The present study describes qualitative research, conducted in 2013, that may help to guide ongoing efforts to improve immunization coverage for some areas of India that have experienced persistently low coverage levels. Researchers collaborated to conduct the study utilizing the RED indicators to assess strengths and weaknesses of immunization services in select PHCs located in Gujarat, India.

Immunizations are considered the most successful and cost-effective public health interventions employed today. While immunization coverage in India has improved dramatically in the last decade, areas of very low coverage persist. The University of Michigan School of Public Health and the Indian Institute of Public Health Gandhinagar collaborated to document strengths and weaknesses of immunization service delivery in two districts in India.

This report describes a qualitative assessment of clinic level immunization service delivery in ten primary health centers (PHCs) located in two districts of Gujarat, India. Assessment criteria were derived from the Reaching Every District (RED) strategy that is intended to provide a framework for delivering childhood immunizations. Staff from the PHCs were interviewed in April 2013.

Interviews revealed several barriers to immunization service delivery including 1) Vaccine and supply stockouts; 2) Hard to reach communities; 3) Unreliable Internet access; 4) Cold chain equipment malfunctions; 5) Inconsistently maintained and utilized immunization records and registries.

To improve vaccine coverage among migrant communities and other hard to reach populations, one innovative suggestion from a participant was to implement targeted immunization programs during the marriage season and during festivals. Because people travel to family homes for these events, it may be easier to reach them compared to other times during the year.

Perhaps there should be additional or special vaccination outreach activities during these events. This strategy may be a viable option to reach unimmunized groups but needs to be supported with adequate supplies and a robust tracking system because all doses of childhood immunization cannot be fully completed during a single period of time.

The goal of this study was to use established criteria to identify weaknesses and to understand differences in vaccine delivery system implementation at the PHC level, between a high and a low immunization coverage district in Gujarat, India. We expected to see serious breakdowns in the vaccine delivery system, particularly in Dahod (the low coverage district).

However, while PHCs did not report optimal vaccine delivery (based on the RED criteria) they reported that overall they have very high coverage within their jurisdiction and identified very few problems. This in itself is inconsistent as immunization coverage in both districts is clearly suboptimal, based on estimates of immunization coverage in each district and the epidemiology of many childhood vaccines preventable diseases that are still endemic or epidemic in India.

These issues must be addressed in order to improve vaccination coverage of India’s children, particularly as additional vaccines are added to India’s National Immunization Schedule. A robust vaccine delivery system is needed in India to insure age-appropriate immunization of all children and to realize a significant reduction in the incidence of vaccine-preventable diseases.

Immunization service delivery is a complex process that can encounter barriers at many stages. A RED-based evaluation of the vaccine delivery system in Gujarat, India identified several points where the system was performing sub-optimally and possible solutions to successfully address these challenges.