BMJ · 2017-08-18 · launched Mission Indradhanush (MI) in 2014, a strategy targeting underserved, vulnerable, resistant and inaccessible populations.8,9 MI ran between April 2015

Confidential: For Review Only

Improving vaccination coverage in low performing districts

of India: lessons from IMI (intensive mission indradhanush) a cross-sectoral systems strengthening strategy

Journal: BMJ

Manuscript ID BMJ.2018.046558

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the Author: 17-Aug-2018

Complete List of Authors: Gurnani, Vandana; India Ministry of Health and Family Welfare, Joint Secretary, Reproductive and Child Health Jhalani, Manoj; India Ministry of Health and Family Welfare, Additional Secretary and Mission Director, National Health Mission Haldar, Pradeep; India Ministry of Health and Family Welfare, Deputy Commissioner (Immunization) Das, Manoj; The INCLEN Trust International Dasgupta, Rajib; Jawaharlal Nehru University, Centre of Social Medicine & Community Health Dubey, Anand; ESI-Postgraduate Institute of Medical Sciences and Research, Professor, Department of Pediatrics Massodi, Muneer; Government Medical College Srinagar, Professor,

Department of Community Medicine Rai, Sanjay; All India Institute of Medical Sciences, Professor, Department of Community Medicine Khan, Muhammad; Government Medical College Srinagar, Professor, Department of Community Medicine PEMDE, Harish; Lady Hardinge Medical College, Pediatrics; Kalawati Saran Children's Hospital, Pediatrics Jain, Pankaj; Uttar Pradesh Rural Institute of Medical Science and Research, Professor, Department of Community Medicine Angolkar, Mubashir; Jawaharlal Nehru Medical College, Professor, Department of Public Health Sharma, Pragya; Maulana Azad Medical College, Professor, Department of

Community Medicine Singh, Raghavendra ; Maulana Azad Medical College, Assistant Professor, Department of Pediatrics Chauhan, Ashish; India Ministry of Health and Family Welfare, Senior Consultant, Immunization Murray, John; Independent consultant, Arora, Narendra; The INCLEN Trust International, Research; The INCLEN Trust International, Research Sudan, Preeti; India Ministry of Health and Family Welfare

Keywords: India, Childhood vaccinations, Vaccines, Vaccination campaigns, Child

https://mc.manuscriptcentral.com/bmj

BMJ

Confidential: For Review Onlyhealth

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IMPROVING VACCINATION COVERAGE IN LOW PERFORMING DISTRICTS OF INDIA: LESSONS

FROM IMI (INTENSIVE MISSION INDRADHANUSH) A CROSS-SECTORAL SYSTEMS

STRENGTHENING STRATEGY

Vandana Gurnani1, Manoj Jhalani2, Pradeep Haldar3, Manoja Kumar Das4, Rajib Dasgupta5, Anand

Prakash Dubey6, Muneer Masssodi7, Sanjay Rai8, S. Muhammad Salim Khan9, Harish Pemde10, Pankaj

Jain11, Mubashir Angolkar12, Pragya Sharma13, Raghavendra Singh14, Ashish Chauhan15, John Murray16,

Narendra Kumar Arora17, Preeti Sudan18

1 Joint Secretary (RCH), Ministry of Health and Family Welfare, Government of India, New Delhi, India 2 Additional Secretary and Mission Director, National Health Mission, Ministry of Health and Family

Welfare, Government of India, New Delhi, India 3 Deputy Commissioner (Immunization), Ministry of Health and Family Welfare, Government of India,

New Delhi, India 4 Director Projects, The INCLEN Trust International, New Delhi, India 5 Professor, Department of Community Health, Jawaharlal Nehru University, New Delhi, India 6 Professor, Department of Paediatrics, ESI-Postgraduate Institute of Medical Sciences and Research,

New Delhi, India 7 Professor, Department of Community Medicine, Government Medical College, Srinagar, Jammu and

Kashmir, India 8 Professor, Department of Community Medicine, All India Institute of Medical Sciences, New Delhi,

India 9 Professor, Department of Community Medicine, Government Medical College, Srinagar, Jammu and

Kashmir, India 10 Professor, Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India 11 Professor, Department of Community Medicine, U.P. Rural Institute of Medical Sciences & Research,

Etawah, Uttar Pradesh, India 12 Associate Professor, Department of Public Health, Jawaharlal Nehru Medical College, Belagavi,

Karnataka, India 13 Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India 14 Assistant Professor, Department of Paediatrics, Maulana Azad Medical College, New Delhi, India 15Senior Consultant (Immunization), Ministry of Health & Family Welfare, Government of India, New

