of every cold
chain point.
6.Enhance management capacity and
numbers of cold chain and vaccine
logistics staff at all levels with the
district being responsible for stock
distribution planning, management and
repair.
India is a vast country and putting a robust cold
chain system in place requires a larger number
of staff at all levels. As recommended in the
Mavalankar report there shall be a position
created for a focal point on cold chain at the
national level. Each state should also make
provision for a cold chain officer along with an
assistant at that level. In addition, each district
should have one Vaccine Logistics Manager
and one Cold Chain Handler. The majority of
issues and barriers related to cold chain and
vaccine logistics pertain to program
management rather than technical faults. All
staff associated with cold chain and vaccine
logistics will be provided training on various
aspects of program management.
7. Promote mentoring and supportive

supervision to ensure that vaccines are
stored within the correct temperature
range
Various models of supportive supervision exist
-using line supervisors, externally hired
monitors or medical college faculty to provide
mentoring and supportive supervision. A
mixed approach will be applied based on state
requirements to ensure that RI sessions use
quality vaccines that have been stored at
appropriate temperatures throughout the cold
chain. Effective cold chain and vaccine
management consultants will be used to review
these improvement plans and vaccine store selfassessments using standard formats and local
improvement plans from facilities visited
8. Scale up a system for SMS-enabled
real-time temperature monitoring for
cold chain as part of electronic Vaccine
Intelligence Network (eVIN)
Real-time monitoring of cold chain equipment
along with prompt alerts and corrective action
are critical for the immunization program as all
vaccines under the program are temperaturesensitive and cannot be used once damaged. As
most cold chain points in the country are
located in remote village settings with limited
facilities, a special SMS-enabled temperature
monitoring system has been developed and is
being currently piloted. The technology will be
further refined to prepare for its expansion to all
cold chain points in the country. As part of the
eVIN strategy, the possibility of unifying
vaccine logistics management, temperature
monitoring and cold chain equipment
inventory management into one system will
also be explored.
9.Enhance capacity of cold chain
handlers and mechanics across the
country
The training for vaccine and cold chain
handlers shall be based on standard technical
guidelines developed by the government.16 In
addition to induction training, the cold chain
mechanics and technicians will also be
15
Accessories include voltage stabilizer with every ILR and DF and toolkits for cold chain technicians
Handbook for Vaccine and Cold Chain Handlers 2010.Ministry of Health and Family Welfare,
Government of India and UNICEF.
16
................................
provided training on cold chain equipment

WIC, WIF, DF, ILR, cold chain accessories,
solar and hybrid equipment. Refresher
trainings will be held every three years to
sustain capacity and ensure quality.
Expected Result 1.2: Strengthen vaccine and
syringe logistics management across the
country including forecasting and
procurement at central level
A significant challenge in improving RI
coverage is lack of visibility at every levels in
the chain. Managers do not have real-time
vaccine stocks status at all levels, consumption
patterns, wastage rates and so on. Without such
information, it is difficult to hold system
functionaries responsible for lack of
performance, or to generate prompt responses
to breakdowns/bottlenecks in the vaccine
supply chain. Data from the states where
VMAT, EVMs and deep dives were conducted
by UNICEF and ITSU indicate that the
distribution of vaccines is uneven with some
cold chain points holding excess stock levels,
while others have stock-outs within the same
district or division. Even when there are few
stock-outs reported, there is evidence that store
managers are slowing down vaccine
distribution to cold chain points below them, or
to session sites as a means of preventing stockouts. This can lead to insufficient vaccines
reaching immunization sessions, thus directly
affecting the immunization coverage.
Strategies
1. Develop a vaccine and syringe
logistics management system in the
country with real-time stock visibility.
Under the Universal Immunization Program,
vaccines and syringes are centrally procured
and supplied to States and Union Territories
(UTs). The details of vaccines/syringe receipt,
issue, wastage and consumption are
documented in a variety of registers across the
country. Some states have also started
computerized documentation of stock levels,
but only down to the district level. No
nationwide vaccine logistics management and
monitoring system currently exists that
provides real-time visibility of the stock data,
26
consumption patterns, wastage rates etc. In

absence of such a system, a variety of ad hoc
principles and processes are applied in
distributing vaccines. With the potential
introduction of more costly vaccines under the
UIP, a robust vaccine logistics management
system is a dire need.
A vaccine logistics management model is being
developed that can cater to requirements at all
levels i.e. from GMSD to the last vaccine
storage point (last cold chain point). The
product will be field tested and updated to be
made ready for country-wide rollout. When
fully implemented, the system will also provide
better estimates for further procurement and
will outline the effects on the logistics system of
delays in procurement and erratic vaccine
supply patterns. Based on data analysis and the
vaccine supply schedule being followed, new
guidelines for defining minimum and
maximum stocks at different levels will also be
developed.
2. Strengthen HR capacity at all levels
for vaccine management, including
effective vaccine store management and
forecasting
An effective vaccine logistic management
system must be supplemented by an operations
team that keeps the network operational as well
ensures prompt response based on data. The
government will introduce a position for VLM
at national, state and district levels at least in
the 12 high-priority states. The district-level
VLM will also oversee the functionality of cold
chain equipment in the district and will ensure
swift repair or replacement of cold chain
equipment with support from the district
refrigerator mechanic. These staff will be
provided training on vaccine logistics and cold
chain management.
3. Pilot new technology for improving
vaccine logistics and cold chain
management with an overall objective to
develop an electronic Vaccine
Intelligence Network (eVIN)
There is substantial technology upgradation
going on rapidly across the world in the field of
vaccine logistics and cold chain management.
27
These interventions can be useful in ensuring

the availability of safe and potent vaccines upto
the last cold chain point. Such technological
inter ventions will be field-tested for
performance and will be considered for
implementation with the ultimate aim of
developing an electronic Vaccine Intelligence
Network (eVIN).
Computer optimization models, such as
HERMES, will be used for exploring means to
maximize vaccine and syringe logistics
efficiency.
4. Implement Effective Vaccine
Management (EVM) improvement plans
EVMs assessments were conducted in ten
priority states in 2013. These states include
Jammu & Kashmir, Haryana, Rajasthan, UP,
Bihar, Chattisgarh, MP, Karnataka, Kerala and
Tripura.17 The key recommendations from the
EVM assessments will be implemented
through the PIPs of the respective states. These
recommendations are included in Annex 4. A
trained pool of effective cold chain and vaccine
management consultants will review the
progress of PIPs in states that have completed
an EVM assessment and prepared
improvement plans.
Expected Result 1.3: Ensure safer injection
practices and reduced vaccine wastage
Strategies
1. Review existing mechanisms and
policies on waste management
The disposal of syringes and other waste
associated with immunization sessions shall be
based on the Biomedical Waste Management
and Handling Rules, 1998, and Central
Pollution Control Board (CPCB) Guidelines
for hospital and immunization waste disposal.
Under the NRHM, an Infection Management
and Environment Plan (IMEP) policy
framework has been formed to guide waste
disposal processes. These guidelines will be
widely disseminated and shared during review
meetings. All health facilities will have 'waste
management guidelines' prominently
displayed at the site of waste generation.

2. Strengthen the implementation of
Open Vial Policy (OVP) and Bundling
Policy to reduce waste at session sites
India had adopted the Multi-Dose Vial Policy
(MDVP) for OPV during SIA campaigns. In
2011, the Multi-Dose Vial Policy was adopted
for the birth dose of the Hepatitis B vaccine,
and the zero dose of the Oral Polio vaccine in
the UIP. Later, in the year 2011, the Multi-Dose
Vial policy was adopted and implemented as
part of RI for the Pentavalent vaccine in two
states. The current open vial policy (OVP)
applies to multi-dose vials of DPT, TT,
Hepatitis B, Oral Polio and Liquid Pentavalent
vaccines (where applicable). This policy does
not apply to Measles, BCG, and Japanese
Encephalitis (JE) vaccines (See Annex 5).
Relevant immunization trainings shall have a
component on the OVP to facilitate the
appropriate use and return of vials and reduce
wastage. The policy of bundling shall be
adopted for all vaccines, AD syringes,
reconstitution syringes, diluents, disposal bags,
and hub cutters to reduce wastage and improve
logistics efficiency, wherever applicable. The
required amount of vaccines for a session will
be packed along with the needed logistics, so as
to ensure that safe injection practices are
adopted.
3. Scale up training on injection safety
and waste disposal guidelines for all
categories of staff
A vaccine wastage assessment carried out by
UNICEF in 2010 revealed high wastage rates
ranging from 61 percent (for BCG) to 27
percent (for DPT).18 The main causes of
wastage include vaccine expiry, discarding
unused doses, poor reconstitution practices,
exposure to heat, frozen vaccines, missing
inventory and theft.
To reduce vaccine wastage, all categories of
staff shall be trained on this aspect of the
program as part of their regular training
regimen and given job aids on injection safety
and safe waste disposal.
17
National Effective Vaccine Management Plan 2013: Summary Report. UNICEF and MoHFW.
Vaccine Wastage Assessment: Field assessment and observations from national stores and five selected states of India.
UNICEF, April 2010.
18
................................
28
4. Expand the availability and use of hub

cutters in all districts and explore other
technological advancements to ensure
safe and appropriate bio-waste handling
To ensure safer injection practices, health
workers will be trained on the use of hub cutters
as part of their on-going trainings. In addition,
technological developments in injection safety
and bio-waste management will be explored
and field tested. Based on performance
evaluations, cost considerations, feasibility of
use at the field level etc., the inclusion of these
technologies in the Immunization program
will be considered.
Expected Result 1.4: Ensure that regular
immunization sessions are planned and held
and coverage increased
Strategies
1. Conduct risk analysis at state and
district level
The country has identified high-priority
districts for interventions under RMNCHA+A
where immunization coverage has been
considered a one of the key elements. States
have also identified high-priority district under
Emergency Preparedness and Response Plan
(EPRP) to prevent wild polio vir us
importation. Further risk analysis will be done
to identify high risk blocks and urban dwellings
with low coverage.
2. Provide training to and follow up with
relevant staff on preparing and
implementing RI micro-plans
Continuous training and skill building of
health staff involved in routine immunization
program is required to achieve and sustain
quality and coverage of immunization.
Training modules for frontline health workers,
medical officers and cold chain and vaccine
supply staff have been prepared and states are
using them regularly to train the staff. Ministry
updates these modules on regular interval and
provides to states. These modules include all
relevant components for preparation of plan
for RI and its implementation and monitoring.
However, the Government of India has
identified issues in implementation of training

that varies from state to state resulting in gaps in
performance. The Government of India will
encourage all states to develop a time-bound
schedule for training for all staffs and refresher
trainings at regular intervals. These cycles will
be aligned with annual PIP.
Guidelines for micro-planning and service
delivery have been developed and included in
the immunization handbooks for medical
officers and health workers. Health workers
and other relevant UIP staff will be trained on
preparation of micro-plans that ensure
inclusion of areas with underser ved
population, hard-to-reach areas and others.
The efforts will be made to reach the unreached population at least four times a year.
The support of the development partners will
be sought for the micro-planning efforts. The
districts should ensure that micro-plans are
available and being used to provide
immunization services in the area.
3. Promote fixed-day, fixed time and
fixed site strategy
MoHFW has recommended fixed-day, fixedtime and fixed-site strategy for outreach
sessions for delivering immunization services
to ensure that communities are aware of the
immunization day that is now being
implemented by all states. Under this strategy,
the Government of India has recommended
that immunization sites be fixed for each
habitation, preferably at sub-centers; in villages
at anganwadi centers, school and panchayat
chaupal, etc. The day of the week and time of
session in a particular location are also fixed.
The immunization session can also be
combined with Village Health and Nutrition
Days (VHNDs) under NRHM to help
maximize the opportunity for community
mobilization and service delivery.
The Government of India is planning to
strengthen health service delivery in urban
areas now. This will be further strengthened
with special focus to reach poor and
underserved populations living especially in
slums, streets and peri-urban areas.
29
4. Fill up gaps in RI coverage through

strengthening alternative vaccine
delivery to provide needs-based
immunization services in difficult to
reach areas
To ensure improved vaccine and logistics
supply and help ANM to spend more time at
outreach session site and focus on improving
i m mu n i z a t i o n s e r v i c e d e l ive r y, t h e
Government of India has provided funds for
implementing alternate vaccine delivery
(AVD) system. These efforts will be further
strengthened. Under the plan for
intensification of RI, the Government of India
has planned to provide vaccine delivery vans to
high-priority districts and blocks to strengthen
vaccine supply. In this regard, the Government
of India has already provided 120 vehicles in
six districts of five states Madhya Pradesh,
UP, Haryana, Jammu & Kashmir and
Rajasthan to implement a pilot before
expansion. These vehicles have been branded
Teeka Express. These vehicles will be used
not only for vaccine delivery but carrying other
logistics for immunization sessions, promoting
IEC for RI, running mobile health clinic etc.
depending on the need of the district.
5. Reduce left-outs and missed
opportunities, drop-outs and ensure
booster doses
The Government of India aims to identify all
areas/populations/opportunities to reduce
left-outs and to improve booster coverage
beyond primary immunization schedule. This
is also important in view of new antigens being
introduced in UIP. To improve the access with
the aim of reducing left-outs the Government
of India has developed guidelines to include all
high risk populations/areas, identified through
polio eradication program, in the routine
immunization micro-plans. The Government
of India has also recommended to use polio
micro-plan to identify all small areas/hamlets
under each sub-center area to be reflected in
micro-plan to improve reach and monitoring. It
will be further strengthened by identifying all
opportunities and places like OPDs and
schools to enquire and vaccinate children..
a) Health facilities: Every contact of health

care system with children of vaccination age
will be used to enquire about the child's
vaccination status. Vaccines will be
administered where applicable, provided the
minimum interval between doses is respected.
Possible reasons for non-vaccination shall be
identified and addressed.
b) Schools: School health programs will be
strengthened. The LHVs will visit every school
with ANMs at least once a year with vaccines
to assess the immunization status of children
and ensure vaccination with DPT of children
aged 56 years, and TT vaccination for children
aged 10 and 16 years.
Once a beneficiary is registered, all the efforts
will be made to ensure full utilization of
immunization services for completion of
immunization scheduled. Special efforts will
be made in the areas where immunization
coverage is low and dropout rates are high.
a) Strengthen use of Due List by frontline
health workers for tracking beneficiaries and
improve communication with parents to
reduce drop-outs:
Ensure that states and UTs make available the
standardized Due List to all the FHWs with
appropriate guidelines and trainings for its
effective use.
b) Strengthen Mother and Child Tracking
System (MCTS): The Government of India has
launched Mother and Child Tracking System
to improve registration of pregnant women and
infants and utilization of Ante-Natal Care
(ANC) and immunization services. This is
being implemented as a mission mode project
and all states have implemented this. The
implementation and utilization of MCTS will
be further strengthened to achieve the
objectives.
States will utilize the NRHM framework to
innovate to increase immunization coverage.
The best practices and successful examples will
be disseminated widely for cross learning and
adoption by the states.
................................
30
6. Strengthen the RI supervision and

monitoring system
MOHFW will focus on improving program
supervision and monitoring for RI at all levels
using data generated in the program and
through field monitoring. RI partnership in the
country is actively participating in monitoring
of implementation at field level and assisted
states in involving their program managers and
staff in the monitoring. Haryana has developed
a monitoring system by involving independent
monitors using NRHM funds. Other states will
also be encouraged to prepare plans for
monitoring and propose in PIPs.
7. Involve private facilities in delivering
RI services
The involvement should be underpinned by
accountability and quality standards that are
regulated by the state nodal medical authority.
Public and private practitioners providing
vaccination will be provided free of charge
vaccine and immunization cards etc. All
private practitioners, offering vaccination
services, will be expected to maintain
appropriate institutional records, retrievable on
demand. They will also be expected to report
coverage, VPDs, AEFI, and wastage on a
monthly basis. Private sector accountability
and quality issues will be coordinated by the
nodal medical authority providing the vaccines
as per the Government of India guidelines.19
Necessary efforts will be made to implement
the guidelines for involvement of private
practitioners in immunization program.
8. Plan and conduct immunization weeks
at regular intervals to improve coverage
level in missed out and hard-to-reach
areas, followed by integration of these
areas under the district RI micro-plans.
Expected Result 1.5: Improve program
coordination at all levels
Strategies
1. Conduct bi-annual national level
meetings of state EPI officers
National-level half yearly meetings of all state
EPI officers will be conducted regularly. State
19
immunization officials will be requested to

conduct regular and quality quarterly review
meetings with district immunization officers to
strengthen the program at ground level.
The Government of India has issued directives
to all states for setting up state and district-level
task force on immunization for improved
program coordination and monitoring. States
will ensure that these task force meetings are
held every month and necessary feedback is
shared with national immunization division.
2. Improve coordination with
development partners through regular
meetings and information sharing
The ministry recognizes various efforts being
done and the support provided by development
par tners in routine immunization
strengthening both at national and subnational level. Efforts will be made to ensure
better coordination between government and
development partners through regular
coordination meetings, partner's forum and
other relevant platforms.
3. Promote immunization and related
interventions through Immunization
Action Group (IAG) including academia,
CSOs, political representatives
IAG, which has been setup by MoHFW, will
advise and provide technical inputs to the
national immunization division on ways to
improve routine immunization coverage and
issues around newer and underutilized
vaccines.
KEY OBJECTIVE 2: Increase demand

and reduce barriers for people to
access immunization services
through improved social
mobilization.
1. % of caregivers whose child received partial
or no immunization who did not feel the need
for adhering to the schedule of immunization
2. % of caregivers not recalling any of routine
vaccine
The indicators will be disaggregated by gender,
Guidelines for involvement of private practitioners in the universal immunization program (UIP). Government of India,
Ministry of Health and Family Welfare, Immunization Division, 31 August 2009.
31

Expected Result 2.1:Develop and implement a
multi-pronged national communication
strategy with a focus on priority states
Strategies
1. Develop state-specific
Communication Implementation plans,
advocacy and social mobilization plans
A national strategic communication plan for
RI will be prepared. States and districts will
also be encouraged to prepare an integrated
communication work plan. This plan will have
focus upon components and strategies for
addressing the issues related to left-outs and
drop-outs, and to increase community
participation in immunization.
The IRI communication guidelines have been
developed by the Government of India to
provide a roadmap to the immunization
program managers and IEC functionaries at
state, district and block level. These guidelines
can be used as a reference while formulation
state-specific communication plans.20
2. Strengthen national and state capacity
on behavior change communication
National and state-level workshops will be
conducted for immunization program
managers and other staff working on
communication. The trainings will focus on
strengthening their communication and
planning skills to better operationalize and
implement IEC interventions. MOFFW will
also conduct regular national and state-level
meetings to monitor the progress, identify gaps
and suggest possible solutions on
communication strategies. In addition,
effective communication activities and best
practices will be documented and shared with
all the stakeholders to be used for inter-state
learning.
RI services. The CSO engagement strategy will

focus on engaging civil society in policy and
advocacy processes. The Government of India
will engage the private sector to work in
immunization program as part of their CSR
utilizing their strengths in communication.
4. Ensure adequate funds are available
for communication interventions
NRHM has provided necessary flexibility to
use funds for activities related to immunization
program. The available funds with districts will
be utilized for health communication. The
untied funds with AWW/ASHA, VHSC and
A N M m ay a l s o b e u s e d f o r t h e s e
communication efforts, if funding from other
sources is not available. States will be
encouraged to prepare a detailed IEC plan for
immunization and funds will allocated to this
activity from NRHM PIP part A
Expected Result 2.2:Effective communication
channels are set up with the community for
better acceptance of vaccines
Strategies
1. Use frontline health workers and
community platforms like Village Health
and Nutrition Day to promote RI through
inter-personal communication (IPC)with
families
Utilize the widespread network of over
860,000 ASHA workers to conduct social
mobilization for improving immunization
coverage. Interpersonal communication (IPC)
with individuals and families will be strongly
promoted through the frontline health workers
ASHA, ANM, Anganwadi workers and
other key leaders in the communities.
3. Engage with partners to ensure a

wider dissemination of immunization
messages.
The Government of India has developed a

training kit to improve IPC skills of frontline
health workers to improve awareness among
parents about need for immunization and
completion of recommended schedule and to
reduce fear of AEFI to reduce drop-outs. All
FHW will be trained on using this kit.
Enhanced partnerships with CSOs and NGOs

will promote greater awareness and access to
The community members, non-government

organization and interest g roups in
20
Intensification of Routine Immunization: Communication Operational and Technical Guideline. 2012.

