Dr. S. Muhammad Salim Khan
No challenge is so steep, or adversity so great, to obstruct Ms. Posha Bagum’s path to duty. For Posha, a Female Multi-Purpose Health Worker (FMPHW), posted at Sub Center (SC) Jumgand, Block Trehgam, Jammu & Kashmir, travelling long distances is not out of the ordinary. With the Block Headquarters situated at a distance of 24 KMs from her SC, she is used to covering the path on foot, much to the admiration of her peers and fellow community members. They marvel at her ability to endure the challenging, hilly terrain of Jumgand and make round trips, all in the line of duty. But humble Posha credits her commitment to her work, and not her physical strength and endurance, as the motivation for her to keep moving forward.
One such display of resilience and sheer determination was witnessed on 1 May 2020, when Posha, due to the unavailability of public transport owing to heavy snow fall over the past few days, embarked on a 10 KM long upward, steep journey on foot to conduct an immunization session in Village Jumgand. Upon reaching her destination after a three-hour arduous walk along snowbound roads, the parents of the beneficiary children were awestruck to learn that not only had Posha managed to cover this distance unscathed, she had done so carrying her infant on her left arm, and the bulky vaccine container on her right arm.
Overcome with gratitude, the parents expressed their appreciation for her efforts. The mothers hugged and kissed Posha, while the fathers arranged for a comfortable stay for her as she conducted the immunization session. After relaxing and rejuvenating her strength with a drink of hot, steaming kahwa, Posha successfully vaccinated two four-month-old baby boys, and one two-month-old baby girl. As she prepared for another long journey back home, the parents expressed their heartfelt regard for her selflessness once again, and sent her along her way with good wishes and duas.
This inspiring account is just one among the many instances of dedication and the will to constantly strive for improved immunization demonstrated by the state health team. J&K has consistently shown marked improvement in the uptake of vaccination services, to tremendous results, despite one of the most difficult geographical terrains, speckled with several hard-to-reach areas in the country.
The Universal Immunization Program in the country is the largest immunization program in the world. The vaccines provided under the programme in the UTs of Jammu & Kashmir and Ladakh includes those against the severe form of childhood tuberculosis, diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, measles, hepatitis B, rotavirus diarrhoea, rubella, meningitis &pneumonia caused by Hemophilus Influenza type-B.
Over the years, the government has attempted to consistently strive and improve access and coverage of life-saving vaccines for women and children. Despite the progress, challenges prevail and decelerate the pace of coverage of these vaccines among the target population. Issues related to difficult geographical terrains, lack of awareness among communities, gaps in health systems, as well as micro-planning at district and sub-district level have resulted in the children being left out or dropped out from the program. In addition to the slow improvement rate, there are regional differences in the immunization coverage. The state of Jammu and Kashmir (now Jammu Kashmir UT and Ladakh UT as on 31 October, 2019) saw an increase in the full immunization coverage of <~ 10% over 10 years from 2005 to 2015 (as per NFHS 3 & 4 data, respectively). This slow improvement could be attributed to various reasons of difficult geographical terrain, loss of connectivity during the winter months, vaccine hesitancy, and civil unrest among many others.
To address this issue of low immunization coverage and accelerate the reach of the lifesaving vaccines to each child and pregnant women in the country the Government of India launched its flagship immunization program called Mission Indradhanush in 2014 and the government of J&K followed suit. Mission Indradhanush aimed to reach unvaccinated and partially vaccinated children and pregnant women across underserved and hard-to-reach areas, with a goal to reach a 90% immunization coverage across the country. The campaign started off in Jammu & Kashmir right since the first phase of MI (in 2015) and has so far been conducted in 15 districts. The efforts have yielded results. A total of eight phases of MI (including GSA and EGSA) has been held in the UT so far covering around 1.1 lac children and 11497 pregnant women.
In 2017, Intensified Mission Indradhanush (IMI) was conducted in Jammu in order to enhance focus to urban areas, including sub-center pockets and urbans slums with migratory populations. Under IMI, four consecutive immunization rounds were conducted for 7 days every month between October 2017 and January 2018. The inter-departmental coordination, program review, and monitoring were intensified to ensure rapid immunization coverage. An independent survey of IMI-CES(Coverage evaluation survey), done following the Intensified Mission Indradhanush in 2017-18, showed an increment of >20% in the full immunization coverage from the baseline of NFHS-4 in Jammu District. The district was felicitated for this achievement during the Silver jubilee of Pulse Polio programme in October 2019 at New Delhi.
With the vision of comprehensive and inclusive growth, the Government of India identified aspirational districts across the country for quick and effective transformation. The NITI Aayog initiated Gram Swaraj Abhiyaan, a high-intensity outreach programme to deliver welfare schemes to select villages of the aspirational districts across India and Mission Indradhanush was added as part of the campaign. Baramulla and Kupwara were identified as aspirational districts in Jammu & Kashmir. The full immunization coverage (FIC) for children between 12-23 months in the district of Baramulla was 78.6% and 77.8%district of Kupwara respectively as per NFHS-4. The Extended Gram Swaraj Abhiyan covered 279 villages across Baramulla district and 222 villages in Kupwara District.
Being a difficult terrain, the state focused on hard to reach geographies with low coverage in Kupwara and Baramulla, to provide adequate logistics and human resource so that all children are reached with the lifesaving vaccines, with special focus on tribal and migratory population. A total of three phases of MI have been held in the aspirational districts covering 22696 children and 3258 pregnant women. Social mobilization of children was carried out through a mix of awareness generation activities and inter-personal communication interventions by ASHAs, Anganwadi Workers and ANMs.
With the convergence of field workers across various departments, such as the ASHAs, ANMs, Anganwadi workers, self-help groups, and with setting strong linkages within the community and with the faith-based organizations, Jammu and Kashmir scripted a sustained success in delivering immunization services to the children and pregnant women.
Universal Immunization Program (UIP) has been further strengthened through Intensified Mission Indradhanush (IMI) 2.0 to reach the unreached and partially vaccinated children in 2 districts of Jammu and Kashmir i.e. Baramulla and Kupwara. 4 rounds of IMI 2.0 were conducted from December 2019 to March 2020, wherein 2259 children and 320 pregnant women were vaccinated. Despite harsh weather, the sessions were planned meticulously and with the involvement of the Panchayati Raj Institutions (PRIs) representatives and the religious leaders, 100% of the identified children and pregnant women were vaccinated. The trend analysis of HMIS data for the financial year 2018-19 and 19-20 highlights marked improvement in the full immunization coverage of the two Union Territories.
In this success, hundreds of Female Multipurpose Health Worker FMPHW Nurses like Posha Begum, and other hundreds of ASHAs, Anganwadi workers and ANMs play a huge role, who cross rough terrains, rough weather and snow to reach the last child. However, Posha Begum and her colleagues overcome these hurdles like champions to script the story of a healthy India. From national campaigns to unique challenges during the pandemic, J&K is also a case study in overcoming it all with the right mindset and will power, and implementing strategies to achieve the best results.
The writer is a FAIMER Fellow (Medical Education), MAMS, FIAMS, Professor & HOD, Community Medicine (SPM), Government Medical College, Srinagar, Jammu and Kashmir