Delhi, India 16International Health Consultant, Iowa City, Iowa, USA. 17 Executive Director, The INCLEN Trust International, New Delhi, India 18 Principal Secretary, Ministry of Health and Family Welfare, Government of India, New Delhi, India

Corresponding Author and guarantor*

Dr Narendra Kumar Arora

Executive Director, The INCLEN Trust International Address: F-1/5, Okhla Industrial Area Phase - 1, New Delhi, Delhi 110020, India

Phone number: 91 11 47730000-99

Email: [email protected]

*Submitted by John Murray on behalf of the corresponding author; all subsequent correspondence with

Dr. Narendra Kumar Arora

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Word Count: 1 983

Key words: India, childhood vaccinations, vaccines, vaccination campaigns, child health, cross-sectoral

programming

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Stand first

The Intensified Mission Indradhanush (IMI) strategy in India demonstrated that cross-sectoral

participation is a powerful mechanism for vaccinating more high-risk children, but that a number of

systems changes are needed to incorporate this approach into routine practice and allow expansion to

the hardest to reach populations.

Introduction

India’s immunization programme is the largest in the world with annual cohorts of around 26.7 million

infants and 30 million pregnant women.1 Despite steady progress, routine childhood vaccination

coverage has been slow to rise, with an estimated 38% of children failing to receive all basic vaccines in

the first year of life in 2016.2-4 A number of factors limit vaccination coverage including mobile and

isolated populations that are difficult to reach and low demand from under-informed populations

influenced by fear of side effects and anti-vaccination messages.5-7

In response to low childhood vaccination coverage, India’s Ministry of Health and Family Welfare

launched Mission Indradhanush (MI) in 2014, a strategy targeting underserved, vulnerable, resistant and

inaccessible populations.8,9 MI ran between April 2015 and July 2017, contributing to an increase in full

immunization coverage of 6.7% (7.9% in rural areas and 3.1% in urban areas) after the first two

rounds.10 In October 2017, the Prime Minister of India spearheaded an ambitious plan to accelerate

progress further, launching Intensified Mission Indradhanush (IMI), in districts and urban cities with

persistently low immunization coverage, with the aim of reaching 90% full immunization coverage by

the end of 2018.11

This case study was developed to document the lessons learned from IMI, with an emphasis on

understanding how cross-sectoral and multi-stakeholder engagement worked to strengthen access to

and quality of vaccine services (box 1). The study hoped to identify the impact of IMI and whether the

approach can be used to build sustainable vaccination programming.

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Box 1: Approach to conducting the IMI case-study in India

The case-study was led and coordinated by the Ministry of Health and Family Welfare (MOHFW). A

steering committee under leadership of the Joint Secretary, Reproductive and Child Health was

formed and a country working group under leadership of the Deputy Commissioner for Immunization.

A team comprised of technical experts in immunization, public health and research was responsible

developing the protocol for the case-study, data collection and analysis. A modified multistakeholder

approach was used including: 12

1. Desk review of available data, including: national health coverage surveys, implementation

guidelines, standard operating procedures, performance reports from states and districts,

monitoring reports and other programmatic documents.

2. In-depth and informal interviews with key stakeholders from the national and state levels and

from five randomly selected districts.13 Sampled districts represented a cross-section of

different socio-cultural and geographic regions of the country. In each district, high performing,

low performing and vulnerable population areas were selected. Two hundred stakeholders

involved in planning, implementation and monitoring of IMI were interviewed using qualitative

interview guides organized by thematic area and summarized using a standard format (table

1).14

3. Analysis of stakeholder interviews using a modified Framework Method for comparing and

contrasting large-scale textual data across cases.15 Similarities and differences in the data were

identified and relationships drawn across different parts of the analysis, resulting in descriptive

or explanatory conclusions by theme. A health systems framework was developed populated

by main policy and programme inputs across all interviews.

4. A multi-stakeholder meeting to review and discuss of findings with key health and development

partners and stakeholders to review and agree on the main findings.