Immunization Division, Ministry of Health and Family Welfare. Government of India.
................................
immunization like women's self-help groups

w i l l b e i nvo l ve d i n a dvo c a c y f o r
implementation and increasing demand for
services. Events like VHNDs will be utilized as
opportunities for community mobilization.
Wherever reports of mistrust towards
immunization by community members are
noticed, these should be studied and
appropriate corrective actions need to be taken.
2. Promote inter-sectoral synergies
between organizations, communities
and individuals on promoting
immunization
At the community level there is a greater scope
of better social mobilization and reaching local
community leaders through convergence of RI
with ICDS, women self-help groups and
panchayati raj institutions. The program will
also seek to involve local MLAs and MPs to
utilize their funds to ensure that each and every
child in their community is vaccinated. Local
institutions, community networks, and
religious groups will also be reached out in
coordinated way to reach specific groups of
people for dialogue with planned messages.
School children and adolescents will also be
engaged as change agents to dispel myths and
misconceptions related to immunization.
Expected Result 2.3: Evidence based and
contextually relevant communication
messages are disseminated in the community
Strategies
1. Identify issues and barriers for
immunization in hard-to-reach
populations and address them in the
communication plan
Targeted communication will be needed for
those who have never participated before, or
who are not participating consistently because
o f l a c k o f k n ow l e d ge, d o u b t s a n d
misconceptions, or frustration with the quality
of health services. The issues and barriers for
the immunization will be addressed in the
integrated communication work plan. The
focus will be on SC, ST population, migratory
32
population and difficult to access areas. The

reasons for low coverage and level of
knowledge about immunization program will
be regularly assessed. The findings from these
assessments will be a base for communication
and social mobilization plans.
2. Develop and disseminate widely, new
communication material on
immunization
Promote the RI branding with a new logo color
coding and tagline through various media.
New audiovisual communication messages for
TV and radio along with print material will be
developed. The government will also use social
media as a parallel communication channel to
increase visibility about RI with multiple target
audience. The program will strengthen delivery
of interpersonal communication using Polio
SMNet (from UNICEF), school teachers,
student networks, national-level youth
networks to support social mobilization.
Institutions like NSS and NCC will be
mobilized to reach out of school youth and
eligible children in hard-to-reach population
areas
Standard Operating Procedures (SOPs) will be
developed for production of new
c o m mu n i c a t i o n m a t e r i a l s a n d t h e i r
dissemination to the states.
3. Increase people's confidence in
vaccine safety through generation and
dissemination of supportive data
The Government of India will engage all
categories of media print or electronic
through regular workshops, meetings and
field visits to advocate for and create an
enabling environment that leads to an
increasing demand for immunization services.
With newer vaccines planned for introduction
in the coming years, all efforts will be made to
educate people and dispel any misinformation.
Communication strategies for newer vaccines
including campaigns will be developed in
consultation with all stakeholders.
33
4. Develop effective communication

response for AEFI crisis management
To dispel any public misapprehension around
adverse events following immunization the
G ove r n m e n t o f I n d i a w i l l d eve l o p
communication guidelines to handle situations
around AEFI.
KEY OBJECTIVE 3:Strengthen and

maintain a robust surveillance
system for vaccine-preventable
diseases (VPDs) and Adverse Events
Following Immunization (AEFI)
The burden of diseases preventable by the
vaccines is the most significant factor for
making a decision on introducing relevant
vaccines in the UIP. Therefore, a robust
surveillance system to detect cases and deaths
due to vaccine-preventable diseases is essential
to generate evidence to inform the decision on
introducing the vaccine as well as to measure its
impact on the disease after its introduction.
Besides that, the completeness and quality of
VPD surveillance data is also necessary to
observe the trends in disease incidence and
geographical spread to help plan to strengthen
the immunization program. Reporting of
VPDs has been an integral part of UIP
reporting system. Major challenges for UIP
include the following:
weak capacity of frontline health workers to
identify cases,
improve coordination among various

surveillance systems
include private sectors and other institutions

for improving VPD surveillance in the
country.
The goal of immunization is to protect

individual and the community from vaccinepreventable diseases (VPD). Although modern
vaccines are safe, no vaccine is entirely without
risk; adverse reactions will occasionally occur
following vaccination. Some people experience
adverse events after immunization ranging
from mild side-effects to rare life-threatening
illnesses. However, in most serious cases these
events are merely coincidences. In others
words, they are caused by the vaccine or by an
error in the administration or handling of the
vaccine. Sometimes there is no causal
relationship between the vaccine and the
adverse effects. Maintaining public trust in
vaccine safety, therefore, is key to the success of
all vaccination programs.21
Irrespective of the cause, when adverse events
following immunization (AEFI) occur, people
become confused to the extent that they refuse
further immunization of their children, making
the children susceptible to VPDs that are more
disabling and life-threatening. Surveillance of
AEFIs, i.e. systematic collection of data on
events following immunization,
lack of attention in the health system for

VPD reporting,
poor coordination between various

surveillance systems
poor reporting from private sectors and large

institutions.
This has adversely impacted informed decision

making on newer vaccine introduction and
vaccine impact assessment. Therefore, it is
necessary to
develop the capacity of health workers for
improved detection of VPDs,
have regular review of reports and data
provides valuable information to help plan and

take necessary actions in order to sustain public
confidence and ensure smooth functioning of
the program. The national AEFI surveillance
program supports the effective vaccine
pharmacovigilance function for ensuring use
of safe vaccines. Aggregate data for serious and
non-serious AEFI are currently collected
through routine monthly reporting in the
HMIS but, details of serious AEFIs are also
reported directly using the FIR, PIR and DIR
formats.
Along with the national health programs, such
as HIV and TB, that generate their own
respective data through surveillance, different
surveillance systems in India provide
information of various diseases, including
21
Immunization Safety Surveillance: Guidelines for Managers of Immunization Programs on Reporting

and Investigating Adverse Events Following Immunization. WHO Regional Office for Western Pacific. 1999.
................................
34
VPDs. These include:

Integrated Disease Surveillance Project
(IDSP): This is a nationwide system that
captures information on outbreaks of diseases
including VPDs, such as diphtheria, pertussis,
measles, AES, AFP, and Hepatitis B.
Central and State Bureaus of Health
Intelligence (CBHI and SBHI):This
nationwide system captures information on
suspected cases through passive surveillance
including that of VPDs that are under the
current UIP.
Health Information Management System
(HIMS): Within the NRHM framework,
HMIS is an electronic data reporting system
that captures data for health service delivery at
health facility level every month to assist health
departments, at all levels, in managing and
planning health programs. HMIS also captures
information on VPD disease burden from subblock level on a monthly basis.
WHO supported AFP and Measles outbreak
surveillance through NPSP network: AFP
surveillance is a laboratory-based system for
poliovirus detection in all states. The lab-based
measles surveillance covers 15 states
generating data on measles and rubella
outbreaks. The laboratory assisted joint AFPmeasles surveillance system is planned to cover
all states and UTs by the end of 2014.
Acute Encephalitis Syndrome (AES/JE)
surveillance: This is a facility-based
surveillance system providing information on
AES as per the guidelines under the National
Vector-Borne Disease Control Program with
lab support provided by ICMR.
years admitted with acute gastroenteritis and

given rehydration for at least six hours are
enrolled. Sites for sample collection for
Rotavirus surveillance are in following cities:
Delhi, Mumbai, Pune, Vellore, Jabalpur,
Imphal, and Kolkata.
1. % of sentinel sites providing timely and
complete reports on VPDs (including zero
report) on 90% occasions
2. Increase in the number of notified serious
AEFI cases above the 2012 baseline value
Expected Result 3.1:Institutionalize and
strengthen surveillance mechanisms for VPDs
Strategies
1. Assessment of trends on VPD burden
in context of reported immunization
coverage
There is a need to use epidemiological methods
to better measure the impact of the
immunization program. This will involve an
initial landscaping of existing surveillance
systems in the country, efforts will be made for
collating, and analyzing data on VPDs
generated from different surveillance systems
and collate them to provide appropriate
feedback. The following will be analyzed:
data on the VPD disease burden,
emerging trends in the molecular

epidemiology of different VPD antigens,
Multicentre Pneumonia and Meningitis

Surveillance: Sentinel surveillance sites are
functional to identify etiologic diagnosis of
pneumonia and meningitis among children
below two years.
Rotavirus Surveillance Network in India:

The Indian Rotavirus strain surveillance
network is functional in seven regions, four
hospitals and four labs. Children below five
MoHFW will work towards developing a

system that facilitates convergence of relevant
data from various surveillance systems, such as
IDSP and NPSP, in the country.
seroprevalence of protective antibodies

against the VPDs,
geographical variations in VPDs.
35
2. Strengthen and improve coordination

between Health information system
(HMIS) and disease surveillance
systems such as IDSP and NPSP to
gather information on VPDs
IDSP-based surveillance system, along with
other systems, need to be strengthened from
district onwards to capture information on all
VPDs. The model of District/Municipal
Corporation-based surveillance unit for action
and reporting to the state would be further
strengthened. To better streamline information
sharing on VPD and AEFI occurrence across
the country, MoHFW will strengthen
coordination and data sharing between IDSP
and Immunization Division at national level to
monitor and improve program performance.
Similarly coordination at the state and district
levels will also be promoted to strengthen
DIO's role as focal person for all information
on VPD and AEFI.
3. Involve private sector in reporting of
VPDs to further strengthen surveillance
systems and inform policy making
In view of the number of patients using private
healthcare, lessons learnt from Kerala will be
used to link surveillance and monitoring
mechanisms with the private sector.
Community reporting of VPDs will also be
encouraged and specific strategies will be
reviewed. Mechanisms for coverage data
collection, compilation and flow from session
sites/sub-centers/private clinics to the district
and then to the State on uniform patterns will
be highlighted. VPD surveillance mechanisms
will attempt to integrate as much as possible
with other surveillance mechanisms, without
losing the required responsiveness for outbreak
response or diluting the focus on AFP
surveillance.
4. Strengthen laboratories(including
polio and measles lab network) and
epidemiology units at medical colleges
and other institutions for timely
reporting, case investigation and
detailed data analysis
For improved coordination and information
sharing Infectious Diseases Hospitals(IDH)
and super speciality hospitals should be

integrated into IDSP. There is a network of
IDH that needs to strengthen their laboratory
capacity to provide updated information on
outbreaks of existing or potential VPDs. India
has developed a Health Management
Information System (HMIS) for reporting of
all health-related data from field. This tool will
be used for updating VPD surveillance data in
India.
5. Strengthen sentinel surveillance for
newer antigens
Improve coordination, information sharing
with existing agencies and systems such as
IDSP, ICMR, CBHI and SBHI networks so as
to coordinate, collate and generate robust data
that will guide a more evidence-based policies
and prog ram inter ventions in the
immunization program future.
Expected Result 3.2: Institutionalize and
strengthen surveillance mechanisms for AEFIs
Strategies
1. Revitalize the institutional framework
and guidelines for AEFI surveillance in
the country
The national AEFI guidelines mandate that all
states and districts in the country constitute
AEFI committees at each level, to assist in
streamlining AEFI reporting mechanism,
investigating serious AEFI, and be involved in
causality assessment at state and national level.
An AEFI secretariat for the National AEFI
committee has been set up at ITSU-MoHFW,
New Delhi, to coordinate all AEFI related
activities in India with technical support and
oversight from a leading medical college
(LHMC). In addition Zonal AEFI consultants
are planned to be in place to provide technical
support and oversight to the AEFI Secretariat
in the four zones of the country and enable
timely reporting, investigation and support to
the states.
The National AEFI committee has been
reconstituted to support the program in
reviewing and updating information on tasks
and responsibilities of key stakeholders in the
AEFI system, including the Drug Controller
................................
36
General of India (DCGI), Indian

Pharmacopoeia Commission (IPC), National
UIP managers and state-level UIP managers.
2. Train field level staff on new National
AEFI Guidelines
National AEFI Operational Guidelines, which
were revised in 2010, are being revised and will
be published in 2014.22 These guidelines will be
distributed to all medical officers till Primary
Health Centers and will be used for training the
UIP staff including ASHA and ANMs.
Innovative AEFI reporting models shall be
piloted to enable enhanced AEFI reporting.
The revised guidelines will also be utilized for
trainings of AEFI committee members in the
country. An abridged Standard Operating
Procedure (SOP) for AEFI surveillance and
case investigation version been printed and
widely disseminated in 2011.23 There is well
known poor reporting of minor AEFIs in
India. The efforts will be made to train the field
staff in collecting data on minor AEFIs and
pass this information to the next level.
3. Convergence with vaccine
pharmacovigilance stakeholders and
private sector for AEFI reporting and
analysis
Since 2010, India has been participating in
WHO Global network of post-marketing
surveillance and the Government of India has
nominated Maharashtra state for uploading
AEFI data into the Uppsala Monitoring Centre
vaccine safety database. The national
immunization division has also started
coordination with the IPC, the coordinating
agency for the National Pharmacovigilance
Program of India to collate and monitor
vaccine safety reports in the country. The
National AEFI Program already shares all data
on vaccine safety with the national regulatory
authority to inform all vaccine safety
stakeholders.
4. Electronic database and reporting
system for AEFI
AEFI surveillance data require detailed
analysis on numerous parameters in the
context of the doses distributed and children
vaccinated in the UIP. Currently serious AEFIs
22
are reported manually on FIR/PIR and DIR

formats by districts but can be transmitted
electronically to the higher level (state and
national). The government will pilot an
electronic AEFI database and reporting system
that is E2P compliant for AEFI reporting by
2015 in a phased manner.
KEY OBJECTIVE 4: Introduce and

expand the use of new and
underutilized vaccines and
technology in UIP
As UIP evolves, newer antigens, such as
rotavirus, JE, rubella, Pneumococcal and
Pentavalent vaccines, are expected to be
introduced and expanded in the schedule. This
will require a strong epidemiological
underpinning for estimating disease burden in
the country through a robust surveillance
system to be put in place. There will be a need
for improving coordination among different
stakeholders and experts to develop an
evidence-based policy for introducing newer
antigens in the program in the medium term. In
addition to newer antigens, improved service
delivery will require innovations in technology
and approaches.
The choice of newer vaccines to be included in
the UIP will be determined and periodically
reviewed by the MoHFW, taking guidance
from the NTAGI. Basic clinical and
operational studies will be encouraged to
provide inputs for NTAGI. These studies will
provide evidence for decisions on the timing
and selection of new vaccine introduction and
provide guidelines for the use of these new
vaccines. Such analysis will include the major
mortality-causing diseases of children in India,
namely acute diarrheal diseases and acute
respiratory diseases, in anticipation of
rotavirus vaccine and pneumococcal vaccine
becoming available. Disease burden and health
economic analyses will help assess the costbenefit ratios of new vaccine introduction. Box
2 captures the key principles that will guide the
inclusion of newer vaccine in UIP as per the
national vaccine policy 2011. However,
introduction of new vaccines would be as per
decision of Mission Steering Group (MSG)
following NTAGI recommendations.
Adverse Event Following Immunization (AEFI): Surveillance and Response Operational Guidelines. MoHFW,
Government of India. 2010.
23
Standard Operating Procedures for reporting AEFI. MoHFW, Government of India. 2011.
37
Box 2: Principles to guide the inclusion of newer vaccines
Disease burden (incidence/prevalence, absolute number of morbidity/mortality,

epidemic/pandemic potential);
Safety and efficacy of the vaccine under consideration;
Affordability and financial sustainability of the vaccination program, even if the initial introduction is
supported by the external funding agency;
Program capacity to introduce a new antigen, including cold chain capacity;
Availability of a domestic or external vaccine production capacity;
Cost effectiveness of the vaccination program and also of the alternatives other than vaccination

1. Number of newer vaccines that have been
reviewed for introduction in UIP by NTAGI
2. Number of States that have introduced
Pentavalent vaccine
Expected Result 4.1: Set up and strengthen
institutional mechanisms, framework and
policies for newer and underutilized vaccine
introduction
Strategies
1. Institutionalize mechanisms to guide
the introduction of newer and
underutilized vaccines in the country
The introduction of new vaccines involves
reviewing all licensed vaccines in different
parts of the world and identifying those that
would be relevant to India in the context of the
burden of disease in the country and
prioritization of target vaccine-preventable
diseases in the country. There are several
vaccines that are popular in the private market,
and many of those are recommended by the
Indian Academy of Pediatrics. Accurate
information on which to base the decision of
introducing a new vaccine to the UIP requires

periodic review and assessment on an objective
scale by all agencies concerned through strong
coordination and collaboration.
In this regard, the immunization decisionmaking process has been institutionalized by
the establishment of an independent advisory
body, the National Technical Advisory Group
on Immunization (NTAGI) in 2001,
comprising of independent experts from
diverse fields such has immunology,
community medicine and health economics;
representatives from partner organizations like
WHO, UNICEF, ICMR and DCGI as well as
liaison officers from the government. The
NTAGI has been reconstituted twice in 2008
and again in June 2013. The current
reconstituted NTAGI comprise of a Standing
Technical Sub-Committee (STSC) tasked with
undertaking a detailed technical review of the
issues highlighted above and a broader body
with representations from all organizations
mentioned above. In addition, a secretariat for
this advisory body has been established by
ministry under Immunization Technical
Support Unit to facilitate technical and
managerial support required for continuity and
follow up to this body. However, the mandates
of both the NTAGI and STSC are still work-inprogress. The spelling out of well-defined
Standard Operating Procedures (SOPs) for the
functioning and decision making of the
................................
38
NTAGI is necessary to institutionalize the

evidence-based decision-making process for
the introduction of new and underutilized
vaccines in the country. It is also imperative to
adopt and standardize mechanisms to grade
the quality of evidence available, such as
burden of disease, published literature, global
data, cost effectiveness data, for the NTAGI to
review and make evidence-based
recommendations.
2. Identify newer vaccines that will be
introduced and/or expanded to use
during the plan period
There are several vaccines that are already
licensed and available or soon to be licensed
with expanded indications for particular
groups in India. Unfortunately, access to the
bulk of these vaccines is available only to the
privileged few who have access to private
health care. The NTAGI is the highest advisory
body tasked to review the available evidence
on disease burden, potential impact, safety,
efficacy etc. To assess these vaccines and
prioritize vaccines for inclusion in the program.
Vaccines that can be potentially considered for
review include the Injectable Polio
Vaccine(IPV), rotavirus and pneumococcal
vaccines
3. Assess disease burden for which
vaccine are becoming available or will
become available in the near future
The absence of reliable baseline estimates for
the burden of VPDs in India is a major obstacle
in informed policy-making process. Currently,
there are multiple systems to measure different
VPDs including antigen/disease specific
sentinel surveillance network (Indian
Rotavirus Sentinel Surveillance Network,
National Polio Surveillance Program (NPSP)
network and Infectious disease surveillance
eProgram (IDSP). With plans to expand the
range of vaccines in the UIP and improve its
reach (coverage), the surveillance of VPDs will
be intensified and steps will be taken to
establish stronger collaboration between the
already established networks and the
immunization program. At the national level,
the newly formed STSC of the NTAGI has

been tasked for undertaking critical review of
disease burden data prior to recommending the
introduction of a new vaccine in the UIP. The
NTAGI secretariat at ITSU will collaborate
closely with the disease surveillance centers in
the country to collate the evidence for the
review of the NTAGI and STSC.
4. Conduct operational research
Generate evidence for introducing new vaccine
including areas like vaccine safety, equity,
vaccine ethics and financial sustainability, IPV
as part of post-polio eradication.
Expected Result 4.2: Scale up and sustain the
implementation of JE vaccination in identified
endemic districts as part of Japanese
Encephalitis (JE) control
Strategies
1. Identify disease burden and endemic
districts for prioritization
In India there are 175 districts currently
identified as being endemic for JE. Most of the
cases occur in UP and Assam. Though any age
group can be affected by JE, children between 1
and 15 years of age bear the brunt of the
disease. A study carried out in South India
showed JE incidence to be 15/10,000 children
between 5 and 9 years. Mortality due to JE has
been estimated to be between 20 and 30
percent. Recent studies under the WHO
surveillance program in India undertaken in
selected centers (Bellary, Dibrugarh, Madurai
and Burdwan) show that about 10 to 20 percent
of the total Acute Encephalitis Syndrome
(AES) cases are JE.
JE, at present like other vaccines in India's UIP,
is restricted to children but there is an
increasing demand for use of JE vaccine to
protect the adult population in endemic
districts. The NTAGI will discuss the safety
and immunogenicity data of the vaccine for use
in the program. Since JE is a vector-borne
disease, immunizing adult populations will
prove critical in breaking the transmission cycle
and control of the disease.
39
2. Continue JE campaign in the endemic

districts
ICMR recommends that JE vaccination
program should continue for another five years
in endemic areas. It was suggested, that in view
of low evaluated coverage with JE vaccine, the
strategy in 2010 should be to re-immunization
all children up to 15 years with high vaccine
coverage in a campaign mode. Thereafter
coverage should be sustained by immunization
of children below than 2 years through Routine
Immunization.24
3. Expand training and advocacy on JE
vaccination
Coverage survey conducted for JE vaccine
suggests that overall community knowledge on
JE vaccines is low. While some people are not
convinced about the need for JE vaccination,
others do not know where to access the vaccine
from. Some pockets of communities have fear
of side effects or have formed a negative
opinion on the vaccine following some AEFIs
in their area.25, 26
Information about JE vaccination has been
incorporated in immunization handbooks for
Medical officers and health workers.
Operational guidelines for JE vaccination
program has been prepared and widely
disseminated to ensure correct reporting and
clarification on the role and responsibility of
each health care provider in JE vaccination.
Publicity around the JE vaccination will be
made more intense prior to the campaign dates
and respective states shall ensure that the IEC
material reaches the target users well in in time.
Adverse publicity around the vaccine will need
to be countered through appropriate messages.
4. Introduction of JE vaccine in routine
immunization program
The planned strategy was to complete SIAs for
JE vaccine and subsequent introduction of the
JE vaccine routine immunization program of
endemic districts to ensure adequate

vaccination coverage for new birth cohort. As
from April 2013, the Government of India has
already introduced a 2-dose schedule for JE
vaccines in the districts implementing JE
routine immunization. The 1st dose is given at
9 months of age and the 2nd dose at 16 24
months of age
5. Roll out indigenously produced JE
vaccine
In India, currently the SA-14-14-2 imported
from China is being used in the national
immunization program. Efforts will be made
to ensure that JE vaccine is produced
indigenously from local strains and introduced
in the program.
Expected Result 4.3: Streamline and expand
the use of Pentavalent vaccine to cover all the
states
Strategies
1. Nationwide scale up of Pentavalent
vaccine to introduce HiB vaccine in
other states of the country
As of 2012, the Haemophilus Influenzae b
(HiB) vaccine has been introduced in eight
states of India (Tamil Nadu, Kerala,
Karnataka, Puducherry, Goa, Gujarat, Jammu
and Kashmir and Haryana) in the form of the
combined Pentavalent vaccine (DPT+ Hep B+
HiB). On 23 September 2013 the NTAGI
endorsed the STSC's recommendation for
further scale-up of the vaccine in the remaining
states of India in a logistically structured
manner with simultaneous strengthening of
the AEFI and sentinel surveillance systems in
the country. Preparations for the expansion of
vaccination to the other states are planned. The
operational guidelines on HiB as part of
Pentavalent vaccine have been already been
developed and will be useful for immunization
program managers at state, district and subdistrict level.27
24
Minutes of the Meeting of ICMR Core Committee on Vaccines. 2010

