A fair amount of media attention has been given to the resurgence of diphtheria in Kerala, which has been attributed to some Muslims rejecting immunisation efforts due to misinformation. However, a much more dangerous and widespread trend of declining immunisation rates as evidenced by the recent National Family Health Survey 4 data, seems to have gone entirely unnoticed.

Immunisation is perceived to be a function of public health services in which India has made significant gains over the last few decades. The country has been globally lauded for being able to successfully halt the incidence of polio, albeit with some initial costs to routine immunisation.

Health experts also feel that India has prioritised immunisation more than the much-needed overall strengthening of health care services, perhaps because the delivery of immunisation is relatively dependent upon frontline workers and relatively less complex, or because of a greater focus by international donor agencies.

However, even for this simpler service, there have been critical supply-side issues related to the closure of public sector manufacturing units, shifts towards private sourcing of vaccines, unethical trials of new vaccines, poorly evidenced introduction of new vaccines, considerable wastage and inadequate supplies of the routine vaccines, including injectable vaccines for polio that are considered essential to consolidate the gains made towards polio eradication.

Surprising reversals

Thus there has been no reason to anticipate any stagnation or decline in immunisation. However, a decline is becoming visible on looking at the National Family Health Survey 4 data closely.

The National Family Health Survey 4 has put up fact sheets for 18 states so far. Here we examine results for 10 major states covered. Since Andhra Pradesh was bifurcated after previous surveys, its results are not comparable, hence it has been omitted from this discussion.

Clearly, as expected, there have been significant gains in full-immunisation coverage in many states, most notably, high focus states like Bihar, Madhya Pradesh and Assam. Bihar has made most remarkable progress between 2005-’06 and 2015-’16 – from 31.4% to 61.7%, an increase of 29.3 percentage points.

Among the non-high focus states West Bengal has made the most significant progress, with a 20 percentage point improvement in coverage. Goa is the other state which has done consistently well over the two rounds.

However, most counter-intuitively, states which had done well in terms of immunisation coverage in the National Family Health Survey 3 conducted in 2005-’06 have slipped over the last 10 years.

These states are Tamil Nadu, Haryana, Uttarakhand and Maharashtra (Fig 1). The decline in Tamil Nadu is most significant. From being among the leading states in terms of full immunisation coverage, it has now experienced a dramatic 11.2 percentage point decline.

On further examination, the major reason for stagnancy or decline in immunisation outcomes appears to be due to a decline in coverage in urban areas (figure 2 ).

Here, among the 10 states covered, in six cases coverage has either declined or remained stagnant over the decade.

Most noteworthy is the decline in Haryana (from 82.2% to 57%), Maharashtra (68% to 55.8%), Tamil Nadu (83.7% to 73.3%) and Uttarakhand (67.2% to 56.5%).

At the same time, encouraging improvements have taken place in Assam where coverage has increased massively by 41.6 percentage points; an astonishing increase over the span of a decade. In Bihar the improvement has been of 14.1 points and West Bengal has made progress of 7.4 points.

The findings from rural India show that barring Tamil Nadu that registers a 10 point decline, immunisation coverage has increased in all states surveyed (figure 3). All the high focus states being considered here, namely, Bihar (30.8 points), Madhya Pradesh (18.7 points) and Assam (12.7 points) have experienced a remarkable increase in coverage. Among the non-high focused major states, West Bengal has experienced the most remarkable increase in coverage – 24.3 percentage points.

Anecdotal information from senior officers from Tamil Nadu suggests that the dramatic decline is due to a recent change in the delivery model from delivery at village level to primary health centre level, and this is now being reconsidered.

However, if we leave aside the specific outlier case of Tamil Nadu, for which a specific enquiry would be needed before an analysis can be offered, there clearly appears to be a complacency amongst the relatively better performing states with perhaps an over reliance upon the private sector that is offering vaccines at enormous cost.

Rural gains and urban losses

It is also clear that the National Rural Health Mission has shown an impact upon the largely state- controlled immunisation in rural areas. The failure to develop similar systems in urban areas has deprived millions of children of this essential service and created this critical public health situation. This is especially significant considering that about half of the country’s poor now reside in urban slums.

It can be hypothesised that the systematic lack of investment in public health systems, combined with a continuing notion that the public should pay out-of-pocket for their health, and a thrust towards privatisation of health care, seems to be leading to a situation wherein better-off states are showing a worrying trend, while poor states are still receiving relatively greater state support.

It is also to be noted that while we are failing to deliver even the vaccines that are a part of the universal immunisation programme, there are constant efforts to further expand the programme to cover newer vaccines, even in the face of criticism by public health experts.

While all this remains mere conjecture for now, for a service – considered the more achievable of health sector functions – to show any kind of decline can only raise a massive concern about the overall state of health services in the country.

While we consider how to work respectfully with communities to create trust and take action on behalf of their own health, we would be well advised to analyse the grave portents arising from this overall immunisation data with immediacy and sincerity.