Description of Intensified Mission Indradhanush (IMI)

Programme focus

IMI targeted areas with higher rates of unimmunized children and immunization drop-outs. Updated

coverage data were used to select districts and urban cities in which: 1) At least 13,000 children were

estimated to have missed DPT3/Pentavalent 3 the previous year or; 2) DPT3/ Pentavalent 3 coverage

was estimated to be less than 70%.16 Using these criteria, the weakest 121 districts, 17 urban cities and

an additional 52 districts in North Eastern states were selected (fig 1). All children up to 5 years of age

and pregnant women were targeted, with a focus on ensuring full vaccination for children under 2 years

of age. A chain of support was established from the national level through states to districts, with senior

staff providing regular reviews of progress and receiving updates on progress.11

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Figure 1: Map of the 121 districts, 17 urban cities and 52 north-eastern districts identified for

Intensified Mission Indradhanush

Implementation

A seven-step process was developed to support district and sub-district planning and implementation of

IMI, with staff at all levels receiving training on their role in implementation (fig 2).11 Door-to-door head

count surveys and due-listing of beneficiaries were conducted by community workers and validated by

supervisors for completeness and quality. Session-planning identified new sites for conducting

vaccination sessions if needed, organised mobile teams for remote areas and ensured that supplies

were available. If inadequate numbers of staff were available at health sub-centres, resources were

provided to hire Auxillary Nurse Midwives (ANMs) or staff from other areas. Vaccine supplies were

tracked using the Electronic Vaccine Intelligence Network (e-VIN) and cold chain tracking programme

and distributed using the alternate vaccine delivery mechanism.17 Districts developed a communication

plan and materials, with stakeholders organized and coordinated to provide support matching their

roles and expertise, including household listing, supervision, identification of new vaccination sites,

community mobilisation for vaccination sessions and counselling on barriers to use such as a fear of

adverse events (table 1). Four monthly cycles of immunization were conducted between October 2017

and January 2018, each lasting 7 days.

Figure 2: Strategy for Intensified Mission Indradhanush

Monitoring and evaluating progress

Vaccination session monitoring included the collection of administrative data by ANMs and transmitted

through the routine health information system, external monitoring of sessions and small-sample

assessments of households after sessions to validate childhood vaccination coverage. E-dashboards on

mobile phones were used to collect vaccination session and household validation data which facilitated

real-time aggregation of each vaccination round. Local monitoring was conducted by ANM supervisors,

district supervisors and zonal medical officers; with support from World Health Organization (WHO) and

United Nations Children’s Fund (UNICEF) monitors. During vaccination rounds, daily supervisor

meetings were conducted to review available data and discuss problems and solutions. External

oversight was provided by national and state monitors, with meetings during each round to review

progress and structured feedback to all levels. Population-based household vaccination coverage

surveys were conducted in April and June 2018 in IMI districts.

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Table 1: Stakeholders involved in IMI implementation

Staff categories Roles

Government – Health (Ministry of Health and Family Welfare)

• Secretary & Additional Secretary, Ministry of

Health

• Joint Secretary, Deputy Commissioner, Consultant

• Secretary/Mission Director-National Health

Mission, State Expanded Programme of

Immunization Officer, Reproductive and Child

Health Officer

• State and district vaccine store managers

• District Magistrates

• Immunisation Officers

• Chief Medical Officers

Policy development, administration,

management, planning,

implementation, supervision

• Primary Health Care Centre Medical Officers

• Auxillary Nurse Midwives (ANMs)

• Accredited Social Health Activists (ASHAs),

• Nursing and medical students

Service delivery, planning, supervision

Household listing, communication,

social mobilization

Government – 12 Non-health ministries (including Women’s and Child Development, Sports and

Youth, Panchayati Raj, Urban development, Labour, Education, Minority Affairs, Information and

Broadcasting)

• Integrated Child Development Services –

Anganwadi (courtyard) centres; Anganwadi

Workers (AWW)

• Panchayati Raj members (a system of community

governance)

• Programme management staff

• School teachers

• Youth organisations (National Cadet Corps, Nehru

Yuka Kendra Sangathan, National Service Scheme)

• Child development programme officers

Health education

Mass media and print communication

Social mobilization

Household visits

Community education

Multilateral and bilateral organisations: World Health Organisation (WHO), United Nations

Children’s Fund (UNICEF), United Nations Development Programme (UNDP), Immunization

Technical Support Unit, Global Health Strategies

• National managers

• Regional WHO team leaders and surveillance

medical officers

• UNICEF health officers, consultants and social

mobilisation network coordinator

National task force

Programme implementation

Policy development

Communication

Monitoring, supervision, data analysis

Civil society individuals and groups: Non-governmental organisations, Rotary International,

religious leaders, community officials

• Community political leaders

• Community volunteers

• Thought leaders

• Educators

Social mobilization, education, celebrity

endorsements

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Summary of progress

Between October 2017 and January 2018, 97 628 vaccination sessions were conducted in IMI areas,

delivering over 15 million antigens.18 During this period, administrative data estimate that 5.95 million

children were vaccinated, with around 850 000 children vaccinated for the first time and 1.4 million

children 12 months of age or older fully vaccinated. An estimated 1.18 million pregnant women were

also vaccinated, with over 660 000 estimated to have been fully vaccinated. Vaccine and cold-chain

stock-outs were uncommon during the IMI period, with 98% of monitored sites having adequate

supplies available for sessions.19 Eleven states distributed additional funding for IMI rounds, with the

total additional funds dispersed estimated to be US$7.8 million.20

Preliminary population-based household coverage surveys conducted in IMI areas 3-5 months following

the last vaccination cycle, estimate the proportion of children 12-23 with full immunization coverage