Japanese Encephalitis Coverage Evaluation Survey Report, 2008. UNICEF and NRHM
A coverage evaluation survey of JE vaccination in two districts of Karnataka. Kumar KR et al. Journal of Communicable Diseases.Sep2010;42(3):179-84;
27
Operational Guidelines: Introduction of HaemophilusInfluenzae b (HiB) as Pentavalent Vaccine in Universal
Immunization Program (UIP) in India. MoHFW, Government of India. 2011.
25
26
................................
40
2. Conduct a revision of recording and

reporting formats for improved
surveillance and data management
Introduction of newer vaccines will
accompany the revision of recording and
reporting formats. Vaccination cards will also
be revised and updated to include newer
vaccines. The reporting system in the country
will also have necessary column to collect
information on newer vaccines.
3. Conduct training of FHWs and their
supervisors on newer vaccine
ANMs and their supervisors will be trained on
newer vaccines and other related aspects
including the vaccine administration and AEFI
reporting as part of regular training. The DIOs
and other Mid-level managers (MLM) will be
specially trained prior to the new vaccine
introduction in their respective states.
4. Strengthen surveillance system for
HiB and AEFI reporting
The surveillance system for newer vaccines will
be further strengthened and expanded in India.
Eleven sentinel sites for HiB meningitis in six
different states have already started in 2013.
These selected sites for bacterial meningitis
surveillance (including HiB) will monitor the
disease trends to measure impact trends of
vaccination on the study populations. The
surveillance sites for other newer vaccines are
also likely to be introduced to cover additional
states. Model AEFI systems are also being
planned to ensure timely reporting and
management of AEFIs before they snowball
into a crisis.
Expected Result 4.4: Evaluate Rubella antigen
for introduction in RI program
During the 66th SEARO regional committee
meeting in New Delhi in 2013, India has
committed to the elimination of measles and
control of rubella and CRS by 2020.
Strategies
1. Expansion of Congenital Rubella
Syndrome (CRS) surveillance
The public health importance of rubella
infection stems from the fact that rubella
infection in pregnancy has the potential to
cause Congenital Rubella Syndrome (CRS) in
the new born. The risk of development of CRS
is highest when infection is in the first trimester
of pregnancy. While there is no hard data on
CRS, the estimated incidence in India from
modelling studies gives a range of around 123
per 100,000 live births. CRS results in a
cumulative burden on the health system and
families of affected children on account of the
chronic sequelae (such as disability of sight,
hearing or cardiovascular systems) and the
economic burden in diagnosis, assessment and
treatment of congenital malformations and
challenges to providing education in an
increasingly nuclear family structure in society.
There are plans at national level to establish
and expand CRS surveillance through partner
agencies and existing surveillance programs.
The surveillance sites will be established in
selected states for observing the trends in CRS,
before and after vaccine introduction.
2. Introduction and expansion of rubella
vaccine in UIP
The strategy for introducing the rubella vaccine
in India's UIP will be planned to fulfil the
commitment the country has made to the
SEARO declaration for control of rubella
disease and CRS burden in the country. Since
immunization program performance differs
across states, expansion of rubella sentinel
surveillance sites is also planned. The strategy
for phase-wise implementation will be chalked
out over the cMYP period. The STSC of the
NTAGI shall play a crucial role in reviewing
and recommending a potential strategy for
implementation. The NTAGI has also
recommended the establishment of a Measles
41
& Rubella- India Expert Advisory Group (MRIEAG) on the same lines as polio to develop a
comprehensive strategy and monitor progress
for rubella control and measles elimination in
the country.
3. Conduct Rubella surveillance through
the existing systems
Existing measles surveillance system in India
frequently report rubella outbreaks or mixed
measles and rubella outbreaks. The existing
measles network will continue to be utilized for
identifying rubella outbreaks. It is envisaged
that with introduction of rubella vaccine, cases
of rubella will go down and, thereafter, a
possibility and need for case based surveillance
will be explored.
4. Conduct research on CRS and trends
Once CRS surveillance system is established,
the information collected from surveillance
network will be utilized for assessing the trends
in CRS in states and the country. Studies
should be carried out to estimate incidence of
CRS and the social and economic burden
resulting from it.
Expected Result 4.5: Evaluate Rotavirus
antigen for introduction in RI program
Strategies
1. Assess disease burden due to
rotavirus and the potential impact of a
preventive vaccine
Diarrheal diseases are one of the largest causes
of childhood (under-5 years) deaths in India
and rotavirus is the leading cause.28,29 WHO
estimates that 23 percent of the annual 527,000
deaths due to rotavirus occur in India. It is
estimated that even with a vaccine with 50
percent effectiveness, a rotavirus vaccination
program in India would prevent 44,000 deaths,
293,000 hospitalizations, and 328,000
outpatient visits annually which would avert
$20.6 million in medical treatment costs.30
2. Strengthen national level surveillance

on rotavirus
The Indian Rotavirus Surveillance Network
was set up on 2005 with four laboratories and
ten hospitals in seven different parts of the
country.31 The network provides valuable
information on epidemiology of rotavirus that
will underpin the policy decisions regarding
the introduction of rotavirus vaccine in RI.
3. Develop the vaccine schedule in line
with EPI schedule
NTAGI recommends that assuming several
vaccines will be licensed and recommended for
use in India, it would be preferable for each
child to complete all doses using the same
vaccine formulation. This could be facilitated
by choosing a specific vaccine for national use
or by ensuring that each region or state is
supplied with only one specific rotavirus
vaccine.32
KEY OBJECTIVE 5: Strengthen

health system for immunization
program
A strong RI program will contribute to the
overall health system strengthening both in the
urban and rural areas. Four states with large
populations - Uttar Pradesh, Bihar, Madhya
Pradesh and Rajasthan contribute
approximately to 2/3rd of the unimmunized
children in the country (CES 2009). In addition
there are other states that are not performing up
to the mark as shown in Annex 1. Future
strategies for RI will need to be adapted and
contextualized for these high-priority states to
increase the vaccination coverage levels and
reduce VPD mortality and morbidity.
Following polio eradication the technical
support structures established for polio
eradication, both at the national and subnational levels, by WHO, UNICEF and other
partners are now 'transitioning' to provide
support to intensification of routine
immunization from 2012 onwards, based on
the lessons learnt from polio. This feeds into the
28
Causes of neonatal and child mortality in India: A nationally representative mortality survey. The Million Death Study Collaborators.The Lancet.Vol 376, November 27, 2010
The Global Enteric Multicenter Study (GEMS) of diarrheal disease in infants and young children in developing countries: epidemiologic and clinical
methods of the case/control study.Kotloff K L, et al. Clinical Infectious Diseases. 2012 Dec;55 Suppl 4:S232-45
30
Projected Impact and Cost-Effectiveness of a Rotavirus Vaccination Program in India.Douglas H. Esposito et al.
Clinical Infectious Diseases.2011:52 (15 January)
31
Multicenter, Hospital-Based Surveillance of Rotavirus Disease and Strains among Indian Children Aged <5 Years.
Gagandeep Kang et al. Journal of Infectious Diseases.2009:200 (Supplement 1)
32
Minutes of NTAGI meeting. 3rd August 2009.
29
................................
42
overall goal of strengthening health systems in

the country.
1. Number of districts with full
immunization coverage rate of >80%
Expected Result 5.1: Increase the pool of
skilled human resources to provide quality
immunization services in an integrated manner
Lack of adequate numbers of trained and
skilled human resources has been a major
barrier in improving the overall quality and
outreach of UIP. The Immunization Division
at MoHFW is small with few technical officers
to manage such a large program. The
Government of India has addressed this
capacity gap by setting up an Immunization
Technical Support Unit (ITSU) in year 2012
with technical officers to support various
components of UIP. In addition to the national
level, the HR capacity on UIP in the states need
to expand. It is important to identify key
functions within the UIP at state level also that
would need full time positions to ensure a
smoother functioning, improve institutional
memory and enhance the overall coverage of
immunization in the state. Under NRHM PIP,
the Government of India has given the
flexibility to the states to propose human
resource augmentation plans at state and
district level.
Strategies
1. Increase the number of technical
managers for immunization at national
and state level and strengthen
organizational capacity to adequately
perform strategic and technical
functions under UIP
The strength and capacity of the national
immunization division has been enhanced
with the setting up of ITSU at MoHFW with

recruitment of technical officers for key
functions of UIP such as strategic planning and
system designs, monitoring and evaluation,
cold chain and vaccine logistics, strategic
communication, vaccine safety and AEFI, and
evidence to policy. This unit will help in the
development of policies, procedures and
guidelines to improve program management at
national level. This setup will be further
strengthened to augment the capacity for
operational research and use of more
technology in UIP. Similarly, a state-level
structure is also proposed that includes
recruiting focal points for the program
management, Cold Chain, Vaccine Logistics,
Management Information System (MIS), and
Technology and research etc.
2. Conduct relevant training and
induction programs and develop needbased immunization training materials
Relevant trainings will be carried out for new
staff working in the immunization cell at all
levels based on the existing training norms and
guidelines under NRHM. Immunizationspecific training norms will also be used, e.g.
cold chain training norms. The training
material for both medical officers and health
workers in routine immunization has been
updated, printed and widely disseminated.
This material is being utilized for conducting
need-based training.
3. Strengthen training infrastructure
National Institute of Health and Family
Welfare (NIHFW) is the national nodal agency
for training activities including Immunization.
T h e N I H F W, i n c o o r d i n a t i o n w i t h
Immunization and Training Divisions within
MoHFW, will review the training plans from
all states; conduct Training of Trainers courses,
as well as monitor and evaluate the quality of
trainings. The State Institute of Health and
Family Welfare (SIHFW) is nodal agency at
state level to plan, implement, monitor and
evaluate the immunization training activities.
43
A plan is being instituted to conduct induction

training for new State Immunization Officers
as per the need and refresher trainings on
regular interval.
Strategies
4. Hire and train more field level staff

under NRHM
1. Prepare a national financial

sustainability plan
There is need for strengthening the existing

training infrastructure and also starting new
facilities. The issues of shortage of health
workers and their training needs can be
addressed by institutionalizing training
mechanism for this category of staff. This can
be achieved by:
A core team for immunization financing

named Financial Management Group (FMG)
has been established within the MoHFW.
Using tools that are already available, this team
w i l l a n a ly z e c u r r e n t a n d p r o j e c t e d
immunization costs factoring in the plan for
scale up and introduction of newer vaccines in
the coming years. These will be compared to
projected finances available and funding gaps
will be highlighted.
On-the-job refresher training every two years

for every health functionary.
Each state will identify core district training

teams for each district. This team will move
to each block identifying gaps in knowledge
and train appropriately,
Monthly block meetings will provide an

opportunity for supervisors to help identify
gaps in knowledge and provide some
training.
NRHM provides for hiring staff on contract

basis. All staff members (medical officers, staff
nurses, health workers including ANMs) hired
on contract basis will also be trained. ANM
and ASHA vacancies will be filled up by the
states on urgent basis.
5. Promote integrated delivery of
different health interventions through
UIP
A stronger immunization program will also be
used as a platform to deliver other child health
services in an integrated manner. Preventive
child health interventions like Vitamin A,
deworming, ORS, growth monitoring can also
be given along with immunization. A wellfunctioning RI program will act as a catalyst in
getting more people to use the health facility
and contribute to overall demand generation
and better address equity issues.
Expected Result 5.2: Ensure that adequate

financial resources are available for UIP.
2. Provide funding for laboratory

strengthening and surveillance
The country will be expanding the VPD and
AEFI surveillance, which will require a wellfunctioning laboratory network. A mechanism
for the separate budgeting mechanism will be
devised for the strengthening of the laboratory
and surveillance mechanism in the country
3. Explore the possibility of setting up a
Vaccine Fund through innovative
financing mechanisms
Expected Result 5.3: Improve program
accountability, monitoring and reporting at all
levels.
Strategies
1. Hold regular program reviews at all
levels
Quarterly review meetings will be held at
national and state level; and monthly meetings
at district and block levels to track the progress
in immunization program, to identify
problems, analyze the issues and address them.
State-level meetings will be chaired by State
Secretary/MD-NRHM and district-level
meetings will be chaired by the DM.
................................
44
Comprehensive EPI reviews will be held in the

good and poor performing states to help
prepare state specific action plan.
2. Develop national monitoring and
evaluation plan for immunization
MoHFW will develop a monitoring and
accountability tracking framework for UIP that
will identify key program indicators and assign
responsibility of delivering results on specific
individual or organizations
3. Formalize and make accountability
mechanisms system-led as part of
community participation
At the service-delivery level, more formal,
institutionalized systems for complaint and
redressal should be put in place. They must be
supported by timely emergency response
systems, such as telephone helplines, and
proper managerial authority should be granted
so that structures are in place to rectify acute
challenges related to referral and
transpor tation or the mistreatment/
exploitation of patients at the facilities. A
formal system to lodge complaints and seek
redress should also provide oversight to help
protect women who register complaints, from
f u t u r e r e p r i s a l s. T h e d e m o n s t r a t e d
initiatives/innovation for accountability, for
instance call center for integrated grievance
handling system, can be considered.
4. Expand the usage of Mother and Child
Tracking System (MCTS) to all districts
to help reduce the gap between reported
and evaluated coverage
The Mother and Child Tracking System
(MCTS) is designed to collate information of
all pregnant women and infants into a central
database to ensure that all pregnant women
and children receive full maternal and
immunization services. This centralized
database will enable functions like data
analysis, report generation, and therefore
contribute to greater strategic decision-making
and need-based allocation of resources. It will
act as a feedback system for health workers like
Auxiliary Nurse Midwives and ASHAs and

will enable better health service delivery by
drawing out action plans for health workers for
ante-natal care, pre-natal care and child
immunization. MCTS will also generate
reports such as facility service statistics and
Auxiliary Nurse Midwife monthly action
plans. Currently the states aggregate the
relevant data in a Microsoft Excel template
available on the HMIS portal. MCTS has been
fully operational since April 2010 and has
picked up speed in terms of usage by states and
union territories as of 1 April 2011. Under this
system, SMS alerts are sent to pregnant women
who are nearing the delivery date to remind
them of the need to visit the PHC for pre-natal
check-up and delivery. Women are also
reminded over the cell phone on the due dates
for immunization of their children to ensure
follow through with RI. Bring out annual
reports on UIP as part of a strengthened HMIS
at state and district level.
5. Introduce the Quality Assurance (QA)
system for immunization services as
part of RMCH+A
The scope of the Quality Assurance (QA)
system is now enhanced to include the full
range of RMNCH+A services. For rolling out
QA system, organizational arrangements will
be set up at various levels with clearly defined
roles and responsibilities for each level. These
will include
(1)
Central Quality Supervisory Committee;
(2)
(2a) State Quality Assurance Committees,

(2b) Quality Assurance Cell and
(2c) Full time quality assessors;
(3)
District Quality Assurance Committees;

and
(4)
Quality Circles at the District Hospital

level.
The central QA team will comprise technical

officers from the program divisions of the
Ministry of Health and Family Welfare and
45
counterparts working with technical support

partners. The QA standards will be defined for
each technical theme, categorized by the level
of health facilities.
planning units, and would visit each unit twice

a month (total four visits in a month). S/he will
provide regular supportive supervision services
to the unit as well as the vaccinators in the area.
Expected Result 5.4: Strengthen RI program

management and service delivery through field
level supportive supervision in high priority
states
Skill building of ANMs is required for ensuring

supportive supervision of ASHAs (and
AWWs). While ANMs do perform supervisory
functions informally, their skills in supportive
supervision are limited and need to be
enhanced on this specific issue.
To achieve immediate and sustainable

improvement in RI coverage at national level,
the Government of India needs to focus on
high priority states, Rajasthan, Madhya
Pradesh, Uttar Pradesh and Bihar, which have
the maximum number of unimmunized and
p a r t i a l ly i m mu n i z e d c h i l d r e n . T h e
RMNCH+A strategic approach recognizes the
need to strengthen supportive supervision of
frontline workers (ASHAs and ANMs) and
service providers (Staff Nurses and Medical
Officers) in order to bring about integration of
primary care services, improve quality,
enhance skills and skill application.
2. Leverage expertise and experience of

development partners and medical
colleges
The supportive supervision by Institute of
Child Health in Tamil Nadu has led to
significant improvement in quality of
maternal-newborn care in eight districts. A
similar engagement of Medical College faculty
in other districts and states would be a useful
strategy. The technical expertise available with
the partners will be utilized to impart
knowledge to the state and district level staff.
Strategies
1. Augment HR for supportive
supervision and program management
To support the implementation and monitor
the activities at the district level, there will be a
State Level Supportive Supervision Team
consisting of officers from the state health
department, partners and students and Staff of
Medical Colleges (Department of Community
Medicine). Each state officers or medical
college team will support and monitor 4 to 5
districts for implementation through regular
visits, and help establish a link between districts
and the state. It will establish State and district
RI supportive supervision team. The mobility
support will come from NRHM.
At the district level the supportive supervision
team will consist of selected medical officers,
senior supervisors, medical college staff to
support PHC/planning unit. Each member of
supportive supervision team including medical
college staff will be responsible for two PHC or
3. Establish an institutional mechanism

for program oversight and monitoring
the implementation of supportive
supervision model
State-level mechanisms will be strengthened to
monitor the program, and guide the districts to
improve, implement and monitor the program.
a) Quarterly review meeting will be held at the
state for all DIOs and District RI managers
b) Monthly meetings will be held between State
and District Task Force meeting
c) Monthly review meetings will be held at the
district for all block and PHC medical
officers in charge and RI coordinators
d) All supportive supervision checklists will be
collected at the district level, and entered
into software. This data will be sent to the
state for compilation and subsequently the
state will send the data sheets to the national
................................
46
immunization division.
Strategies:
e) Data will be presented and feedback

provided at all the levels (state, division,
district and block level) for appropriate
action.
1. Define areas for Operational Research

and mechanisms for translating
evidence-based approaches into
program service delivery
4. Carry out capacity building and on-job

training of staff for strengthening RI
supervision all level
Areas for OR could include, but not be limited

to, HR training in immunization, operational
aspects of cold chain system, vaccine freezing,
vaccine wastage, injection safety, barriers to
service access and utilization.
State RI cell/RRT members will be trained

through Training of Trainer (ToT) by a
national team once in a year. District RI team
will be trained once a year by the state core
team. District RI team shall be responsible for
training, providing supportive supervision and
implementation of RI activities at the block
and PHC level. On-job regular capacity
building will take during the visits of Support
Team members from the state. District-level
immunization officers from par tner
organizations will also contribute to the
capacity building process.
Block and PHC team members will be trained
annually by the team comprising of members
of the district team and one of the facilitators
from the state. They will also receive on-job
training on a regular basis by district
immunization facilitators during their visits
and review meetings.
5. Prepare integrated guidelines and
checklists for supportive supervision
linking UIP-MNCH (Universal
Immunization Program and Maternal,
Newborn And Child Health) supervisory
mechanism
These guidelines will be developed as part of
the RMNCH+A strategy to further augment
the supportive supervision mechanisms.
Result 5.5: Build institutional capacity to
promote operational and translational research
for successful implementation of UIP
2. Evolve institutional mechanism for

operational research
A leading research organization may be
identified to work in collaboration with
immunization division and other stakeholders
3. Ensure sufficient funding for
operational research
Funds will be ear-marked and sufficient
amount will be ensured for operational
research and implementation in UIP.
4. Ensure adequate knowledge
management and translation for greater
public good
National immunization cell will seek to avoid
long time lag between conducting research and
translating the findings for advocacy,
communication and UIP interventions.
Technical expertise of partners working on
immunization shall be availed as and when
required.
KEY OBJECTIVE 6: Contribute to

global polio eradication, measles
and maternal and neonatal tetanus
elimination and rubella control
1. No wild polio virus detected in the country
2. Non Polio AFP rate is maintained or
47
exceeds 2 per 100,000 children under 15

years
3. Reported AFP cases have two adequate
stool specimens collected within 14 days of
onset of paralysis in > 80% cases
4. Number of States with MCV 1 coverage of >
90%
5. Number of States with MCV-2 coverage of>
90%
Polio SIAs in 2014

l
Two NIDs with tOPV in all areas in 1st
quarter of 2014
l
Three SNIDs with bOPV, ideally one in each
of quarters 2, 3, and 4 of 2014 targeting all of
UP, Bihar, Delhi, and associated high risk areas
of Haryana, Rajasthan, and Uttarakhand, and
migrant/high risk areas in Maharashtra,
Punjab, Gujarat, Jharkhand, and West Bengal.
Polio SIAs in 2015

