Those listening to Bill Gates’ acceptance speech at the Indira Gandhi prize ceremony last week could have felt one of two things: Either immensely proud or immensely ashamed, depending upon which side of the window, as it were, that they sat on. The more optimistic could focus on that part of Mr Gates’ speech where he went on about the polio eradication campaign. “Vaccinators visit more than 200 million homes, one by one,” Gates exulted, “200 million.” He went on to talk of how, to make sure they never missed anyone, “they also go to train stations, bus stations and ferry terminals to immunise children who are on the move.” More heart-warming numbers were trotted out — every national immunisation day, more than two million health workers are mobilised, the number of lines of polio transmission have been cut from 14 to just two in the last two years, and a new injectable vaccine is being developed. But in between the praise, Mr Gates also spoke of the fact that fewer than a half of Indian children get fully vaccinated. The number of children getting BCG rose from 62 per cent in the first National Family Health Survey in 1992-93 to 78 per cent in NFHS-3 in 2005-06, measles from 42 per cent to 59 per cent, and so on, though the number of “fully-vaccinated” children in the 12-23 month age group has risen to just 44 per cent in NFHS-3, up marginally from 42 per cent in NFHS-2 in 1998-99. That full immunisation levels are just 34 per cent in states like Bihar is sad, though perhaps understandable. But how do you explain levels of just 45-46 per cent in states like Andhra Pradesh and, if you please, Gujarat? High drop-out levels are another serious issue — while 93 per cent of children came for their first polio drops according to NFHS-3, only 89 per cent came for the second shot and just 78 per cent for the third. The numbers for DPT fall from 76 per cent to 55 per cent.
It is difficult to understand why these outcomes are the way they are, given that the same state machinery that is in charge of delivering one set of vaccines is responsible for delivering the others as well. The answer could lie in what is called the Mission Mode approach to problems. The Prime Minister, or some other worthy, decides that something is very important and so the entire government machinery gears up to deliver that one thing, as in the case of the pulse polio programme, on that one day. With the attention so focused, it would appear that the routine work of vaccination for other diseases takes a back seat. If immunisation, indeed any such public health programme, has to succeed, the government machinery needs to build this into its routine work — Mission Mode, by definition, cannot be used for routine, everyday tasks. It is fashionable to hope, and Mr Gates alluded to some successful PPP initiatives in rural areas, that private sector providers can replace the government’s creaky delivery mechanism. This may work in a few cases but, by and large, the incentive structures for private players are far too different from what is required for public health delivery.