(FIC) to be 69% in IMI districts, representing a 18.5% increase from 2016 estimates (fig 3).4,21 Percentage

Improvement in FIC ranged from 12% in Rajasthan IMI districts to 31% in Assam. Of the 190 districts

surveyed, the FIC increased by more than 30% in 56 districts, 10-30% in 83 districts (43.7%) and <10% in

51 district (26.8%).

Routine process monitoring was conducted for 98% of sessions, with head counts available in 92%, and

updated due lists in 82% (table 2).18 Of those children on due lists, 56% received needed vaccinations

during sessions. This varied considerably between states, ranging from 13% and 95%. Reasons for non-

vaccination of children on due lists from household monitoring of 24,324 cases included lack of

awareness (35%), apprehension about adverse events (26%), vaccine hesitancy (8%), child travelling

(12%), and programme related gaps (14%).18

Figure 3: Proportion of children 12-23 months fully immunized in 190 IMI districts, by state, 2016 and

2018

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Table 2: Process indicators of service delivery from routine monitoring of IMI, October 2017 – January

2018

1 Based on monitoring visits to a total of 95675 (98%) IMI vaccination sessions18

2 Due lists include unimmunized children and vaccination drop-outs requiring additional antigens 3 Monitoring data for 18 districts not available: (Arunachal Pradesh- 6, Meghalaya 3, Mizoram-1,

Nagaland-7, and Sikkim-1)

State Total number Percentage 1

Districts

in IMI

Sessions

held

Sessions

with head-

count done

Sessions

with due list

available2

Sessions

Supervised

Children on due

lists vaccinated3

Andhra

Pradesh 2 249 90 85 55 62

Arunachal

Pradesh 13 67 91 62 69 60

Assam 7 341 94 93 76 76

Bihar 16 11292 97 78 71 67

Delhi 3 1392 96 79 14 68

Gujarat 3 400 99 84 70 63

Haryana 4 942 81 81 40 48

Jammu &

Kashmir 1 114 52 81 69 70

Jharkhand 2 1198 87 84 41 53

Karnataka 3 1060 99 95 55 72

Kerala 1 91 100 100 97 25

Madhya

Pradesh 14 5015 86 93 65 78

Maharashtra 11 4127 100 89 71 52

Manipur 4 178 97 85 30 17

Meghalaya 7 135 100 100 47 53

Mizoram 3 33 67 82 58 20

Nagaland 11 50 100 64 32 37

Odisha 2 363 100 99 47 60

Rajasthan 12 3826 98 94 40 73

Sikkim 2 14 100 43 100 95

Tripura 5 75 93 77 61 13

Uttar Pradesh 60 63796 99 88 90 69

Uttrakhand 1 393 100 77 44 59

West Bengal 1 524 88 44 45 53

India 187 95675 92 82 58 56

Rural 118 80320 92 84 58

Urban 17 14462 96 91 66

North East 52 893 93 76 59

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Factors contributing to effectiveness of implementation

Introduction and acceptance

Introduction of IMI was facilitated by Prime Minister Modi who launched the initiative on 8th October

2017. The Prime Minister sent letters to Chief Ministers explicitly stating the goal of 90% full

implementation coverage in their states; and participated in regular IMI review meetings. Regular video

conferences were conducted with states by the central health minister and senior officials to monitor

progress. Twelve non-health ministries were officially contacted, informed of IMI objectives and their

roles. They committed to providing support at all levels and facilitated engagement of youth

organisations.11,22 Thus IMI saw high-level political commitment and early engagement of multiple

sectors (table 1). Adoption was driven by several factors. Close engagement and oversight by the Prime

Minister of India was very important to generating and sustaining political will and for ensuring the

commitment of government staff at all levels. IMI used programme experience built from polio

elimination, including the Reaching Every District strategy, and the development of criteria for

identifying high-risk areas.23 These methods had a track record of success in different parts of the

country, and were understood by all stakeholders. Use of existing systems and mechanisms allowed

rapid uptake, while the focus on increased accountability at the state and district level helped better

tailor activities to local needs.