6. % of districts with >80% TT2 coverage for
pregnant women
Expected Result 6.1: Achieve country-wide
certification of polio eradication by 2014
l
Two NIDs with tOPV in all areas in 1st
quarter of 2014
l
Two to three SNIDs with bOPV (depending
on global epidemiology) targeting all of UP,
Bihar, Delhi, and associated high risk areas of
Haryana, Rajasthan, and Uttarakhand, and
Strategies
The polio eradication program and the polio
endgame strategy shall continue to be guided
by India Expert Advisory Group constituted by
the Government of India.33
1. Maintain high level of population
immunity
Conduct regular supplementary immunization
activities (SIAs), ensure that the SIAs maintain
good quality and conduct regular
seroprevalence surveys to detect immunity
levels. The plans for SIAs to be conducted in the
coming two years are as below
SIAs for the remainder of 2013
As per current national plans, three large scale
SNIDs with bOPV, targeting all of UP, Bihar,
Delhi and associated high risk areas of
Haryana, Rajasthan, and Uttarakhand, and
The timing of sub-national rounds should be at

the discretion of the national program and
based on operational and epidemiological
considerations
2. Maintain the quality and effectiveness
of the existing surveillance and
laboratory systems to detect and
respond to outbreaks
An extremely high level of vigilance will be
maintained through to global certification of
eradication, and through to cessation of use of
oral poliovirus vaccines; this requires ensuring
that adequate financial and human resources
and attention are devoted to the surveillance
and laboratory systems by the Government of
India and partners.
Regular field reviews of surveillance would
continue to be conducted on a rotational basis
and with particular attention to high risk areas
as determined by epidemiological, surveillance
or immunization indicators.
33
http://www.npspindia.org/advisory.asp
................................
48
Environmental surveillance for detection of

polioviruses in the sewage would be expanded
in other states of the country. All detected
VDPVs would continue to be thoroughly
investigated to determine any risk of
circulation, and appropriate actions taken
based on investigation findings.
5. Work towards the certification

process
3. Augment the current response

capacity by developing a national and
state-level emergency response
preparedness plan and maintain a
rolling stock of bOPV and tOPV
6. Develop post-eradication policy in

preparation for the polio endgame
The Emergency Preparedness and Response

Plans (EPRPs) at national and state-levels will
be updated annually; the update will include a
full new risk analysis to inform risk mitigation
measures. See Annex 7 for EPRP details.
A simulation exercise ('table top exercise') for
the emergency response plans at national and
selected state levels will be conducted annually
to maintain readiness and sharpness of
response. Government of India will ensure a
rolling stock of 40 million doses of bOPV and
10 million doses of tOPV to enable response to
any wild poliovirus or vaccine derived
poliovirus detection.
4. Reduce risks of polio importation
based on WHO recommendations for
travelers coming to or from endemic or
infected areas
Immunization of travelers at land border
crossing points from neighboring countries is
the most significant risk reduction strategy and
will continue until there is no longer an
epidemiological risk. Particular attention
should continue to be paid to border
populations to ensure that they are effectively
covered by SIAs and routine immunization.
The Government of India will strongly
promote implementation of the current WHO
polio immunization advisory
/recommendations for travelers to and from

endemic or infected areas.
The Government of India will develop the

inventory of all labs holding polio virus(phase
1) and securing the WPV (phase 2).
This includes planning for tOPV/bOPV shift,

IPV introduction process, and operational
assessments of the cold chain system.
7. Conduct periodic seroprevalence
studies in high priority areas.
These sero-surveys will be conducted in the
traditionally high risk areas of UP and Bihar
and other regions with potential risk of wild
poliovirus importation or emergence of
circulating vaccine derived poliovirus. This will
provide an epidemiological description of the
trends on population immunity and possible
reasons for these trends.
Expected Result 6.2:Achieve measles
elimination and control for rubella/congenital
rubella syndrome (CRS) by 2020
Strategies
1. Increase coverage with the first dose
of measles vaccine for infants (9-12
months)
The first-dose Measles Containing Vaccine
(MCV1) at 9-12 months is delivered through
Routine Immunization. Efforts will be made to
improve coverage with MCV1 by strengthening
RI services with a target to reach all children. In
addition follow-up campaigns will be
conducted in low coverage areas. It will be
ensured that the coverage in every district is
more than 90 percent and progress is sustained.
49
2. Increase the coverage of second dose

of measles vaccine (at 1624 months of
34
age) based on global guidelines
Conduct measles SIAs in 14 states where MCV
1 coverage is below 80 percent vaccinating all
children in age group of 9 months to 9 years.
All states where MCV1 coverage was more
than 80 percent have already introduced MCV2
in routine immunization at the time of DPT
booster 1.
3. Strengthen and expand the laboratory
surveillance for measles and rubella
Twice yearly state-by-state review of all
measles data will be conducted. The
laboratory-based measles and rubella
surveillance has started in eight states, namely
Andhra Pradesh, Gujarat, Karnataka, Kerala,
Tamil Nadu, West Bengal, Rajasthan, Madhya
Pradesh, Bihar and Assam. The surveillance
laboratory network will be further expanded
with priority being given to the states with
measles morbidity and mortality. In addition,
surveillance data on measles outbreak from
IDSP will also be collated and analyzed for
action.
Expected Result 6.3: Eliminate maternal and
neonatal tetanus by 2015
Strategies
1. Strengthen service delivery and
improve institutional deliveries
Promote institutional delivery and safe
delivery by skilled birth attendants (SBA)
under NRHM and ensure that TT is offered at
all ante-natal clinics and routine immunization
sessions. Provide twoTT doses for the first
pregnancy (with immunization card) and
further doses according to the national
schedule. The tetanus vaccine for pregnant
mothers will also be ensured in all outreach

sessions being conducted.
2. Increased surveillance for tetanus
cases
Establish MNT as a reportable disease and
report MNT cases from every health facility.
MNT will be included with weekly AFP in
active surveillance and zero reporting. Case
investigations for hospital-based cases and the
cases from low-risk areas are regularly done.
3. Conduct targeted SIAs
Improve TT coverage through quality RI in all
areas. SIAs may be considered for those areas
where coverage with 2 doses of TT is poor. The
Government of India will take need-based
decision to conduct targeted SIA for
elimination of MNT. The mode and time for
these SIAs will be decided by an expert group.
4. Establish national MNT database
A national MNT database will be established
with regular review of indicators, identifying
high-risk districts within states. The high-risk
districts within states will be validated for
elimination of MNNT by Lot Quality
Assurance Surveys (LQAS) and districts
prioritized on the basis of this for targeted
corrective action.
5. Maintaining the elimination status
In states where MNT has been validated to
have been eliminated, efforts will be made to
maintain the high coverage with TT2, and safe
delivery practices to ensure the elimination
status in those states.
15 states have validated MNT till 2008, and
four more states have conducted MNT
validation exercise in 2013. The remaining
states and UTs will be assessed in 20142015.
34
A Guide to Introducing a Second Dose of Measles Vaccine into Routine Immunization Schedules. 2013.
World Health Organization, Measles and Rubella Initiative.
................................
5
National Monitoring And
Evaluation Plan For UIP
5.1 Rationale
The Universal Immunization Program
(UIP) in India uses a set of indicators to
measure the performance at national as well
as other levels of program implementation.
For this purpose, the country uses various
data sources that include:
Routine administrative reporting,
5.2 Objective
The overall objective of this National
Monitoring and Evaluation (M&E) Plan is to
systematically generate, capture and
disseminate knowledge to guide UIP
implementation monitoring and UIP impact
evaluation.
5.3 Methodology
Reports from various disease surveillance

systems and field level monitoring by
partners,
This monitoring and evaluation plan will work

at three levels:
Periodic Coverage Evaluation Surveys

(CESs) at national and sub-national level,
I. Strengthen routine data reporting
systematically identify data needs as well as

data sources to meet dynamic program
requirements,
Currently UIP does not have its own electronic

data management system. The Health
Management Information System (HMIS)
captures immunization data from the health
facility-level and the Mother & Child Tracking
System (MCTS) tracks ante-natal and
immunization services at the individual
pregnant woman and child level. The National
Monitoring and Evaluation Plan will aim to
strengthen these existing data reporting
systems through the following mechanisms:
review the process of data gathering,
a) Structured Review Mechanism
Various assessment studies conducted from

time-to-time by different organizations.
Despite the availability of multiple sources of

data, there is no comprehensive independent
UIP Monitoring & Evaluation (M&E) Plan in
the country to
l
conduct Data Quality Assessments (DQAs).
In the absence of this plan, there is also no

mechanism to identify information gaps,
especially to measure process indicators, and
plan targeted studies to inform the program.
Though there are provisions for immunization
program reviews at all levels, these are not
regular and are not effective in the absence of a
real-time quality data.
There is currently limited use of HMIS and

MCTS data sets for analyzing and reviewing
program implementation and for providing
feedback to the concerned districts or blocks.
The proposed monitoring and evaluation plan
will establish a structured review mechanism in
the countr y to enhance the use of
immunization data and to further improve data
quality.
................................
51
52
b) Human Resource & Capacity Building

A core part of the plan is to improve
monitoring and evaluation human resource
capacity through trainings, supportive
supervision, mentoring, and providing
guidelines and tools.
c) Data Quality Assessments (DQA)
DQAs will be conducted regularly in
coordination with state governments and with
the support of technical and development
partners. State Immunization Managers will
also be trained in conducting these DQAs by
using WHO DQA tools.
d) Feedback to program managers
Data quality will be improved by examining the
immunization information system in operation
at all administrative levels from data
collection at the point of vaccination, to the
periodic compilation of data at the national
level. Practical feedback will be provided to
managers on how to improve the quality of
their administrative immunization reporting
systems.
I. Conduct targeted studies and field
assessments to fill knowledge gaps in
the program
Knowledge gaps identified through routine
program monitoring and reporting will be filled
by targeted studies and operational research.
The results from these research activities can
help the UIP in taking ongoing corrective
measures for better outcomes. The monitoring
and evaluation plan will also include regular
audit at facility and service level using WHO
tools and provide feedback to program
managers for strengthening the facilities and
services.
II. Plan and conduct coverage evaluation
studies
Currently, evaluation surveys conducted in the
country address all MCH services, and the
immunization component is limited only to
antigen-wise and full immunization coverage.
Moreover, these surveys are done every three to
four years, and do not provide latest coverage

numbers on a yearly basis. The monitoring and
evaluation plan will propose a yearly
evaluation survey for routine immunization,
focusing on outcome and impact indicators of
all RI components. This can be done through
external agencies, in line with NFHS and
DLHS surveys.
5.4 Process for national M & E Plan

development
MOHFW will guide the development of the
national monitoring and evaluation plan. The
Monitoring and Evaluation division of
will coordinate the development of the plan.
ITSU will hire a consultant to work on the plan
after consultation with ministry and technical
partners for the scope. The consultant will work
closely with ITSU team and, in consultation
with all stakeholders including states, with the
aim of creating a realistic, expedient and
effective national monitoring and evaluation
plan for the UIP.
5.5 Components of National

Monitoring and Evaluation Plan
The National Monitoring and Evaluation plan
will be developed in line with the cMYP and
five-year plan of the country. The proposed
national monitoring and evaluation plan will
cover all major areas for establishing and
running an effective monitoring and evaluation
system in the country. These include:
Organizational structure along with roles
and responsibilities for monitoring and
evaluation at various levels
Plan for capacity building of monitoring and

evaluation staff on transmission, analysis
and use of data at all levels
Key coordination mechanisms for the

country
Immunization monitoring and evaluation

performance and accountability tracking
framework and implementation plan at
national and state level (see Annex 6)
ANNEXURES
................................
53
55
A N N E X U R E S
ANNEX 1: List of states showing good performance on immunization coverage and other parameters
States
Full
immunization
coverage (%)
Children aged No. of sub12-23 months

centers
having an
without
immunization ANM/HW*
card (%)
Mos
trained
(%)
Sessions
held vs.
planned
(%)**
Dropout rates
in age
group12-23
months for
BCG- measles
(%)
No. of severe
AEFI cases
reported***
Andhra Pradesh
68.0
64.9
93.7
N/A
8.3
21
Delhi
71.5
50.7
55.5
92.8
6.5
12
Goa
87.9
60.6
93.7
99.2
1.4
Haryana
71.7
42.7
N/A
72.8
93.9
5.3
10
Himachal Pradesh
75.8
60.3
178
4.0
98.2
2.2
Jammu & Kashmir
66.6
60
N/A
7.3
90.5
9.4
N/A
Karnataka
78.0
52
N/A
44.8
95.4
7.4
Kerala
81.5
78.9
50.5
N/A
8.3
Maharashtra
78.6
58.8
N/A
51.8
80.2
3.7
71
Punjab
83.6
53.2
N/A
95.8
95.1
9.6
Tamil Nadu
77.3
44.8
140
82.2
99.1
0.6
Mizoram
73.7
77.9
N/A
48.3
66.7
7.3
N/A
Sikkim
85.3
85.2
75.0
N/A
0.1
N/A
Tripura
66.0
75.9
30.0
92.9
7.3
Uttarakhand
71.5
41.1
34
19.5
91.8
14.2
West Bengal
64.9
77.8
N/A
19.7
91.6
13.6
28
* Collated data from state review meetings on immunization obtained from MoHFW, GoI.
* * Data from the HMIS web portal April to October, 2011;
** *Severe AEFI cases reported to the Government of India by the states till mid-December, 2011;
................................
56
ANNEX 2: List of States showing poor performance on immunization coverage and other parameters
States
Full
immunization
coverage (%)
Children aged No. of sub12-23 months

centers
having an
without
immunization ANM/HW*
card (%)
MOs
trained
(%)
Sessions
held vs.
planned
(%)**
Dropout rates
in age group
12-23 months
for BCGmeasles (%)
No. of severe
AEFI cases
reported ***
Arunachal Pradesh
24.8
41.9
N/A
43.8
81.5
27
N/A
Manipur
51.9
55.6
N/A
49.4
89.6
12.9%
N/A
Meghalaya
60.8
63.8
93.4
80.8
9.4
Nagaland
27.8
45
40.1
93.7
11.5
N/A
Assam
59.1
66.9
84.7
97.4
7.2
Bihar
49.0
43.1
200
18.3
95.1
29.3
19
Madhya Pradesh
42.9
45.8
119
32.5
96.1
24
Orissa
59.5
58.3
535
44.9
96.0
17.6
Rajasthan
53.8
24
392
33.4
113.9
20.6
Uttar Pradesh
40.9
35.9
1,776
32.1
89.8
30.9
21
Chhattisgarh
57.3
46.3
458
8.7
90.3
13.8
N/A
Gujarat
56.6
49.5
488
24.7
97.2
8.1
Jharkhand
59.7
63.1
36.3
94.4
22.8
11
*Collated data from state review meetings on immunization obtained from MoHFW, GoI.
**Data from the HMIS web portal April to October, 2011;
***Severe AEFI cases reported to the Government of India by the states till mid-December, 2011
57
A N N E X U R E S
ANNEX 3: NCCVMRC concept approved by MoHFW

ESTABLISHMENT OF
NATIONAL COLD CHAIN AND VACCINE MANAGEMENT
RESOURCE CENTRE (NCCVMRC)
AT NATIONAL INSTITUTE OF HEALTH AND FAMILY WELFARE, NEW DELHI
PROPOSAL ESTIMATES
(With blueprint)
Submitted to
IMMUNIZATION DIVISION,
MINISTRY OF HEALTH AND FAMILY WELFARE, NEW DELHI
By
National Institute of Health and Family Welfare, New Delhi
Establishment of national cold chain

and vaccine management resource
centre and nihfw, new delhi
BACKGROUND
The Immunization Division, MOHFW, New
Delhi has proposed to establish a National
Cold Chain and Vaccine Management
Resource Centre (NCCVMRC) at NIHFW,
New Delhi and it has been approved by the
competent authority of MoHFW, Government
of India (Annexure A). Further it has been
intimated that NIHFW may utilize any
MOHFW, GoI funds available or the proposal
estimates be provided for necessary approvals
from the competent authority. MOHFW, GoI
shall support the establishment of
NCCVMRC, trainings of officials from
Central/state Governments related to cold
chain equipment, vaccine and logistics
management, etc. and the human resources
needed for the trainings on regular and /or
contractual staff and all other expenses related
to the Training Centre. The necessary technical
support will be provided by UNICEF.
National Institute of Health and Family
Welfare, New Delhi has on its part demarcated
adequate space in the unused portion of the

Animal House for the establishment of
NCCVMRC. UNICEF has supported the
establishment by hiring an architect to prepare
the plans and estimates for remodeling of the
existing building of the Animal House.
Immunization Division has provided five tool
kits for the training center. NIHFW has already
conducted a six days pilot Training for Cold
Chain Technicians in Repair and Maintenance
of ILRs and DFs from 17-22 October 2011
using alternate temporary space made
specifically available for the training.
Brief about resource centre
The Resource Centre will be set up to train cold
chain mechanics in repair and maintenance of
all electrical cold chain equipment (ILRs, DFs,
WICs, WIFs and voltage stabilizers). In
addition, it will also conduct trainings related
to vaccine and logistics management for
vaccine and logistics managers in the country.
It is expected to make it a cold chain training
center for other countries in South-east Asia. In
addition to trainings, NCCVMRC will be a
repository of documents such as guidelines,
government orders/notifications and other
resource materials related to cold chain and
................................
vaccine management. The soft copies will be

on the resource centre website and hard copies
will be maintained in a small library in the
centre.
58
The following are the different types of

trainings to be undertaken at the NCCVMRC,
New Delhi:
The resource center will be set in the unused

portion (earlier Primate Section) of the Animal
House. There will be a Lecture Room, a work
lab (for repair of ILRs and DFs) and a room for
housing a Walk in Cooler and a Walk in
Freezer. In addition, there will be an
administrator's room and a facilitator's room as
well as a store room. The ingress will be
separate from the animal House with adequate
accessibility for heavy vehicles (for loading and
unloading of cold chain equipment).
1. Training for Cold Chain Technicians in

Repair and Maintenance of ILRs and DFs
2. Training for Cold Chain Technicians in
Repair and Maintenance of WICs and WIFs
3. Training on repair and maintenance of
voltage stabilizers
4. Training on installation and repair of Solar
cold chain equipment.
5. Training for Vaccine and Cold Chain
Handlers
6. Training on Vaccine Management
A training coordinator, an assistant and a

support staff are the human resources needed
for the resource center. MoHFW has agreed to
support in hiring of the training coordinator
and support staff from NIHFW can be deputed
to work in the resource center. UNICEF may
also initially support the hiring of technical
staff.
There are more than 500 cold chain technicians

and vaccine logistics managers in the country.
Some of these are newly inducted have had no
induction training. Many of the older
refrigerator mechanics need refresher trainings
for which such a course will be designed
separately. Therefore the establishment of the
NCCVMRC is justified.
59
A N N E X U R E S
ANNEX 4: Key Recommendations from Effective Vaccine Management Assessment Report 2013
The recommendations are categorized in to
five broad categories Management Policy,
Human Resource and capacity building,
Infrastructure, Planning and Documentation
and improvement in practice and development
of an improvement plan to implement these
recommendations through NRHM state PIPs.
Greater role of NCCTC and NCCVMRC

for CCVLM
1. Management Policy
Review Mechanism of CCVLM
Procurement Policy for CCE

Institutional Capacity Building of NCCTC
and NCCVMRC
Induction Training of HR engaged for Cold

Chain and VM
Introduce VAR for Vaccine stores up to Sub

National level
Develop and implement real time MIS for

Vaccine Logistic Management for 5 levels of
supply chain.
Integrate vaccine management MIS with

NCCMIS
Improvement of management skills of

program managers
2. Human Resource and capacity

building
Dedicated staffs for CCL at all level (at least
up to district)
Accelerate NCCMIS implementation for

GMSDs
Each GMSD and SVSs need to have VLM

and CCT
Segregate all SVSs attached to RVS and

RVSs attached to DVS: Building,
equipment, documents and Staff.
Some of the existing staffs of GMSD can be

profiled for Data management
Develop National Cold Chain action Plan
Cold rooms should have some semiskilled

helpers
Develop National standards for:

Vaccine store at all levels as per WHO
standards
Cold Chain point expansion guidelines
Cold Chain Equipment plan for different

level of vaccine stores
Develop Training package for the VLMs and

also for the Immunization program
managers and house them in the institution
to overcome attrition
Review of Knowledge (Training) to skills

transformation barriers
Quality maintenance of vaccine
Temperature Monitoring of cold chain

system
3. Infrastructure
Human resource for Cold Chain and VM
A.Building
CCE Testing Lab
Regular orientation, at least every 3 years for

all staffs
Dedicated stores for State, Division, District
................................
60
and Health Facilities(PHC),
Temperature monitoring booklet.
Consider the future need, national standard
Greater collaboration with PWD, Electricity

and Municipal corporation/bodies for
regular maintenance
B.Equipment
Equipment specification as per global
standards
Diluents MUST be marked in supply

voucher and should be recorded just like the
vaccines in stock registers.
At CHC and PHC the DF must be used

exclusively to prepare ice packs. Vaccines
must never be stored in the same unit. All
vaccines should be kept in ILRs at the CHC
and PHC.
Always use standardized Ice Packs after

conditioning
Minimize variety of equipment to reduce

number of spare parts
All WIC/WIF with working hooters
Mapping of spare parts and ensuring

availability to make non-functioning
equipment (Solar, Haier, Blue star,
others)functional
4. Planning and Documentation

Define realistic stock level in months at five
supply chain level
Define, print and distribute standard vaccine

stock registers
Vaccine indent and distribution plans based

on the required peak stocks.
Preventive maintenance plan for technicians
Regular data uploading in NCCMIS for

performance assessment of CC at all level
Establish a system for recording wastage in

vaccine registers
5. Improvement in Practice
Manual temperature monitoring and
recording to be carried out 2 times daily, for
all 7 days including holidays
Maintain a service log sheet for each

equipment. This can be done as part of the
6. Improvement Plan (IP)

EVM is a diagnostic tool and it assess, 3 Ps like
Process, Practices and Policies of health system
requires for efficient cold chain and vaccine
management.
Improvement Plan(IP )is the intervention for
Strengthening of existing Cold Chain and
Vaccine Logistics System to make it Reliable
,Affordable and Efficient. Issues identified
through EVM needs to be fixed and to be
sustained success of the EVM initiatives lies in
developing an implementable improvement
plan and then actually implementing the IP and
reviewing the IP on the regular basis for
strengthening the Cold chain logistics system.
While EVM is a diagnostic tool, IP lay down
the treatment strategies for the gaps in the CCL
system. Development of an improvement plan
is the key output that comes from the EVM
assessment and its recommendations. While a
skilled facilitation is needed to make sure that
the plan does indeed address key deficiencies, it
should be possible to provide a menu of
innovative approaches and technologies for
consideration, guided by country realities. A
menu of innovations approaches is included in
the Improvement Plan to guide planning for
future system design and to enhance
monitoring of the implementation of the plan.
While planning, guiding principles that need to
be considered for an effective and
implementable IP are:
61
A N N E X U R E S
Government ownership
Plan which need to be reviewed regularly for

progress of implementation
Engagement of all levels
Integration with other planning processes
IP template should be adapted by

government to align with existing planning
and budgeting documents
Disseminate widely , leveraging existing

mechanisms
Make IP foundational plan for improving

immunization supply chain performance
o IP should be consistent with and input into

other planning documents such as cMYP,
national and sub-national annual work
plans, etc.
Dynamic and living document
o Identifies priority action areas and

establishes accountability for improving
performance
o Takes longer-term view and reflects future
needs (NVI, population growth, etc.)
Plan that needs regular review and

monitoring for implementations of
recommendations IP need to be prepared
through consultative process and it should
be integrated annual health PIP.
................................
ANNEX 5: National Open Vial Policy 2013
62
63
Guidelines for use of open vial in

immunization program
1. This opened vial policy applies to multi-dose
vials of the DPT, TT, Hepatitis B, Oral Polio
Vaccine (OPV) and Liquid Pentavalent
(where applicable). This policy does not
apply to Measles, BCG, Japanese
Encephalitis (JE) vaccines.
Conditions that must be fulfilled for the
use of open vial policy:
2. Use the DPT, TT, Hepatitis B, Oral Polio
vaccine (OPV) and Liquid Pentavalent
(DPT + HepB + HiB) where applicable)
vaccines opened in a fixed or outreach
session can be used at more than one
immunization session up to four weeks
provided that:
a. The expiry date has not passed.
b. The vaccines are stored under appropriate
cold chain conditions both during
transportation and storage in cold chain
storage point.
c. The vaccine vial septum has not been
submerged in water or contaminated in any
way.
d. Aseptic technique has been used to
withdraw all doses.
e. The vaccine vial monitor (VVM), has not
reached the discard point.
3. Discard vaccine vial in case any one of the
following conditions is met:
a. If expiry date has passed.
b. VVM reached discard point (for freeze dried
vaccine, before reconstitution only) or
Vaccine vials without VVM or disfigured
VVM.
A N N E X U R E S
vials removed from a vaccine carrier that has

water.
f. If vaccine vial is frozen or contains floccules.
4. Health workers must be able to distinguish
between vials that can be used in subsequent
sessions and vials that must be discarded.
Training and supervision materials should
be revised to reflect the policy change.
Cold chain maintenance and vaccine
distribution
5. Maintain temperature of ILR between 20 to
80C for storage of vaccines & diluents and
monitor temperature twice daily regularly.
6. Note the manufacturer, batch and expiry
date of the vaccine and diluent in the stock
register.
7. Proper recording and reporting of vaccine
distribution and usage has to be ensured.
8. Keep stock up to date, don't over-stock or
under-stock vaccines and diluents.
9. Multi-dose vials from which at least one
dose has been removed may be at risk of
contamination of the vial septum. These
vials should therefore, never be allowed to be
submerged in water (from melted ice for
example) and the septum should remain
clean and dry. NOTE: Well-sealed
conditioned ice packs should be used in
vaccine carriers and water should not be
allowed to accumulate where the vials are
stored. Vaccine vials must be transported in a
plastic zipper bag.
10. Keep the returned, partially used vials in
a separate box, and label it accordingly.
d. Any vial thought to be exposed to non-sterile

procedure for withdrawal.
11.Observe earliest expiry first out (EEFO)

policy for issuing vaccines. If the vaccines
are of same expiry date, the partially used
vaccine vials should be re-issued. The vial
opened earlier, as recorded on the vial label,
should be issued first.
e. Open vials that have been under water or
12. Contingency plan has to be in place in case
c. No label or partially torn label or writing on

label is not legible.
................................
64
of any exigency like power failure,

equipment breakdown, etc.
At and during the immunization session
13. Inspect for and discard vaccine vial with
visible contamination (i.e. checking for any
change in the appearance of vaccine or any
floating particles) or breaches of integrity
(e.g. cracks, leaks).
14. All vaccines vials must be marked with date
& time of opening at first use.
15. Note the manufacturer, batch and expiry
date of the vaccine and diluent in the tally
sheet.
16. Always pierce the septum with a sterile
needle for drawing vaccine from the multidose vials used. Except oral polio vaccine
which is given 2 drops orally, cap needs to be
closed after each use.
After immunization session is over
17. Ensure that the vaccine vials are returned
inside a vaccine carrier from the session site
to cold chain point immediately after session
ends, using the alternate vaccine delivery
mechanism in the reverse cold chain.
18. Under no circumstance the vaccine
carrier/vaccines will be kept in the field, in
case of such an event, the vaccines in such
vaccine carriers should be discarded and not
used for subsequent sessions.
19. Storage of vaccines at any place other than
a designated cold chain point will not be
allowed. No vaccines should be stored at

ANM/LHV or other health worker/ASHA
house.
Specific attention while implementing
open vial policy
20. This policy is NOT applicable to opened
reconstituted vials of Measles, BCG and JE
vaccine, which will be used as per following
instructions and discarded immediately
after use:
a. Before reconstitution check that vaccine is
within expiry date and the VVM has not
reached the discard point. Reconstitute the
vial ONLY with diluent provided by
manufacturer for that batch of the vaccine.
b. Date and time of reconstitution must be
mentioned on the label vial at the beginning
of session.
c. Reconstituted vials will only be used for a
single session; they will not be carried from
one session to another, even if the session is
close by.
d. BCG and Measles must be discarded within
four hours of reconstitution or at end of
session whichever is earlier.
e. JE to be discarded after two hours of
reconstitution or at end of session whichever
is earlier.
21. All vaccines are supplied with VVM. Please
note that the VVM has only three status ie (i)
start point (ii) end point (iii) end point
exceeded. The vaccine has to be use before
reaching the end
Start point
Square lighter than circle. If the expiry date has

not passed, USE the vaccine.
End point
Square matches the circle. Do NOT use

the vaccine.
End point exceeded
Square darker than the circle. Do NOT

use the vaccine.
Baseline
value
Indicator Definition
(& unit of measurement)
Target
Data Collection
Sources
Methods and
Frequency &
Schedule
Indicator will disaggregated by

district, gender, geography (urban
slum, urban, rural) and wealth
20 (Source:
CES 2009)
17%
(Source:
DLHS-3)
Full immunization coverage is

defined as infants who have
received all relevant doses in the
first year of life
Numerator: Districts that show full
immunization coverage rates > 80%
Denominator: Total districts in the
country
2. % of districts
having > 80% full
immunization
coverage
3. Number of
States/UTs having
less than 10%
dropout from
DPT1-DPT3 (or
Pentavalent)
20 (Source:
HMIS 201213)
Data will be disaggregated by

district
1. Number of
States/UTs where >
95% sessions were
held as planned
All
States/UTs
(35)
60%
30
HMIS, Periodic
surveys including
DLHS, CES
HMIS, Periodic
surveys including
DLHS, CES
HMIS
Monthly
Monthly
Monthly
KEY OBJECTIVE 1 : Improve program service delivery for equitable and efficient immunization services by all districts
GOAL: Reduce mortality and morbidity due to vaccine preventable diseases through high quality immunization services
Indicator
cMYP (2013-17) - Reaching Every Child

Monitoring and Accountability Tracking Framework
ANNEX 6: Monitoring Framework
MoHFW
MoHFW
MoHFW
Responsibility
65
A N N E X U R E S
................................
16
(Source:
NIHFW RI
training status
report)
0
Self-explanatory
Self-explanatory
2. Number of
States/UTs where
all cold chain staff
are trained in cold
chain and vaccine
management
3. Number of
States/UT where
temperature
monitoring is being
done with wireless
data loggers for all
functional electrical
cold chain
equipment
5
States/UT
All
States/UTs
(35)
All
States/UTs
(35)
Target
Data Collection
Web-based
temperature
monitoring report
State training
reports
NCCMIS
Sources
Methods and
Frequency &
Monthly
Monthly
Monthly
Schedule
This will be implemented across the

districts Bihar and UP
Self-explanatory
1. Number of
districts where real
time vaccine stock
monitoring system
is implemented
2.Number of
States/UTsthat are
using computer
simulation model
for vaccine supply
chain capacity
planning
7
States/UT
110
districts
MoHFW
report/NCCMIS
Web-based stock
monitoring
system
One time
Monthly
EXPECTED RESULT 1.2: Strengthen vaccine and syringe logistics management across the country including forecasting and
procurement at central level
26
(Source:
NCCMIS
2013/State
reports)
Cold chain sickness is defined as cold chain equipment which out of

order as a percentage of total
equipment placed
Baseline
value
1. Number of
States/UTs where
the cold chain
sickness rate
meets the national
standard of < 2%
Indicator
MoHFW
SIO/MoHFW
SIO/MoHFW
SIO
MoHFW
Responsibility
66
Baseline
value
Target
No Baseline
Numerator: Number of cold chain

points having a functional safety pit
Denominator: Total number of cold
chain points surveyed
2. % of cold chain
points having
functional safety
pits as per the
Central Pollution
Control Board
(CPCB) guidelines
100%
80%
Data Collection
State report
Coverage
surveys
Sources
Methods and
Frequency &
Annual
Annual
Schedule
Planning unit is defined as PHC,

Block PHC, CHC or Urban Health
Center
Numerator: Number of planning
units having a AVD plan
Denominator: Total number of
planning units surveyed
2. % of planning
units where AVD
plan is a part of RI
micro plan
No Baseline
No baseline
1. Number of
States where state
taskforce on
immunization is
constituted to
review RI program
and take
appropriate action
Self-explanatory
0 (in 2012)
EXPECTED RESULT 1.5: Improve program coordination at all levels
Planning unit is defined as PHC,

Block PHC, CHC or Urban Health
Center
Numerator: Number of planning
units where micro plans are
available
Denominator: Total number of
planning units surveyed
1. % of planning
units where RI
micro plans are
available
All
States/UTs
(35)
90%
80%
State report
Coverage
surveys
Coverage
surveys
Annual
Annual
Annual
EXPECTED RESULT 1.4: Ensure that regular immunization sessions are planned and held and coverage increased
No Baseline
Numerator: Number of sub centers

having a functional hub cutter
Denominator: Total number of sun
centers surveyed
1. % of sub-centers
with functional hub
cutter available
EXPECTED RESULT 1.3: Ensure safer injection practices and reduced vaccine wastage
Indicator
MoHFW
MoHFW
MoHFW
SIO
MoHFW
Responsibility
67
A N N E X U R E S
................................
35
Baseline
value
Target
Data Collection
Sources
Methods and
Frequency &
Schedule
Responsibility
Numerator: Number of caregivers

not recalling any of routine vaccine
Denominator: Number of
caregivers surveyed
2. % of caregivers
not recalling any of
routine vaccine
12%
(Source: CES
2009)
28%
(Source: CES
2009)
<5%
<15%
Coverage surveys
Coverage surveys
Annual
Annual
MoHFW
MoHFW
Staff should include program

managers (other than ASHA)
Should be stand-alone BCC
training
2. Number of
States where 80%
of health HR are
trained on BCC
0 (as of 2012)
EXPECTED
0 (as of 2012)
All high
priority
States (12)
All high
priority
States
(12)35
MoHFW report
EXPECTED
State PIP
Annual
Annual
1. % of caregivers
who reported that
they got information
about immunization
from ASHA
This will only include rural
population and children who have
received at least one vaccine prior
to the survey
who got information about
immunization from ASHA
caregivers surveyed
19%
(Source: CES
2009)
>80%
Coverage surveys
Annual
EXPECTED RESULT 2.2: Effective communication channels are set up with the community for better acceptance of vaccines
Self-explanatory
1. Number of
State/UT PIPs
which have
communication
action plan for RI
MoHFW
State/MoHFW
State/MoHFW
EXPECTED RESULT 2.1: Develop and implement a multi-pronged national communication strategy with a focus on priority states

whose child received partial or no
immunization who did not feel the
need for adhering to immunization
schedule
caregivers surveyed
1. % of caregivers
whose child
received partial or
no immunization
who did not feel the
need for adhering
to the immunization
schedule
KEY OBJECTIVE 2: Increase demand and reduce barriers for people to access immunization services through improved social mobilization
Indicator
68
The 12 States include Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Gujrat, Jharkhand, Madhya Pradesh, Manipur, Nagaland, Odisha, Rajasthan and UP
Baseline
value
Target
Data Collection
Sources
Methods and
Frequency &
Schedule
Responsibility
40%
0%
Messages as relevant at the time of

survey
who can recall new immunization
messages/tagline
caregivers surveyed
2. % of caregivers
who can recall new
immunization
messages/tagline
Coverage Surveys
State
communication
plan
Annual
Annual
Self-explanatory
2. Increase in the
number of notified
serious AEFI cases
above the 2012
baseline value
372 cases
(source FIR
2012-13)
0%
(as of 2012)
>1500
cases
80%
................................
1. Number of
States that have
conducted VPD
surveillance
workshops
Does not include Polio workshops
0 (as of 2012)
35 (States
and UTs)
EXPECTED RESUL3.1: Institutionalize and strengthen surveillance mechanisms for VPDs
Reference period: Timely reports as

complied over the previous one
year.
Numerator: Number of sentinel
sites providing timely and complete
reports on 90% occasion
Denominator: All sentinel sites
1. % of sentinel
sites providing
timely and
complete reports
on VPDs (including
zero report) on
90% occasions
VPD Surveillance
report
FIR, PIR, DIR
Surveillance
report
Annual
Annual
Annual
KEY OBJECTIVE 3: Strengthen and maintain robust surveillance system for vaccine preventable diseases (VPDs) and
adverse events following immunization (AEFI)
All
States/UTs
(35)
Self-explanatory
1. Number of
States/UTs that
have a defined
media tracking and
assessment plan.
MoHFW/SIO
DIO, SIO
MoHFW
MoHFW
State/MoHFW
EXPECTED RESULT 2.3: Evidence based and contextually relevant communication messages are disseminated in the community
Indicator
69
A N N E X U R E S
Baseline
value
10
(as of August
2013)
Newer antigen includes HiB and

Rotavirus
30
Target
60%
90%
6%
(Source: AEFI
dashboard as
of January
2013-14)
64%
(Source:
MoHFW report
as on April
2013 for cases
upto Dec
2012)
Numerator: Serious AEFI cases

investigated on time
Denominator: All notified serious
AEFI cases whose PIR is received
classified within 120 days
AEFI cases
4. % of Serious
AEFI cases
classified within
120 days of
reporting of the
case
Data Collection
DIR
FIR, PIR
FIR
MoHFW report
MoHFW report
Sources
Methods and
1. Number of newer
vaccines that have
been reviewed for
introduction in UIP
by NTAGI
Vaccines for review include, but not

limited to, IPV, Pneumococcus,
Rotavirus, Rubella
0 (as of 2013)
At least 2
new
vaccines
NTAGI report
KEY OBJECTIVE 4: Introduce and expand the use of new and underutilized vaccines and technology in UIP
80%
3. % of Serious
AEFI cases
investigated timely
as per national
guidelines
.
16%
(Source: AEFI
dashboard as
of January
2013-14)
Timely notification is defined as

submission of notification form
within 48 hours of the event
occurring in the field
notified on time
AEFI cases
2. % of serious
AEFI cases notified
in a timely manner
All
States/UTs
(35)
Self-explanatory
1. Number of
States/UTs with all
DIOs trained on
national AEFI
guidelines
EXPECTED RESUL3.1: Institutionalize and strengthen surveillance mechanisms for VPDs
2. Number of
sentinel sites set up
for newer antigens
Indicator
Frequency &
6 monthly
Annual
Annual
Annual
Annual
Annual
Schedule
NTAGI/MoHFW
SIO, State AEFI

Committee
DIO/SIO
DIO, SIO
MoHFW
ICMR/MoHFW
Responsibility
70
Baseline
value
9 States
(as of
December
2013)
Self-explanatory
All
States/UTs
(35)
Target
Data Collection
HMIS
Sources
Methods and
Frequency &
Annual
Schedule
MoHFW
Responsibility
Self-explanatory
No baseline
At least two
meetings
per year
NTAGI minutes
Annual
MoHFW
Numerator: Number of newly

identified JE-endemic districts
where JE vaccine has been
introduced in UIP
Denominator: 62 (newly identified
districts)
Full immunization coverage is

defined as infants who have
received all relevant doses in the
first year of life
Numerator: Districts that show full
immunization coverage rates >
80%
Denominator: Total districts in the
country
17%
(Source:
DLHS-3)
60%
100%
HMIS, Periodic
surveys including
DLHS, CES
HMIS
Monthly
Annual
MoHFW
MoHFW
36
The newly identified 62 districts as on 2013
................................
1. Number of
States where all
MOs are trained on
RI MO handbook in
last three years
Self-explanatory
5 States/UTs
(Source:
NIHFW RI
training status
report)
30
States/UTs
State training
report
Annual
SIO
\
EXPECTED RESULT 5.1: Increase the pool of skilled human resources to provide quality immunization services in an integrated manner
1. Number of
districts with full
immunization
coverage rate of
>80%
KEY OBJECTIVE 5: Strengthen health system for immunization program
1. % of newly
identified 62 JEendemic districts
where JE vaccine
has been
introduced in
UIP 36
EXPECTED RESULT 4.2: Scale up and sustain the implementation of JE vaccination in identified endemic districts as part of JE control
1. Number of
NTAGI meetings in
a year
EXPECTED RESULT 4.1: Set up and strengthen institutional mechanisms, framework and policies for newer and underutilized vaccine introduction
2. Number of
States that have
introduced
Pentavalent
vaccine
Indicator
71
A N N E X U R E S
Baseline
value
2
(Source:
NCCMIS
2013)
Self-explanatory
25
States/UTs
Target
Self-explanatory
7
(Source:
MoHFW
finance report
2011-12)
All
States/UTs
(35)
Data Collection
NRHM FMS
State PIP,
NCCMIS
Sources
Methods and
Data will disaggregated by State