Shifting responsibility to the district and sub-district levels

At district level, planning, implementation, engagement of partners, and assignment of responsibilities

was organized by District Magistrates through IMI district task forces. To streamline the participation of

non-health sectors and development partners, a lead partner was identified in every district. This

administrative model shifted responsibility for managing IMI to the district and sub-district levels who

developed plans tailored to local circumstances. To facilitate local implementation, routine vaccination

funds were used for human resource costs, incentives for staff, transportation, social mobilization and

production of information, education and communication materials. Guidelines for how additional

resources could be requested from central government and allocated for specific activities were

developed; additional funds were provided on demand to the states through supplementary plans.24 To

be effective, district magistrates and district immunization officers took responsibility for mobilising

government and non-government resources to fill staffing gaps, improve communication and

community mobilisation for vaccinations. Cross-sectoral coordination therefore required local staff

who were familiar with existing roles and areas of responsibility of partners and could provide them

with specific roles. Key informants in two areas reported delays in staff payments due to administrative

and procedural weaknesses at district level and this may have also slowed deployment of staff and other

activities. In addition, the intensity of staff time commitments (sometimes requiring temporary transfer

to under-served areas) took staff away from routine duties. There were voices of concern regarding the

long-term sustainability of this approach at both state and district level.

Household listing to improve reach

Detailed microplanning and listing of beneficiaries (creating due lists) is the heart of the IMI approach,

essential for reaching high-risk populations, and conducted for the majority of sessions (table 2).

Achieving household listing is central to the roles of ANMs, ASHAs and AWWs and where all three staff

were available and motivated this was feasible. However, household listing was difficult, particularly in

districts with staff shortages and in urban areas. In these cases, staff from outside the district and

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locally available nursing students were hired to support door-to-door household listing and other IMI

activities using IMI funds. In addition to additional staffing needs, household listing in more remote

areas required significant investments in time, innovation and transportation. Field staff found that

household beneficiary listing needed monthly updating because of frequent population shifts. Coupled

with improved listing, the creation of new vaccination session sites, the use of flexible vaccination

session times and use of mobile teams were important for improving reach.

Social mobilisation to improve access and equity

In sub-districts local stakeholders were central to mobilising families and communities for vaccination

sessions (table 3). Process monitoring data showed that even when eligible children had been placed on

due lists, not all of them were brought to vaccination sessions. In some areas communication plans

were inadequate, with no effective materials or strategies in place. Field interviews showed that

engagement of local stakeholders across sectors worked best when all were included in planning,

assigned specific tasks and communities, and provided with communication materials and strategies

that could be used to overcome vaccine hesitancy. A number of different mechanisms were used by

partners across sectors to engage families (table 3). Community health workers in several areas,

reported that inadequate time, skills and materials limited their ability to provide effective counselling

to address barriers to accepting immunizations. In some cases sites chosen for additional IMI vaccination

sessions (which included private homes, businesses and schools) had inadequate toilets, seating and

running water which may have discouraged attendance.

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Table 3: Cross-sectoral stakeholder collaboration and coordination for IMI – summary of effective

strategies and challenges

Strategies identified as important Challenges

Improve linkages with the health system

� Joint meetings between ASHAs, Angawadi Workers and

ANMs to plan strategies for reaching communities

� Household reminder slips about IMI sessions and sites

� Mobile immunization teams

� Providing prompt medical care for adverse events

� Team home visits– ANMs and community stakeholders

to improve acceptance and reduce hostility

• Inadequate infrastructure for session sites in

some communities

• Household listing made difficult by

inadequate manpower and lack of

engagement of community stakeholders to

do household listing in their own areas

Engage influencers

� Involvement of religious leaders to dispel fears and

instil confidence in vaccination

� Youth groups: awareness generation and mobilization

� Community political leaders: public endorsement

� Prabhat feri rallies: school children and youth cadets

� School promotion: teachers and students to mothers

and families

• Partner participation and cooperation

became sub-optimal when they were not

involved in planning, consulted on their roles

and availability

• Circulation of vaccine related misinformation

and rumours about adverse events;

conspiracy theories including vaccines

causing sterilization

Better use of local community stakeholders

• Peer counselling: mothers of fully immunized children

interact with and counsel mothers and grandmothers

of non-immunised

• Vikas Mitras and Tola Mitras - community level link

workers of the Bihar Mahadalit Vikas Mission -

mobilized marginalized communities and helped

frontline health workers set up (additional) IMI sessions

within Mahadalit (marginalized and extremely weak

caste groups among the Scheduled Castes) clusters.