Numerator: Total number of infants
registered in MCTS
Denominator: Total estimated
number of infants in the year
57%
(Source:
MCTS portal
as on April
2013)
80%
State PIP
Frequency &
Annual
Annual
Annual
Schedule
States
State manager
NRHM
SIO
Responsibility
Self-explanatory
0
25
States/UTs
State reports
1. No wild polio
virus detected in
the country
Self-explanatory
AFP Surveillance
Bulletin India
0
KEY OBJECTIVE 6: Contribute to global polio eradication, measles,
maternal and neonatal tetanus elimination
1. Number of states
where State Task
Force on
Immunization
(STFI) conducted
at least 10 monthly
meetings during the
reporting year
Annual
Annual
MoHFW
States
EXPECTED RESULT 5.4: Strengthen RI program management and service delivery through field level supportive supervision in high priority states
1. % of infants
registered in MCTS
EXPECTED RESULT 5.3: Improve program accountability, monitoring and reporting at all levels
1. Number of
States/UTs utilizing
>90% of the
allocated fund for
UIP
EXPECTED RESULT 5.2: Ensure that adequate financial resources are available for UIP
2. Number of
States/UTs with no
vacant positions for
refrigerator
mechanics
Indicator
72

district level
Self-explanatory
5. Number of
States with MCV-2
coverage of> 90%
6. Number of
States with >80%
TT2 coverage for
pregnant women
All
States/UTs
(35)
All
States/UTs
(35)
Data Collection
Frequency &
Coverage survey
Annual
Annual
Annual
HMIS
HMIS
Annual
Annual
Schedule
AFP Surveillance
Bulletin India
AFP Surveillance
Bulletin India
Sources
Methods and
................................
Self-explanatory
11
1. Number of
States validated as
NNT eliminated
during the plan
Self-explanatory
18(Source:
WHO report
2013
EXPECTED RESULT 6.3: Eliminate maternal and neonatal tetanus by 2015
1. Number of
States that have
established
laboratory
supported measles
surveillance
systems
All
States/UTs
23 States
/UTs
MoHFW NNT
validation report
MoHFW report
Annual
Annual
EXPECTED RESULT 6.2: Achieve measles elimination and control for rubella/congenital rubella syndrome (CRS) by 2020
29 States/UTs
(Source: CES
2009)
2(Source:
HMIS 201213)
All States
/Uts (35)

district level
4. Number of
States with MCV 1
coverage of >90%
19 (Source:
HMIS 201213)
Self-explanatory
3. Reported AFP
cases have two
adequate stool
specimens
collected within 14
days of onset of
paralysis in > 80%
cases
>2
.>80%
>2
Self-explanatory
2. Non Polio AFP

rate is maintained
or exceeds 2 per
100,000 children
under 15 years
Target
>80%
Baseline
value
Indicator
MoHFW
MoHFW
MoHFW
MoHFW
MoHFW
MoHFW
MoHFW
Responsibility
73
A N N E X U R E S
ANNEX 7: Emergency Preparedness and Response Plan 2011
74
75
Emergency Preparedness and Response

Plan 2011
The Emergency Preparedness and Response
Plan has been developed at the request of the
Minister of Health & Family Welfare to ensure
adequate preparedness and response to an
event of importation of poliovirus anywhere in
India during 2011.
1. Background
India has made remarkable progress towards
polio eradication in 2010. Only 42 wild
poliovirus (WPV) cases have been detected in
the country, compared to 724 cases detected
during the same period in 2009. The progress in
polio eradication was reviewed during the
India Expert Advisory Group (IEAG) meeting
held in November 2010. At this meeting the
IEAG concluded that the epidemiologic,
genetic, serologic, operational & technical
evidence show that India is on the right path to
achieve eradication. However, the IEAG
identified certain risks to the polio eradication
Program in India. One of the major risks
identified includes continued transmission of
poliovirus within the mobile / migrant
populations, resulting in re-introduction and
spread of the virus in Uttar Pradesh (UP) and
Bihar or in areas outside these historically core
endemic states that are at high risk of
importation and further spread of polio. The
IEAG highlighted the fact that as long as virus
transmission continues in any part of India or
elsewhere in the World, the possibility of virus
importation to polio-free areas in India
remains.
In view of these risks, the IEAG recommended
that while intensive efforts should continue to
stop transmission in areas with recent WPV
transmission and the traditionally endemic
areas of UP and Bihar, the program in India
should:
a. make efforts to protect polio-free areas from
importation of virus from within or outside
India
b. rapidly respond to any WPV detected
anywhere in India during 2011 with an
aggressive mop-up vaccination campaign to
stop any further circulation of the virus.
A N N E X U R E S
The IEAG recommended that From now, any

WPV from any source should be considered a
public health emergency and responded to with
urgent mop-ups; government & partners must
deploy additional, highly experienced human
resources to ensure that mop-up rounds are of
the highest quality. Mop-ups should target both
the area of detection of the virus in a case or in
the environment and, if there is a clear genetic
link, the area of origin of the virus. Thus any
isolation of WPV requires a rapid high quality
mopping-up response as an utmost priority to
stop circulation and spread.
This document is a strategic plan for protecting
the polio-free areas of India from WPV and for
implementing high quality mopping-up
operations with the aim of stopping the final
chains of WPV transmission.
2. Immediate actions - Preparedness for
virus importation and response
2.1 National-level Actions
The Government of India will have a Central
Group to ensure adequate preparedness for a
rapid response and manage the actual response
to the detection of a wild poliovirus anywhere
in India during 2011. The group will be chaired
by the Joint Secretary, Health & Family
Welfare, Government of India, and comprise
of senior officials from the Ministry of Health
and Family Welfare (GoI), and representatives
of National Polio Surveillance Project (NPSP)
WHO, UNICEF and Rotary. The key
responsibilities of the group will include:
Identify and train Rapid Response Team
(RRT) members at the national level. The
RRT members will include experienced,
government and partner agency staff from
the fields of epidemiology, public health,
management and communication
(including a media specialist).
l
Follow up with state governments to ensure
that a Rapid Response Team, headed by an
officer of the rank of a Principal Secretary, is
constituted in each state. The state RRT should
include at least 2 to 4 well performing Medical
Officers from within the state who have at least
................................
76
5 years' experience in dealing with senior

district level officials and a familiarity with the
basic principles of mass vaccination campaign
implementation. The RRT members will be
trained by MoHFW, GoI with assistance from
WHO NPSP and UNICEF. In the event of
WPV detection, it will be necessary to assign
the RRT members full time duty by the state
governments to provide support to mop up
vaccination campaigns.
Develop a media response plan to be used in
the event of detection of WPV.
Review the availability of buffer stocks of

oral polio vaccines to manage mop-up
vaccination campaigns.
Organize a training of the RRT members

jointly with NPSP and UNICEF by the
second week of May 2011.
Monitor the identification and training

status of the RRT members.
Procure sufficient buffer stocks of bOPV,

tOPV and mOPVs to manage the mop-ups.
Develop a media response plan by end of

April 2011 that includes mechanisms of
harmonizing messages from union and state
governments to the detection of any polio
cases.
Summary of the national actions with the

proposed time frame:
Constitute the Central Emergency
Preparedness and Response Group by midApril 2011.
Write to state governments and partners, in

the second week of April 2011, for
identification of RRT members in each state
by the end of April 2011.
2.2 State level

2.2.1 States at risk of importation
The following states have been identified at a
high or medium risk of importation based on
past epidemiology of polio: Haryana, Delhi,
U t t a r a k h a n d , M a h a r a s h t r a , P u n j a b,
Rajasthan, West Bengal, Gujarat, Jharkhand,
Madhya Pradesh, Assam, Orissa, Andhra
Pradesh, Himachal Pradesh, Jammu &
Kashmir and Karnataka.
Risk Categorization of States based on history of polio importations during last fiveyears
Endemic states
States at high & medium
risk of importation
States at low risk of importation
High Risk of Importation: 8 or more importations and 5 years or more with importations
Medium Risk of Importation: 5 or more importations and 3 to 4 years with importations
l
l
77
2.2.2 State Level Actions

Each state at high or medium risk should
undertake the following actions to prepare for
the emergency response:
Constitute a State Emergency Preparedness
and Response Group chaired by the
Secretary (Health & Family Welfare) and
comprised of senior officials from the State
Government such as the Director Health
Services, State EPI Officer and other
nominated senior government officials.
State representatives of WHO- NPSP,
UNICEF and Rotary International should
also be a part of the group. This group
should monitor the preparedness and
implementation of the mop-up.
Undertake a risk analysis, in coordination

with WHO- NPSP officials, to identify
districts, blocks or urban areas at high risk of
importation and spread of poliovirus.
This analysis should identify areas that have

had repeated importations of polio viruses
during previous years or a recent clustering
of polio compatible cases in time and space,
or are hard-to-reach areas or have
demographic/ environmental factors that
would facilitate the spread of wild polio
virus following an introduction (such as high
population density, poor sanitation). Special
focus should be on the identification of areas
with low routine immunization coverage
and areas with migratory or mobile
populations in each state as per guidelines
issued by GOI in 2010. This risk analysis
should be completed at the earliest by each
state and the lists of all high-risk areas and
populations shared with GOI.
A N N E X U R E S
Develop and implement a plan to increase

polio SIA coverage and RI coverage in these
high-risk areas/ populations to achieve high
immunity against polioviruses in these
areas, which in turn will prevent spread and
establishment of circulation of any
imported wild polioviruses. These areas
should be targeted for better planning,
training, social mobilization and monitoring
efforts during the SIAs in 201112. The
states should also begin the process of
harmonizing the polio microplans with
Routine Immunization plans in the high-risk
areas.
Identify and nominate two to four

experienced medical officers to be a part of
the Rapid Response Teams (RRTs).
Review the surveillance quality in these

areas with the district and block officials in
coordination with NPSP officials to identify
actions to strengthen surveillance sensitivity
in these areas, which in turn will assist with
early detection and response following any
importation.
Assign senior state government officials to

visit high risk districts and blocks to review
progress in updating and implementing
microplans for improving immunization
coverage and surveillance sensitivity.
Summary of the state actions with the

proposed time frame:
Constitute a State Emergency Preparedness
and Response group by end of April 2011.
Identify RRT members by end of April 2011.
Identify high-risk districts and high-risk are

as within districts by mid-May 2011.
Undertake a communication risk analysis in

coordination with UNICEF/ WHO- NPSP
and based on the analysis develop a
communication plan for issues related to
non-compliance/ resistance to
administration of polio vaccines.
Identify and assign senior officials to

high-risk districts by third week of May
2011.
The above items should be reported back to

the Central Emergency Preparedness and
Response Group by the end of May 2011.

case a virus is detected.
................................
78
3. Response and actions following the

detection of wild poliovirus
3.1 Key steps in the planning phase of
the mopping up vaccination campaign
3.1.1 National-Level Actions:
The Ministry of Health and Family Welfare
will be informed about the detection of the
virus without delay.

will inform the Chief Secretary of the
affected state of the detection of the polio
case in the state.
The Central Emergency Preparedness and

Response Group will meet within 24 hours
of receiving the information. The Group
will review and analyze, in detail, the field
epidemiological investigation findings
pertaining to the polio case. Based on the
above findings, the areas and populations at
risk of poliovirus circulation will be
identified and a SIA response within the
broad strategic framework recommended by
the IEAG will be decided. The group will
make specific recommendations on:
Timing of the response
Areas to be covered during the response
Type of vaccine to be used during the

response
Number of proposed rounds
Additional investigations and analyses to be

conducted
Members from the Central Emergency
Preparedness and Response Group will visit
the concerned state to meet the state health
secretary and other state officials. The
members of the National and State
groups will subsequently visit the concerned
districts accompanied by the state RRT
members to review planning for an
emergency response.

Response Group will meet on a weekly basis
to review the planning and implementation
of the response and provide

recommendations to the immunization
division and state authorities to make
improvements.
Vaccine will be mobilized to reach the state
or districts undertaking the mop-up at least
three days before the start of the campaign.
MoHFW shall seek support from other

government departments such as Social
Welfare, Railways, Panchayati Raj, Urban
Development, Education, for the emergency
mop-up operation.
3.1.2 State level Actions:

The State Emergency Preparedness and
Response Group should be activated within
24 hours of receipt of information to
initiative the following actions:
Inform the Divisional Commissioners and

the District Magistrates of the areas
undertaking the mop-up within 24 hours of
receipt of information.
Allocate geographical areas and operational

responsibilities to all RRT members
ensuring an appropriate distribution of
human resource within 72 hours of receipt
of information.
Assign senior state officials to the districts

and members of the State Emergency
Preparedness and Response Group to visit
and mobilize the districts within 72 hours of
confirmation of case.
T h e c u r r e n t ly ex i s t i n g S t a t e - l eve l
Steering/Coordination Committee for polio
eradication should be requested to organize
a meeting within five days of case
confirmation to seek support and coordinate
a c t iv i t i e s w i t h o t h e r g ove r n m e n t
departments and NGOs.
3.1.3 District-level Actions:

District-level officials from health and
administration should begin mobilizing
block officials to start preparations within 48
hours of identify the importation.
79
District Task Force (DTF) meetings should

be organized in the district with RRT
members, NPSP, UNICEF staff and key
government officials to allocate specific
responsibilities within the district and ensure
participation of all sectors for a successful
implementation of the mop-up. The first
DTF to be conducted within five days of
confirmation of the case. Subsequently there
should be a weekly DTF to take stock of the
situation and address requirements of the
response activities.
Divisional Commissioners should review

the preparedness through participation in
DTFs and field visits.
Tehsil or Block Task force meetings should

be organized at sub-district level in all urban
and rural areas within sevendays of the
confirmation of the case.
All existing micro plans should be reviewed

as per operational guide for mop-up with
special emphasis to ensure no areas are
missed and there is high coverage of high
risk areas and migratory populations. All
micro plans should be reviewed and
modified within 10 days of confirmation of
the case.
All vaccinators should be retrained on

operational and IPC skills in the week before
the start of the mop-up.
The district and block in consultation with

UNICEF and other social mobilization
partners should plan and initiate IEC and
social mobilization measures based on solid
data collected through standardized data
tools.

case a virus is detected.
In consultation with the government, NPSP

should develop a monitoring plan for
intensive monitoring and mid course
corrections during the activity. Additional
independent monitors should be deployed
by NPSP in addition to the existing NPSP
and UNICEF staff present in the district.
A N N E X U R E S
3.2 Key actions during the mopping up

vaccination campaign
3.2.1 National-level Actions
Members from the Central Emergency
Preparedness and Response Group will
monitor the activity in the highest risk
blocks.

Response Group will meet to review the
feedback from its members, states, RRTs and
provide directions for corrective actions.
3.2.2 State-level Actions

Members of the State Emergency
Preparedness and Response Group and the
State monitors should visit high risk blocks
to monitor the activity and provide feedback
to the State Principal Secretary (H & FW)

Response Group should meet daily to review
feedback from the districts and plan
corrections.
3.2.3 District/ Sub District-level Actions:

The district should implement the SIA
activity under the direction of the District
Magistrate (DM) and supervision of the
Chief Medical Officer/Civil Surgeon. The
DMs should report on the quality of the
activity to the State Principal Secretary (H &
FW).
Daily monitoring and review of activity to

plan for corrective actions over subsequent
days
Senior district-level officials from health and

administration (Divisional Commissioner/
DM/ADM/CMO/DPO/Dy
CMO/BDOs) should monitor the
implementation of the activity and attend
evening meetings at the high risk blocks.
A daily evening review meeting should be

organized at the district under the
chairmanship of the District Magistrate.
................................
80
4. Key actions at the end of the activity

The District Magistrate should send a report
of the completed activity to the State
Group for review and corrective actions.

Response Group should meet to review this
and forward the report to the Central
Group.

Response Group will review the activity and
inform the Union Minister who, at his
discretion, will inform the Chief Minister of
the concerned state about the quality of
response activities and ongoing risk
assessment.
5. Role of partners
Partners should participate in the Central and
State Emergency Preparedness and Response
Groups. The key role of the partners will be as
follows:
NPSP: Provide sur veillance data,
epidemiologic analysis and strategic
planning and other technical support to the
group as well as support monitoring of the
preparedness and response at the district,
state and national levels.
UNICEF: Provide suppor t to the

communication/ social mobilization and
media strategies and their implementation
and monitor their impact
Rotary International:Provide support to the

advocacy at the state and district levels and
to the communication strategy and social
mobilization activities
6. States at low risk of importation of

poliovirus
Undertake a risk analysis, in coordination
with WHO-NPSP officials, to identify
districts, blocks, and urban areas at higher
risk of importation and spread of poliovirus.
This analysis should include identification

of areas that have had importations of polio
viruses during previous years or a recent
clustering of compatibles in time and space,
or are hard-to-reach areas or have
demographic or environmental factors that
would facilitate the spread of wild poliovirus
following an introduction (such as low
routine immunization coverage, high
population density, migrant sites, poor
sanitation). Special focus should be on the
identification of areas with migratory or
mobile populations in each state as per
guidelines issued by GOI in 2010. This risk
analysis should be completed at the earliest
and the lists of all high risk areas and
populations shared by each state with GOI.
The state should assign Senior State
Government officials to visit high risk
districts and blocks to review progress in
updating and implementing micro plans
prior to the 2011 NIDs for improving
immunization coverage and surveillance
sensitivity.
7. Strategy for mop-ups

The basic aim of the mop-up would be to
vaccinate all under-5 children in the mop-up
area. Each household in the mop-up area will
be visited by vaccination teams to vaccinate all
under-5 children. The duration of the
house-to-house (h-t-h) search and vaccination
would be decided by the number of available
vaccination teams in the area. In principle,
there would be a minimum of 2 to 5-day h-t-h
activity in all areas to ensure a rational
workload for each vaccination team.
Additional 1 to 2 days of h-t-h activity will be
undertaken in special areas with lesser number
of available teams e.g. in large urban areas. B
team activity will continue in UP and Bihar.
Transit teams and mobile teams will be
deployed to cover migrant and mobile
populations.
In areas that have used booths during the
SNID/NID, booths will also be setup on day 1
of the mop-up campaign because of their
IEC/SM value.
81
The mop-ups shall be implemented as per the

Operational Guide for SIAs published by
Government of India in 2006.
7.1 General principles for mopping-up
operations
The following guidelines as recommended by
the WHA andIEAG should be followed:
Speed of response: As early as possible but
no later than two weeks from confirmation
of the case.
Extent of mop-ups: The response should

consist of at least three large scale,
house-to-house rounds of immunization.
The World Health Assembly Resolution
(59.1) calls for coverage of 2 to 5 million
children in each round. Mop-ups should
cover at a minimum the infected district and
all districts contiguous with it, across state
boundaries if necessary. Where there is a
clear genetic link of the virus to the strains in
another area, the area of origin should also
be included. In the demographic context of
India and considering that this is the final
A N N E X U R E S
stage of polio eradication, the 18th IEAG

has recommended the appropriate target
population for mop-ups around 5 million
children per round.
o In high risk areas: SNID rounds may
constitute one or more of the three rounds,
but in principle at least one additional round
should be carried out in an appropriate area
using a short interval approach all rounds
must be of the highest possible quality!
o In non-high risk areas: Mop-ups should
consist of a minimum of three high quality
rounds, using a short interval approach
(minimum interval of two weeks but within
four weeks) all rounds must be of the
highest possiblequality!
Vaccine of choice for mop-ups is mOPV
appropriate to the local epidemiology or
bOPV; a rolling stockpile of 30 million doses
of bOPV and 10 million doses of mOPV1
should be maintained to allow for rapid
implementation of mopping up vaccination
with the appropriate vaccine.
................................
Costing and Financial

Sustainability of the
Universal Immunization
Program
................................
83
85
C o s t i n g a n d Fi n a n c i a l S u s t a i n a b i l i t y o f t h e U n i v e r s a l I m m u n i z a t i o n Pr o g r a m
1. Introduction
India is at an important time in the
development of its Universal Immunization
Program (UIP). It is planning several
improvements such as the addition of many
new and underutilized vaccines as well as
adding new staff at different administrative
levels. India will need to secure other sources of
financing as it will probably be graduating from
GAVI support since its high Gross National
Income (GNI) per capita1 will make it ineligible
for support. As a result, information on the
costs and sources of financing for the UIP will
be particularly important for policy-makers to
make informed decisions on phasing-in
strategies and timing of these Program
improvements.
The report on costing and financial
sustainability of the India Immunization
Program was developed during the period June
to December 2013, under the auspices of the
in India and assisted by the immunization
partners, WHO and UNICEF. The team that
collected and analyzed the data was led by a
research scientist from the Public Health
Foundation of India and consisted of
Government of India officials, and experts

from the Immunization Technical Support
Unit (ITSU-MoHFW) and the immunization
partners. Data was collected from June to
September 2013. Then meetings were held
with ministry officials to go over the
preliminary findings and assumptions to be
made in the analysis. Finally, from September
to December 2013 the data was analyzed and
put into a report.
2. Summary of Findings on Baseline
Expenditures
The main findings of the cost analysis are the
following:
Total baseline expenditure was INR 3,446
crore2 ($718 million), including shared
personnel costs,3 and INR 2,131 crore ($444
million) without shared costs.
o Expenditure on the routine Program was

INR 1,253 crore ($261 million) and, on the
supplemental immunization activities
(SIAs), was INR 878 crore ($182 million).
Table 1 shows total baseline expenditures
with shared costs and selected indicators on
cost per output and Program financing.
Table 1. Baseline Expenditures and Selected Indicators, 2012.