• Ration dealers used for mobilization and to provide

information

• Requests by some community workers and

groups for incentives/payment for time spent

• Limited recognition for non-health

collaborators

• Financial shortfalls for social mobilization and

IEC activities in some areas

• Youth groups and Rotary participation limited

to urban areas

• Limited competency of CHWs in

communication and mobilization (soft skills)

so that concerns are not always identified

and addressed

Improve messaging

• Distribution of brochures, stickers, buttons, umbrellas,

public announcements

• Involvement of print and electronic media: joint media

briefing by government and partner agencies, including

development partners, NGOs and non-health sectors

• Use of social media

• Productions by the song and drama division (Ministry of

Information & Broadcasting)

• Street plays

• Baby shows with prizes for healthy fully and immunized

children

• No specific messages on adverse events

following immunisation and on debunking

myths in some social mobilization campaigns

• Grievances against the food ration system

(public distribution system) led some families

to resist vaccinations, seen as another

government programme

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Conclusions: building a sustainable routine system using experience from IMI

IMI has contributed to significant increases in fully immunized children (from 50.5% to 69%) in 190 of

the lowest performing districts, a 37% increase in coverage. IMI demonstrated that cross-sectoral

participation is a powerful mechanism for vaccinating more high-risk children, but that a number of

systems changes are needed to incorporate this approach into routine practice and allow expansion to

the hardest to reach populations. First, sustained high-level political support, advocacy and oversight

across sectors and levels and re-allocation of financial resources where needed is essential. Second, all

districts must strengthen staff capacity for household beneficiary listing, add additional vaccination sites

and invest in the transportation required to do both. Third, better communication and counselling skills

and materials are needed by community providers in health and partner sectors to be more effective at

addressing vaccine hesitancy and reluctance. Finally, districts with managerial capacity to effectively

engage with non-health stakeholders across sectors perform better; this capacity must be built in all

districts. There is willingness among all sectors to participate and support immunization programming in

the future, provided roles and commitments are clearly defined, predictable and feasible with partner

resources.

Key Messages

• The Intensified Mission Indradhanush (IMI) strategy demonstrated that cross-sectoral

participation is a powerful mechanism for vaccinating more high-risk children, but that a

number of systems changes are needed for this approach to be incorporated into routine

practice and expand to the hardest to reach populations

• Sustained high-level political support, advocacy and oversight across sectors and levels and

re-allocation of financial resources where needed is essential

• All districts must strengthen staff capacity for household beneficiary listing, add additional

vaccination sites where needed and invest in the transportation required to do both

• Better communication and counselling skills and materials are needed by community

providers in health and partner sectors to be more effective at addressing vaccine hesitancy

and reluctance – and mobilise families to attend vaccination sessions

• District managers with managerial capacity to effectively engage with non-health

stakeholders across sectors perform better; this capacity must be built in all districts.

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Acknowledgements

The authors gratefully acknowledge: contributions of technical experts from development partners

(WHO, UNICEF, UNDP) and the Immunization Technical Support Unit; the commitment and hard work of

leadership and staff in health and partner ministries and departments at district and state levels; and

the field work and technical inputs provided by state experts including: Dr Satinder Aneja, School of

Medical Sciences & Research, Sharda University, Greater Noida, Uttar Pradesh; Dr Kiran Goswami, All

India Institute of Medical Sciences, New Delhi; Dr Sanjay Chaturvedi, University College of Medical

Sciences, New Delhi; Dr Muzammil Khurshid and Dr Swarna Rastogi, Muzaffarnagar Medical College,

Muzaffarnagar, Uttar Pradesh; Dr Ashok Kumar and Dr Prabhat Kumar Lal, Darbhanga Medical College,

Darbhanga, Bihar; Dr A Althaf, Government Medical College, Malappuram and Dr Sairu Philip, T.D.

Medical College, Alappuzha, Kerala; Dr Himesh Barman and Dr Star Pala North Eastern Indira Gandhi

Regional Institute of Medical Sciences, Shillong, Meghalaya; Dr Satish Saroshee and Dr Suraj Sirohi,

Mahatma Gandhi Memorial Medical College, Indore and Dr Abhijit Pakhre, All India Institute of Medical

Sciences, Bhopal, Madhya Pradesh.

Disclosure of Interests

The authors have read and understood BMJ policy on declaration of interests. All authors have

completed the Unified Competing Interest form (available on request from the corresponding author)

and declare: support from the World Health Organization (Partnership for Maternal, Newborn and Child

Health) for the submitted work; no financial relationships with any organisations that might have an

interest in the submitted work in the previous three years; no other relationships or activities that could

appear to have influenced the submitted work.

Funding disclosure

The case-study review was partially funded by the Partnership for Maternal, Newborn and Child Health.

The funder had no role in planning, data collection and interpretation of the data collected.

Authorship Statement

VG, MJ, PS, PH, and AC conceptualized the case-study and approach. NKA, MKD, RD, APD and JM

developed the method. Group members (RD, APD, MM, SR, SMSK, HP, PJ, MA, PS and RS) collected the

data. NKA, MKD, RD, SR analysed the data. NKA, MKD, and JM conducted the data synthesis. NKA, MKD,

and JM drafted the manuscript. All authors reviewed and commented on the manuscript prior to

finalization.

The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all

authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the

BMJ Publishing Group Ltd (“BMJ”), and its Licencees to permit this article (if accepted) to be published in

The BMJ’s editions and any other BMJ products and to exploit all subsidiary rights, as set out in our

licence.

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References

1. Ministry of Health and Family Welfare, Government of India. Immunization Handbook for Medical

Officers [Internet]. Ministry of Health & Family Welfare Government of India; 2016.

http://www.searo.who.int/india/publications/immunization_handbook2017/en/

2. Lahariya C. A brief history of vaccines & vaccination in India. Indian J Med Res. 2014 Apr;139(4):491–

511.

3. Vashishtha VM. Status of immunization and need for intensification of routine immunization in

India. Indian Pediatr. 2012 May;49(5):357–61.

4. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-

4), 2015-16: India. Mumbai: IIPS; 2017.

5. Laxminarayan R, Ganguly NK. India’s vaccine deficit: why more than half of Indian children are not

fully immunized, and what can—and should—be done. Health Aff (Millwood) 2011;30:1096–103

6. Kumar C, Singh PK, Singh L, et al. Socioeconomic disparities in coverage of full immunisation among

children of adolescent mothers in India, 1990– 2006: a repeated cross-sectional analysis. BMJ Open

2016;6:e009768. doi:10.1136/bmjopen-2015- 009768

7. Taneja G, Sagar KS, Mishra S. Routine immunization in India: a perspective. Indian J Community

Health. 2013;25(2):188–92.

8. Ministry of Health and Family Welfare (MOHFW). Mission Indradhanush, Operational Guidelines.

[Internet]. Delhi, India: MOHFW;2014 http://164.100.158.44/showfile.php?lid=4258.

9. Travasso C. Mission Indradhanush makes vaccination progress in India. BMJ. 2015 Aug

13;351:h4440.

10. Immunization Technical Support Unit. Report of Integrated Child Health & Immunization Survey

(INCHIS)- Round 1 and 2. [Internet]. Delhi, India: Ministry of Health and Family Welfare; 2014.

http://www.itsu.org. in/integrated-child-health-immunization-surveyinchis-report-rounds-1-2.

11. Ministry of Health and Family Welfare (MOHFW). Intensified Mission Indradhanush, Operational

Guidelines. Delhi, India: MOHFW; 2017

12. BMJ Methods Supplement.

13. The INCLEN Trust International. Intensified Mission Indradhanush Case-Study Protocol.

Delhi,India:The INCLEN Trust International; 2018.

14. The INCLEN Trust International. Intensified Mission Indradhanush Protocol Interview Guides. Delhi,

India: The INCLEN Trust International; 2018.

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15. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis

of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.

doi: http://dx.doi.org/10.1186/1471- 2288-13-117 PMID: 24047204.

16. Bhatnagar P,Gupta S, Kumar R, Haldar P, Sethia R, Bahl S. Estimation of child vaccination coverage

at state and national levels in India. Bull World Health Organ 2016;94:728–734 | doi:

http://dx.doi.org/ 10.2471/BLT.15.167593

17. Ministry of Health and Family Welfare, United Nations Development Programme, Global Alliance

for Vaccine Initiative. Improving Efficiency of Vaccination Systems in Multiple States: e-VIN

Factsheet. [Internet]. United Nations Development Programme; 2017

http://www.in.undp.org/content/india /en /home/operations/projects/health/evin.html

18. Ministry of Health and Family Welfare (MOHFW). Administrative monitoring data for Intensified

Mission Indradhanush. Delhi, India: MOHFW; 2018.

19. Ministry of Health and Family Welfare (MOHFW), United Nations Development Programme, Global

Alliance for Vaccine Initiative. E-VIN Tracking Database, October 2017 – April 2018. Delhi, India:

MOHFW; 2018

20. Ministry of Health and Family Welfare (MOHFW). Financial reports: funds provided to states for

Intensified Misison Indradhanush. Delhi, India: MOHFW; 2017

21. Ministry of Health and Family Welfare (MOHFW). Coverage Evaluation Survey- Intensified Mission

Indradhanush. Delhi, India: MOHFW; 2018.