Baseline Indicators
Total Expenditures (USD) Total Expenditures (INR)
Routine Immunization only
261,089,884
12,532,314,431
Campaigns
182,995,523
8,783,785,120
Total immunization specific expenditure (A)
444,085,407
21,316,099,550
Total shared cost (B)
273,942,919
13,149,260,100
Grand Total (A + B)
718,028,326
34,465,359,650
Per capita
0.2
9.6
Per DTP3 child
14
672
Percentage national funding
90
90
Percentage total health expenditures
Percentage govt. health expenditures
0.03
0.03
Percentage GDP
Countries' GAVI eligibility for the year 2014 is GNI per capita lower or equal to $1,570.
1 crore= ten million (10,000,000)
Shared costs include the value of inputs that are not specific to immunization and which are used by different
Programs or activities in the health sector i.e. their utilization for immunization is less than 100%.
2
3
................................
3. Details of Baseline Program Cost

and Financing
The year 2012 is the baseline for the cost and
financing projections since it has the most
recent complete information. The actual
expenses of the government and the
immunization partners were taken into
account for the baseline cost calculation.
Table 2 shows the baseline cost profile. In 2012,
the total estimated cost of the UIP was INR
3,446 crore ($718 million), including shared
cost. Shared personnel cost (those who spent
less than 100 percent of their time for
immunization) contributed the maximum in
total expenditure (38 percent) while all routine
recurrent cost contributed 36 percent. The
contribution of SIAs was 25 percent in total
cost. The detailed expenditure on shared
personnel cost is provided in Table 3. Vaccines
86
and injection supplies under routine recurrent

cost are those used for Routine Immunization
only. The amount spent on vaccines and
injection supplies for supplementar y
immunization has been provided under SIAs.
Personnel cost includes salaries and benefits for
all who spent 100 percent of their time for
immunization starting from the national level.
Transport cost included the operational cost of
Teeka Express, vaccine handling cost at
GMSD and the petrol, oil, lubricant for vaccine
transport. It was assumed that there were a
total of 700 vaccine vans (250 4WD and 450
2WD) and 120 Teeka Express in 2012. Training
cost included the actual expenditure of the
government on training as well as the training
expenses by immunization partners. The
components and detailed expenditures under
social mobilization, Program management and
other routine recurrent cost are shown in
Tables 4, 5 and 6 respectively.
87
Table 2. Baseline Universal Immunization Program Costs, 2012

2012 (USD million)
2012 (INR crore)
Percent
Vaccines
59.92
287.60
8.3
Injection Supplies
16.46
79.00
2.3
Personnel
11.40
54.72
1.6
Transport
27.09
130.02
3.8
Cold chain maintenance
9.24
44.34
1.3
Training
5.94
28.53
0.8
Social mobilization, advocacy,

communication activities
50.23
241.10
7.0
Disease surveillance
18.97
91.04
2.6
9.67
46.40
1.3
37.91
181.96
5.3
246.81
1,184.71
34.4
Capital Costs
Cold chain equipment
14.28
68.52
2.0
Subtotal
14.28
68.52
2.0
261.09
1,253.23
36.4
Polio
Vaccines and Injection supplies
Operational costs
Total
95.22
53.00
148.21
457.04
254.37
711.41
13.2
7.4
20.6
Measles
Vaccines and Injection supplies
Operational costs
Total
15.14
13.11
28.25
72.69
62.91
135.59
2.1
1.8
3.9
JE
Vaccines and injection supplies
Operational costs
Total
4.85
1.68
6.54
23.30
8.08
31.38
0.7
0.2
0.9
Subtotal SIAs
183.00
878.38
25.5
Shared personnel costs
273.94
1,314.93
38.1
GRAND TOTAL
718.03
3,446.54
100.0
Routine Recurrent Costs
Program management
Other routine recurrent costs
Subtotal
Total Routine Costs (without

shared costs)
Supplemental Immunization
Activities (SIAs)
................................
88
Table 3: Details of shared personnel cost in 2012

Shared personnel
Numbers in
2012*
Salary per Percentage of time INR (crore) USD (million)

month (INR)
spent on
immunization
MO (in charge) at block level
4,833
35,000
10
20.30
4.23
Data entry operators at block level
4,833
8,000
2.32
0.48
24,049
35,000
10
101.01
21.04
ANM
207,578
12,500
33
1027.51
214.06
MPW
14,648
12,500
33
72.51
15.11
LHV
16,109
12,500
33
79.74
16.61
Data entry operators at PHC level
24,049
8,000
11.54
2.40
1,314.93
273.94
MO (in charge) at PHC level
Total
296,099
Table 4: Details of expenditure on social mobilization, advocacy and communication activities in 2012
INR Crore
USD million
194.62
40.55
24.98
5.20
5.73
1.19
15.77
3.29
241.10
50.23
INR Crore
USD million
10.97
2.29
Office supplies and consumables
0.31
0.06
Micro planning
2.17
0.45
4.77
0.99
Operational cost of polio and other VPDs (UNICEF)
9.36
1.95
Operational cost of polio and other VPDs (WHO)
18.83
3.92
Total
46.40
9.67
Cost components
ASHA incentives for social mobilizations
Printed materials (banners, posters, IEC materials) BCC tool
Advocacy and communication (UNICEF)
SMNet (UNICEF)
Total
Table 5: Details of Program management expenditure in 2012

Cost components
Evaluations, program reviews and assessment meetings
* Source: Rural Health Statistics in India, 2012.
89
Table 6: Details of expenditure for other activities under routine immunization in 2012
INR Crore
USD million
18.39
3.83
132.29
27.56
Planning, supportive supervision and monitoring
6.56
1.37
Intensification of Routine Immunization (WHO)
0.41
0.09
Research studies (Govt. + WHO)
4.05
0.84
Measles, JE control Program (UNICEF)
1.92
0.40
18.35
3.82
INR Crore
USD million
181.96
37.91
Cost components
Service provision in underserved and hard to reach areas
(including slums)
ASHA Incentives
Other state-specific activities

Cost components
Total
Figure 1. Baseline Cost Profile (without shared costs), 2012
Vaccines (routine vaccines only)
6%
Injection supplies
23%
15%
Personnel
Transporation
Cold chain maintenance
4%
Training
6%
7%
4%
Social mobilization, advocacy

and communication activites
Program management
19%
10%
4%

(capital cost)
................................
90
Figure 2 shows the sources of financing in the

baseline year for the UIP. The Government of
India paid for most of the Program
expenditures (90 percent). Other sources of

financing were WHO (4 percent), UNICEF (3
percent),4 and GAVI (3 percent).
Figure 2. Baseline Financing, Indian Immunization Program, 2012
4%
3% 3%
Govt.
WHO
UNICEF
90%
4. Recurrent Costs - Structure and

Analysis
4.1 Demographic projections
The calculation of the birth cohort and other
GAVI
target groups is based on Indian government

estimates and on the latest census of India
(Table 7). The population growth rate is 1
percent and the infant mortality rate is assumed
to decrease from 44 per 1000 in 2012 to 25 per
1000 in 2017.
Table 7. Key Demographic Variables for India, 2012 and 2017

2012
2017
24,676,883
26,323,130
1%
1%
44
25
15%
15%
Demographic Variable
Birth Cohort
Population Growth Rate
Infant Mortality Rate
Childbearing age women
WHO and UNICEF are implementing partners and their activities are funded by BMGF, GAVI and other external partners.
91
4.2 Vaccine and injection

supplies
The vaccine prices used for the baseline and
projections are shown in Table 8. The costs are
a mixture of GAVI prices as well as prices

obtainable by the government of India. India is
unique since it has many local manufacturers
from which it can purchase vaccines for the
national Program.
Table 8. Prices per Dose and Expected start year, and Implementation Strategy for Vaccines
Vaccines
Price per
dose
Expected
start year
Implementation
strategy
Sources of
financing
BCG
USD 0.05
NA
Routine
Govt.
Hep B (birth dose)
USD 0.05
NA
Routine
Govt.
OPV
USD 0.06
NA
Routine
Govt.
Measles
USD 0.16
NA
Routine
Govt.
DTP
USD 0.04
NA
Routine
Govt.
TT
USD 0.02
NA
Routine
Govt.
JE
USD 0.18
NA
Campaign
Govt.
DTP-Hib-HepB
(penta)
USD 2.11
2014-15
Roll out to all states

2014 - 11 states
2015 - 16 states
GAVI up to 2015
IPV
USD 1.00
2015-16
Pan India
Govt.
MR
USD 0.50*
2014-15
Pending NTAGI
endorsement. Start with
campaign (1-15 yr olds)
in 2014. 2015 onwards
under routine at 9
months or 1.5 years old.
Govt.
Rotavirus
USD 1.00
(Bharat)
2016-17
Pending NTAGI
Govt.
Pneumococcal
USD 3.30**
2017
Pending NTAGI
Govt.
Sources: *MR: http://www.gavialliance.org/library/news/press-releases/2013/over-700million-children-in-49-countries-to-be-protected-against-measles-and-rubella/

**Pneumococcal: http://www.pfizer.com/news/press-release/press-release-detail/pfizer signs new agreement with
unicef to supply a total of up to 740 million doses of prevenar 13 for the world's poorest countries through 2025
................................
92
Figure 3 and Table 9 show projected resource

requirements for vaccines from 2013 until
2017. The vaccine wastage rates are given in
Annex Table A.1. During the first four years,
the resource requirements are highest for
pentavalent vaccine as it is scaled up in the
country. However, by 2017, the larger share of
resource requirements will shift to PCV vaccine
if the vaccine is introduced nationwide in 2017.
Introduction of IPV and MR in 2015 will
increase vaccine resource requirements from
INR 633 crore in 2014 to INR 1,455 crore in
2015 (Table 9). Adding rotavirus vaccine in
2016 will increase resource requirements for
vaccines by INR 315 crore while introducing

PCV vaccine in 2017 will double the
requirements for vaccines. It should be noted,
though, that the estimate of resource
requirements in 2017 is probably an overestimate since it assumes that PCV will be
introduced nationwide although the vaccine
will probably be phased-in over time.
Another factor that will affect the impact of the
total resource requirements for India is that it
will likely be graduating from GAVI support
during the period of the cMYP. Thus, it will
have to secure a larger proportion of funding
for new vaccines as well as for pentavalent.
Figure 3. Resource requirements for Vaccines, Routine Immunization, 20132017
4000
PCV
Rotavirus
3500
MR
INR Crore
3000
IPV
TT
JE
Measles
Pentavalent
Help B (primary schedule)
2500
2000
1500
1000
DTP3
500
OPV3
Hep B (Birth dose)
0
2013
2014
2015
2016
2017
BCG
93
Table 9 also shows pentavalent vaccine will be

gradually scaled-up until it is provided
nationwide in 2015. As pentavalent vaccine is
scaled-up, DTP and Hepatitis B (primary
schedule) vaccines will be phased out while the
birth dose of Hepatitis B vaccine will continue.
Resource requirements for pentavalent vaccine

are projected to decrease in 2016 as the price
per dose is assumed to decline from $2.11 to
$1.54. Annex Table A.2 provides the resource
requirements for vaccines in USD.
Table 9. Vaccine Resource Requirements for Routine Immunization by Type and Year, INR Crore, 20132017
Vaccines
2013
2014
2015
2016
2017
BCG
14.9
15.9
15.9
16.1
16.3
6.5
6.1
7.1
8.2
9.3
37.4
33.8
35.6
37.7
40.7
312.7
459.9
858.1
807.4
773.8
DTP
21.0
12.7
8.0
NA
NA
Measles
53.4
54.2
59.6
64.2
68.8
TT
7.6
6.6
6.7
7.1
7.1
JE
37.4
30.5
31.1
31.7
32.2
Hep B (primary schedule)
19.7
13.2
7.5
NA
NA
IPV
NA
NA
230.3
203.1
203.4
MR
NA
NA
195.1
184.0
223.0
Rotavirus
NA
NA
NA
410.4
474.0
PCV
NA
NA
NA
NA
1738.8
Total
510.6
632.8
1,455.1
1,769.9
3,587.1
Hep B (Birth dose)

OPV
DTP-HepB-Hib (pentavalent)
Table 10 shows the resource requirements for

vaccines for SIAs by antigen and year in INR
crore (see Annex Table A.3 for US$). Polio
SIAs are assumed to take place every year while
measles (monovalent) SIAs end in 2013.
Starting in 2015, as part of the commitments to
reach the target of measles elimination in the

region by 2020, UIP will introduce the measlesrubella vaccine through SIAs phased between
2015 and 2016. As JE campaign will depend on
the epidemiological situation, we couldn't
project any cost for the same.
Table 10. Vaccine Resource Requirements for Supplementary Immunization Activities by Type and
Year, INR crore, 2013-2017
Vaccines
2013
2014
2015
2016
2017
OPV
315.4
279.2
279.2
242.4
242.4
39.7
NA
NA
NA
NA
NA
NA
704.1
704.1
NA
355.2
279.2
983.2
946.5
242.4
Measles
MR
Total
................................
94
4.3 Personnel Costs

Resource requirements for health care staff are
projected based on assumptions about salary
ranges, the percentage of time spent on
immunization, increase in number of staff per
year and annual increases in salary levels. The
assumptions on staffing are shown in annex
Tables A.4 to A.6. The assumptions about the
need for new staffing are based on the findings
and recommendations of the 2011 HR Needs
Assessment Study (GoI 2011). The study found
inadequacies in staffing for the UIP at the
national and state levels. Thus, the estimates
include recommended additional staff at
MOH level (three deputy commissioners and
12 assistant commissioners) and at state level
(two Program officers; one MIS officer; one
administrative and finance officers; one data
analyst; two cold chain / vaccine handler and

vaccine store technicians in each state). At the
state level, the estimates also include some new
immunization staff such as cold chain/vaccine
handler and vaccine store technicians.
Apart from full-time staff, there are shared
personnel who work for immunization. Figure
4 shows that resource requirements on shared
personnel are much higher than those of fulltime staff and are increasing due to annual
salary increments and additions to the number
of total staff. The amount spent on full-time
personnel will increase from INR 55 crore in
2012 to INR 101 crore in 2017 if all new staff
are hired as per assumptions given in annex
tables. On the other hand, the shared personnel
cost will increase from INR 1,315 crore in 2012
to INR 2,509 crore in 2017 (Tables 2 and 11).
Figure 4. Personnel Costs, 2012-2017, INR Crore
INR Crore
3000
2000
1000
0
2012
2013
2014
2015
Baseline
4.4 Training, Program Management,

Disease Surveillance, Social
Mobilization, Advocacy and
Communication
Training: The government is the main source
of funding for trainings (Figure 5). However,
the immunization partners such as WHO and
2016
2017
Full time personnel
Shared personnel
UNICEF also implement some training

programs on immunization. The amount spent
by the government on training will increase from
INR 21 crore in 2012 to INR 42 crore in 2017.
The resource requirements are projected to
double by 2017 because of the increased need for
trainings due to recruitment of health workers,
new vaccine introduction and planned SIAs.
95
INR Crore
Figure 5. Training Costs, 2012-2017, INR Crore

60
50
40
30
20
10
0
Govt.
WHO
UNICEF
2012
Baseline
2013
2014
Program management: Expenditure under

this category includes evaluations and meeting
related expenses, micro planning, office
supplies and consumables, operational cost of
immunization technical support unit (ITSU)
and operational cost of different vaccine
preventable diseases. Much of the Program
management is supported through the ITSU.
(MoHFW) and the Public Health Foundation
of India (PHFI) established ITSU in April 2012
with support from the Bill & Melinda Gates
Foundation (BMGF). The primary mandate of
ITSU has been to strengthen human resource
capacity for the UIP and to provide technical
and managerial support to MoHFW for
revitalizing, and successfully implementing
India's UIP. ITSU is currently focusing its
2015
2016
2017
efforts towards improving immunization

coverage in four states of India: Bihar, Madhya
Pradesh, Rajasthan and Uttar Pradesh, which
have been identified as high priority states with
low immunization coverage.
Figure 6 shows the baseline costs for Program
management in 2012 as well as the projected
resource requirements for 2013-2017. The
projected resource requirements for Program
management increase rapidly from 2013-2016
due to increased funding under GAVI HSS.
The GAVI HSS grant which has been
channeled to UNDP from 2013-14 is projected
to be taken over by the government in 2017.
This will result an increase in government
spending on Program management from INR
12 crore in 2012 to INR 183 crore in 2017.
Figure 6. Program Management Costs, 20122017, INR Crore

3000
INR Crore
250
200
GAVI HSS
150
BMGF
100
UNICEF
WHO
50
Govt.
0
2012 2013
Baseline
2014
2015
2016
2017
................................
96
D i s e a s e S u r ve i l l a n c e : W H O i s t h e
implementer of the disease surveillance
activities. Resource requirements for disease
surveillance activities are expected to more
than double by 2017, due to introduction of
new vaccines. The requirements for
surveillance will increase from INR 132 crore
in 2013 to INR 259 crore in 2017 and will be
fully financed by WHO (2013-2016 as "secure"
funding; whereas 2017 is set as "probable"
funding). Donor funding in this area will be
phasing out and the government will need to
increase its investment in disease surveillance.
S o c i a l M o b i l i z a t i o n , A dvo c a c y a n d
Communication Activities: Under this
category, we considered ASHA incentives for
social mobilization, government expenditure
for printing materials such as banners, and
posters, and advocacy, communication
activities and SMNet cost for UNICEF. The
government is the main source of financing for
social mobilization activities and is projected to
double its spending by 2017 (Figure 7). In
2012, the actual expenditure of the government
under this head was INR 220 crore which is
projected to be INR 451 crore in 2017.
Figure 7. Social Mobilization, Advocacy and Communication Activities Costs, 2012-2017, INR Crore
600
INR Crore
500
400
300
Govt.
200
UNICEF
100
0
2012
2013
2014
2015
2016
2017
Baseline
Other Routine Recurrent Cost: We considered

service provision in underserved / hard-toreach areas (including slums), ASHA
incentives for complete immunization,
planning, supportive super vision and
monitoring activities, intensification of routine
immunization, research related expenses and
different state specific activities under this

category. The government is the main source of
funding for these activities while WHO and
UNICEF also support some of these (Figure
8). Government expenditure under this
category will increase from INR 173 crore in
2012 to INR 270 crore in 2017.
97
INR Crore
Figure 8: Other Routine Recurrent Costs, 2012-2017, INR Crore
350
300
250
200
150
100
50
0
Govt.
WHO
UNICEF
2012
2013
2014
2015
2016
2017
Baseline
4.5 Cold Chain

The cold chain related projections are based on
the current assessment of cold chain situation
in India and future needs. The assumptions are
shown in Annex Table A.7. It should be noted
that the number of existing cold chain
equipment includes both the government
purchases as well as those purchased through
partner support (UNICEF). It should also be

noted that KFW is providing 180 crore for cold
chain equipment in 2014-15. We present the
cold chain maintenance related expenditure in
Figure 9. Government finances the most for
cold chain maintenance and the requirement
increases from INR 39 crore in 2012 to INR
218 crore if all assumptions related to cold
chain requirement in India are fulfilled.
Figure 9: Cold Chain Maintenance Costs, 2012-2017, INR Crore
INR Crore
250
200
150
100
Govt.
50
UNICEF
0
2012
2013
2014
2015
2016
2017
Baseline
................................
98
5.0. Future Resource Requirements

Table 11 and Figure 10 show the future resource
requirements for the routine immunization
Program by Program components. Total
requirement for the five-year period is INR
34,336 crore ($5,282 million).

Resource
requirements for vaccines increase rapidly from
INR 510 crore in 2013 to INR 3,587 crore in
2017 as new vaccines are assumed to be
introduced in the Program. The amount in
USD is presented in Annex Table A.8.
Table 11. Resource Requirements for India National Immunization Program, INR crore, 2013-2017
Cost Category
2013
2014
2015
2016
2017
Total
510.6
632.8
1,455.1
1,769.9
3,587.1
7,955.5
Injection supplies
71.8
72.3
89.7
84.7
102.9
421.4
Personnel
78.7
84.7
89.9
95.5
101.4
450.2
Transportation
203.4
234.9
271.3
313.3
361.9
1,384.8
Cold chain and

other capital equipment
maintenance
116.3
149.4
175.9
207.0
220.9
869.4
30.8
36.5
41.5
47.4
54.1
Social mobilization /
advocacy / communication
activities
284.1
373.8
421.3
467.9
483.1
2,030.3
132.9
161.4
186.4
215.3
248.7
944.7
94.1
225.5
215.4
231.7
248.5
1,015.2
219.3
248.4
266.3
282.0
300.2
1,316.3
131.4
198.2
269.2
343.6
419.7
1,362.1
Supplemental Immunization
Activities
789.6
740.6
1,520.7
1,522.6
813.5
5,386.9
Training
Program management
210.3
1,907.1
2,042.5
2,187.5
2,342.8
2,509.1
10,989.0
Total
4,570.0
5,201.0
7,190.2
7,923.9
9,451.0
34,336.1
99
Figure 10. Total Resource Requirements for UIP, 2013-2017, INR Crore
10000

Supplemental Immunization Activities
9000
8000
INR Crore
7000
Program managememt
6000
5000
Social mobilization / advocacy /

4000
Training
3000
Cold chain and other capital

equipment maintenance
2000
Transportation
1000
Personnel
Injection supplies
0
2013
2014
2015
2016
6.0. Future Financing and funding gap

analysis
2017
UIP is the government. The financing gap

increases from INR 56 crore in 2013 to 815
crore in 2015 and further to INR 3,537 crore in
2017 and reflects the fact that funding has not
yet been secured for the new vaccines to be
introduced during those years.
Figure 11 shows the future secure financing

and gaps in financing for 2013-2017. This
figure does not include other financing that is
probable.5 The largest source of financing for
Figure 11. Future Secure Financing and Funding Gaps, 2013-2017, INR Crore
10000
Funding Gap
8000
INR Crore
GAVI HSS
6000
BMGF (ITSU)
GAVI
4000
UNICEF
2000
0
2013
WHO
Govt.
2014
2015
2016
2017
cMYP costing & financing tool has two categories of funding:

1.Secure funding refers to projected future financing available in the short term, that is considered assured;
2.Probable funding refers to all other funding that is not assured but is likely to be made available in the short and medium term.
................................
100
Figure 12 shows the Program financing with

probable as well as secure funding. In this
scenario, the government and GAVI will
provide financing for the new vaccines. As can

be seen, if probable funding is included,
funding gap is insignificant.
Figure 12. Future Secure and Probable Financing and Funding Gaps, 2013-2017, INR Crore
10000
INR Crore
9000
8000
Funding gap
7000
GAVI HSS
BMGF (ITSU)
GAVI
UNICEF
WHO
Govt.
6000
5000
4000
3000
2000
1000
0
2013
2014
2015
2016
Conclusion
Total UIP cost in 2012 was:
INR 3,446 crore ($718 million), including
shared health systems costs
INR 2,131 crore ($444 million) without
shared costs.
Expenditure on the routine program was INR
1,253 crore ($261 million) and, on the
supplemental immunization activities, was
INR 878 crore ($182 million). The cost per
capita for the Program was INR 9.6 ($0.2) and
cost per DTP3 child was INR 672 ($14).
The total projected resource requirement for
2013-2017 is INR 34,336 crore ($5,282
million). The resource requirement will
increase from INR 4,570 crore in 2013 to INR
9,451 crore in 2017 due to the new vaccine
introduction and other Program
improvements. Supplementary immunization
activities are projected to cost INR 5,387 crore
($829 million) during the five-year period.
However, it should be noted that the vaccine
requirement in 2017 is overestimated as we
assumed PCV will be introduced throughout
the country in 2017 while probably it will be
introduced in a phased manner. Secondly, the
total resource requirement is under estimated
as we couldn't project anything for JE
campaign in coming years as the campaign will
2017
depend on the epidemiological situation.
The majority of the UIP resource requirement
is financed by the Government of India.
External partners do, however, provide critical
funding support to technical partners such as
WHO and UNICEF for training, disease
surveillance, IEC/social mobilization. As the
total resource requirement increases steadily,
the funding gap also increases and in order to
fill this gap, the government health budget
needs to increase in the coming years. The
projected increase of government health
expenditure for immunization is from 2.5% in
2013 to 3.3% in 2017.
The UIP could improve its financial
sustainability by improving Program efficiency
through the following:
reviewing immunization expenditure
annually;
monitoring Program performance and input
productivity;
reducing wastage, and
introducing less resource-intensive means of
service delivery.
The Program should investigate some potential
strategies to improve Program efficiency,
particularly since India will be taking over
more of the costs of the Program after the
funding from GAVI and other donors ends.
101
Annexures
A.1 Wastage rates
Proposed wastage rates for single and ten dose vials are in line with WHO/UNICEF
recommendations and others are as per government wastage rate calculations.
Table A.1. Assumptions on Wastage Rates by Antigen

Vaccine
2017 (percentage)
2013 (percentage)
BCG
50
Hep B (birth dose)
15
OPV
25
10
DTP-Hep B- Hib (Penta)
25
10
DTP3
25
Measles
25
MR
25
25
Hepatitis B
25
10
IPV
30
30
JE
25
TT
25
10
Table A.2. Vaccine Resource Requirements for Routine Immunization by Type and Year, US$ millions, 2013-2017
Vaccines
2013
2014
2015
2016
2017
BCG
2.3
2.4
2.4
2.5
2.5
Hep B (Birth dose)
1.0
0.9
1.1
1.3
1.4
OPV3
5.8
5.2
5.5
5.8
6.3
DTP-Hep B-Hib (Pentavalent)
48.1
70.8
132.0
124.2
119.0
DTP
3.2
1.9
1.2
0.0
0.0
Measles
8.2
8.3
9.2
9.9
10.6
TT
1.2
1.0
1.0
1.1
1.1
JE
5.8
4.7
4.8
4.9
4.9
Hep B (primary schedule)
3.0
2.0
1.2
NA
NA
IPV
NA
NA
35.4
31.3
31.3
MR
NA
NA
30.0
28.3
34.3
Rotavirus
NA
NA
63.1
72.9
PCV
NA
NA
NA
267.5
Total
78.5
97.4
223.9
272.3
551.9
................................
103
Table A.3. Vaccine resource requirements for supplementary immunization activities by type and
year, USD (million), 2013-2017
Vaccine
2013
2014
2015
2016
2017
OPV
48.5
42.9
42.9
37.3
37.3
Measles
6.1
NA
NA
NA
NA
MR
NA
NA
108.3
108.3
NA
Total
54.6
42.9
151.2
145.6
37.3
Table A.4. Assumptions on health staff on salaries, annual increases in number and salary,
and time spent on immunization
Staff category
Percentage
time spent on
immunization
Salary range
ANM, MPW, LHV
33
Mos
SIO / DIO
Increase in
number per
year
Salary
increase
per year
Rs. 1,0000 to Rs. 15,000

per month
2%
5%
10
Rs. 35,000 to Rs. 45,000

per month
2%
5%
100
Rs. 40,000 to Rs. 50,000

per month
NA
5%
Rs. 30,000 to Rs. 40,000

per month
NA
5%
State cold chain officer
100
ASHAs
Based on
sessions
Data entry operators

from PHC to block
level
2% increase
in sessions
per year
Rs. 8,000 to Rs. 15,000 per

month
5%
Cold chain technician
100
Rs. 12,500 per month
5%
At Ministry
15 staff (100%)
(including
contract staff)
991,200 per
annum (Total)
5%
At Ministry (Partner
support)
8 staff (100%)
5%
Research consultant
Data analyst
Admin staff
100
100
100
5%
5%
NRHM consultants
100
Rs. 637,700 per

annum (Total)
AEFI related staff (from 2013-14)
................................
5%
5%
105
Table A.5. Assumptions on new immunization staff

Staff category
Salary range
Where posted
Year of
recruitment
District vaccine logistics

manager
Rs. 15,000 to
One in each district
2014-15
Cold chain / vaccine

handler
Rs. 15,000 to
Two in each state

vaccine store
2014-15
Divisional Vaccine logistics

manager
2014-15
State HEMR unit with

engineers supported by state
vaccine store technician
One handles four

districts
Two in large states population 40 million
and above;one in small
states
WIC/WIF handler in govt.

medical store depot (in shift)
Rs. 8,000 per month
Four in each depot

(semiskilled helper)
2014-15
Refrigerator technician at
Govt. medical store depot
One in each depot
2014-15
State vaccine logistics

manager
One in each state
2014-15
Vaccine logistics manager at

GMSD
One each at GMSD
2014-15
2014-15
Table A.6. New proposed staff in Mavalankar report (these positions will be started filling up from 2014
onwards in a phased manner)
Staff category
Gross salary per month
Deputy commissioners at ministry (3)
Rs. 200,000
Assistant commissioners at ministry (12)
Rs. 150,000
State Program officer (immunization) (2 in each state)
Rs. 35,000 - Rs. 45,000
State logistics manager (immunization) (1 in each state)
Rs. 35,000 - Rs. 45,000
State MIS manager (immunization) (1 in each state)
Rs. 35,000 - Rs. 45,000
Administration and Finance officer (immunization) (1 in each state)
Rs. 35,000 - Rs. 45,000
State immunization technology and research officer (1 in each state)
Rs. 35,000 - Rs. 45,000
Quality control and AEFI officer (immunization) (1 in each state)
Rs. 35,000 - Rs. 45,000
IEC officer (immunization) (1 in each state)
Rs. 35,000 - Rs. 45,000
Assistant cold chain officer (1 in each state)
Rs. 30,000 - Rs. 35,000
Store officer (immunization) (1 in each state)
Rs. 30,000 - Rs. 35,000
Data analyst (1 in each state)
Rs. 15,000 - Rs. 18,000
................................
106
Table A.7 Cold chain related assumptions

Assumptions
Sources
Number of cold chain points

(existing)
27,000
State report NCCMIS
Cold chain points required
One cold chain point per 30,000

population (2011 census)
CCO meeting minutes
Total cold chain points

required
40,340
CCO meeting minutes
New cold chain points

required
28,238
CCO meeting minutes
Present number of ILR in

cold chain points
27,000 (assuming one in each

cold chain point)
CCO meeting minutes +

standard assumptions
Present number of DF in
cold chain points
27,000 (assuming one in each

cold chain point)
CCO meeting minutes +

standard assumptions
Existing ILR/DF needs

replacement
50% (27,000) needs immediate

replacement - should be replaced
within 2-3 years
Based on NCCMIS of
ageing and useful life of 10
years
New ILR / DF required at

cold chain points
The required number (56,476) will

be procured within 3 years
Based on NCCMIS of
ageing and useful life of
10 years
Cold chain points need

solar or hybrid
30% of all PHCs will have less

than 8 hours electricity; hence
need solar or hybrid
NCCMIS
50% of these will be hybrid where

there is supply for 4-6 hours
Existing solar or hybrid
Solar - 270; Hybrid - 300.
State CCO Report
Solar or hybrid
The required number (Solar 5,781; hybrid - 5,751) will be

procured in 2-3 years
NCCMIS
At GMSD level
At each GMSD, 8 WIC of 40 cub.

Mt; 4 WIF to accommodate
rotavirus / IPV vaccine
National EVM, 2013
Present number of WIC at

GMSD
National EVM, 2013
Present number of WIF at

GMSD
National EVM, 2013
Required WICs/WIFs
Required number at GMSD level

(22 WICs / 10 WIFs) will be
available in 2 years
National EVM, 2013
107
Assumptions
Sources
At state vaccine store level
At each vaccine store, at least 4

WIC and 2 WIF of 40 cu. Mt
National EVM, 2013
WIC/WIF needs
replacement at state
vaccine store level
50% of the total needs

replacement (117 nos.) - should
be replaced within 2-3 years
NCCMIS
At divisional vaccine store

level
At each store, at least 4 WIC of

40 cu. mt and 2 WIF of 20 cu. mt
Personal discussion with

UNICEF and ministry
WIC/WIF required
replacement at divisional
store level
50% of the total needs

replacement (62 nos. each) - to
be replaced within 2-3 years

UNICEF and ministry
At district vaccines stores
District with population more than

20 lakh, one WIC and 6 DFs are
required

UNICEF and ministry
Districts with population less than

20 lakh, 8 large ILR and 4 large
DF
WIC/WIF/ILR/DF required
replacement at district store
level
231 WICs; 1,386 DFs; 3,272 ILRs

and 1,636 large DFs need
replacement within 2-3 years
NCCMIS
Cold boxes (large and

small) at cold chain points
Every cold chain points (30,000

population) should have two 20 lit
cold boxes; and four 5 lit cold
boxes
CCO Meeting minutes
Cold boxes need

replacement
30% (40,340 large; 80,680 small)

needs immediate replacement should be replaced within 2-3
years
NCCMIS
Cold boxes at state /

divisional vaccine stores
for 30000 population, 2 large cold

boxes

UNICEF and ministry
Cold boxes need

replacement

within 2-3 years
NCCMIS
Cold boxes at district

vaccine stores
Per store, 20 large cold boxes are

required

UNICEF and ministry
Cold boxes need

replacement
30% (6,400) need immediate

within 2-3 years

UNICEF and ministry
................................
108
Assumptions
Sources
Cold boxes at GMSD level
50 large cold boxes are required

at the GMSD level

UNICEF and ministry
Cold boxes need

replacement
30% (100) need immediate

within 2-3 years

UNICEF and ministry
Vaccine carrier
Each ANM should have 2 vaccine

carriers

UNICEF and ministry
Carriers replacement
20% every 3 years (presently

103,789 need replacement).
Should be replaced within 2-3
years

UNICEF and ministry
Ice packs
Each vaccine carrier should have

four ice packs

UNICEF and ministry
Ice packs replacement
Every 2 years, 50% ice packs

should be replaced. (830,312
needs immediate replacement should be replaced within 2
years)

UNICEF and ministry
Voltage stabilizer
Every ILR/DF will have its own

stabilizer
NCCMIS
Stabilizer needs
replacement

replacement - will be replaced
within 2-3 years
NCCMIS
Tool kit
Each technician will have one

toolkit - should be replaced within
3-5 years
NCCMIS
Total number of technicians

/ toolkit
427
NCCMIS
Toolkit supplied by UNICEF
.200
NCCMIS
Toolkit to be procured
227 (To be procured within 2

years)
Temperature monitoring
device
Every ILR/DF should have one

temperature monitoring device should be replaced in 5 years

UNICEF and ministry
Total number required
75,615; should be procured within

2-3 years

UNICEF and ministry
Spare parts
Every year 2 million dollar presently supplied by UNICEF

UNICEF and ministry
Wireless data logger

required
One each in each WIC / WIF total required - 743.
NCCMIS / NEVM
UNICEF supply
54
UNICEF
Wireless data logger
The required number 689 will be

procured in 3 years

UNICEF and ministry
NCCMIS
109
Other cold chain related assumptions
Price of ILR or DF (large): Rs. 50,000

Price of ILR or DF (small): Rs. 40,000
Price of solar: Rs. 200,000
Price of hybrid: Rs. 13, 00,000 (this is an
alternative source of power supports entire
PHC with a load of 2.5 KVA including cold
chain equipment)
Price of WIC / WIF of 40 cu. Mt: Rs. 18,
00,000 (including procurement, installation
and 5 years CMC)
Price of WIF of 20 cu. Mt: Rs. 15, 00,000
(including procurement, installation and 5
years CMC)
Price of large cold box (20 lit.): Rs. 7,350
Price of small cold box (5 lit): Rs. 5,000
Price of vaccine carrier: Rs. 1,000
Price of ice packs: Rs. 35
Price of voltage stabilizer: Rs. 5,000
Price of toolkit: Rs. 115,500
Price of temperature monitoring device: Rs.
10,100 (including installation) (30 percent
reduction of price for bulk purchase)
WIC/WIF wireless data logger: 1 lakh
including equipment, installation, internet,

AMC, and CMC for 5 years
Price increase over the years: 10
percent
Useful life
ILR, DF, WIC and WIF: 10 years

Cold boxes and tool kit: 5 years
Voltage stabilizer and vaccine carrier: 3 years
Ice packs: 2 years
Building
The following numbers of buildings need to be
built over the cMYP period:
At the district level, 64 percent of the
buildings (410 buildings) (Source: National
EVM Assessment Report 2013)
At the state level, 75 percent of the buildings
(29 buildings)
At the divisional level, 75 percent of the
buildings (92 buildings)
Building construction costs:
In districts with 20 lakh population: 2225
lakh
At state and divisional level: 50 lakh
Table A.8. Resource requirements for India Universal Immunization Program, USD (millions), 20132017
Cost Category
Injection supplies
Personnel
Transportation
Cold chain and other capital equipment
maintenance
Training
Social mobilization / advocacy /
Program management
Supplemental Immunization Activities
Total
2013
78.5
11.0
12.1
31.3
17.9
2014
97.4
11.1
13.0
36.1
23.0
2015
223.9
13.8
13.8
41.7
27.1
2016
272.3
13.0
14.7
48.2
31.8
2017
551.9
15.8
15.6
55.7
34.0
Total
1,223.9
64.8
69.3
213.0
133.8
4.7
43.7
5.6
57.5
6.4
64.8
7.3
72.0
8.3
74.3
32.3
312.3
20.4
14.5
33.7
20.2
121.5
293.4
703.1
24.8
34.7
38.2
30.5
113.9
314.2
800.2
28.7
33.1
41.0
41.4
234.0
336.5
1,106.2
33.1
35.7
43.4
52.9
234.2
360.4
1,219.1
38.3
38.2
46.2
64.6
125.1
386.0
1,454.0
145.3
156.2
202.5
209.6
828.8
1,690.6
5,282.5
................................

Comprehensive Multi Year Plan - UIP in India

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Comprehensive Multi Year Plan - UIP in India

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Multi-Year Strategic Plan

GUIDING PRINCIPLES OF UIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

UIP STRATEGIC PLAN: 2013-17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NATIONAL MONITORING AND EVALUATION PLAN FOR UIP . . . . . . . . . . . . . . . . . . .

COSTING AND FINANCIAL SUSTAINABILITY OF THE UNIVERSAL

Adverse Events Following Immunization

Acute Encephalitis Syndrome

Acute Flaccid Paralysis

Accredited Social Health Activist

Alternate Vaccine Delivery

Bivalent Oral Polio Vaccine

Central Bureau of Health Intelligence

Cold Chain Equipment

Cold Chain and Logistics

Comprehensive Multi-year Plan

Common Review Mission

Civil Society Organization

Child Survival and Safe Motherhood

Detailed Investigation Report

Diphtheria Pertussis Tetanus

District Task Force on Immunization

Empowered Program Committee

Emergency Preparedness and Response Plan

electronic Vaccine Intelligence Network

Effective Vaccine Management

Frontline Health Worker

First Information Report

Financial Management Group

Government Medical Store Depot

Health Management Information system

Integrated Child Development Services

Infectious Diseases Hospital

Information, Education and Communication

Integrated Management of Neonatal and Childhood Illnesses

Infant Mortality Rate

Indian Pharmacopoeia Commission

Indian Public Health Standards

Immunization Strengthening Project

Immunization Technical Support Unit

Intra-Uterine Contraceptive Device

Joint Review Mission

Janani Shishu Suraksha Karyakram

Lady Health Visitor

Mother and Child Tracking System

Measles Containing Vaccine

Millennium Development Goal

Multi Dose Vial Policy

Management Information System

Maternal Mortality Rate

Ministry of Health and Family Welfare

Mission Steering Group

Newborn Stabilization Unit

National Cold Chain Assessment

National Cold Chain Management Information System

National Cold Chain Training Center

National Cold Chain Vaccine Management Resource Center

National Institute of Health and Family Welfare

Nutrition Rehabilitation Center

National Rural Health Mission

National Technical Advisory Group on Immunization

Oral Contraceptive Pill

Oral Polio Vaccine

Oral Rehydration Salt

Open Vial Policy