22. Ministry of Health and Family Welfare (MOHFW). Standard Operating Procedures for engaging with

youth institutions (NCC, NSS, NYKS) and Rotary for social mobilization for Intensified Mission

Indradhanush (IMI) and Routine Immunization. Delhi, India: MOHFW; 2017

23. Microplanning for immunization service delivery using the Reaching Every District (RED) strategy.

Geneva: World Health Organization; 2009.: http://apps.who.int/iris/bitstream/

10665/70450/1/WHO_IVB_09.11_ eng.pdf

24. Ministry of Health and Family Welfare (MOHFW). Intensified Mission Indradhanush- Financial

Guidelines. Delhi, India: MOHFW; 2017.

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SUPPLEMENT 1. METHODS USED TO DEVELOP THE COUNTRY CASE STUDY SERIES

This supplement is in two parts. The first part describes the methods used to develop the country case

studies; the second describes the methods used to develop the synthesis paper. A separate paper

analysing the application of the country case study methods, including the challenges encountered and

the necessary adaptations made, will follow at the conclusion of the project.

PART 1: METHODS TO DEVELOP THE COUNTRY CASE STUDIES

The country case studies built on methods that were developed and tested for the study series “Success

factors for women’s and children’s health”.1

The case study approach was adopted because it draws on

multiple sources of both qualitative and quantitative evidence to tell the story of how and why an action

across sectors unfolded over time in a given context, illuminating key moments, people, and processes

to enable the extraction of broader lessons applicable to multiple cases.2 The case studies were

developed in four phases.

• Phase 1 – Evidence review, conceptual framework, and methods development

• Phase 2 – Call for proposals and selection of country case studies

• Phase 3 – Country data collection and convening of multistakeholder dialogues

• Phase 4 – Synthesis and dissemination

In Phase 1 a structured review was undertaken of the evidence about factors influencing successful

collaboration across sectors, including review of other publications concerning the quality of the

evidence, results chain, scale and sustainability, and theory of change.3 4

This review informed the

development of the conceptual framework shown in figure 1. The conceptual framework formed the

basis for the case study methods guide.

Fig 1. Conceptual framework

The methods guide was developed to support participating countries’ use of a standard approach in

developing the case studies, which included key processes, deliverables, and anticipated timelines.4 An

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accompanying semi-structured questionnaire supported the organization, analysis, and synthesis of

documentation for the case study. The questions were framed around the key components of the

conceptual framework, and structured according to programme reporting standards.5 This aided the

assessment of the available data and documentation as well the identification of additional information

that would be required, e.g. through key informant interviews. The guide explicitly noted that country

teams could select and adapt questions according to the specifics of each case study.

Phase 2 was concurrent with Phase 1. An open call and selection process was used to identify the case

studies: PMNCH issued a global call for proposals, which included selection criteria (table 1) and a peer

review selection process as described in figure 2 below.

Table 1. Selection criteria for eligible proposals

Criteria Description Score

Effectiveness/impact

of the collaboration

Evidence of success – either process or impact success across multiple

dimensions: e.g. relating to the collaboration process, operational

improvements, policy and service coverage outputs, or societal, health, and

sustainable development outcomes.

30

Implementation across

sectors at scale or

ready to be scaled

Collaboration across sectors is well established, with related processes and

institutional mechanisms, and has been or is about to be taken to scale to reach

the target population in the country, province, or state.

20

Data and

documentation

Availability of data sources and documentation on the collaboration, including

evaluations, surveys, reports, and other information on which to build the

country case studies. Data are available from 2010 onwards.

20

Innovation Clearly demonstrates what is new or different about this collaboration. 10

Human rights, gender

equality, equity

Integrates human rights, gender equality, equity considerations, including

participation and voice of the target populations.

10

Agreement in principle

from collaborators

In principle, the main stakeholders of this collaboration, including government,

have approved the proposal and agreed to participate in the case study process.

10

Total score Summed review score based on the criteria.

/ 100

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Fig 2. Process for selection of country case studies

During Phase 3, each of the 12 successful country teams established a working group which conducted

an analysis of the main factors leading to successful collaboration in their context. Each country team

had a lead organization that submitted the original proposal. The composition of the country teams

varied depending on considerations such as the nature of the programme, stakeholders involved, policy

and programme context, and technical and other resources available. Country teams were supported by

both a national and an international consultant.

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A Global Steering Committee of partners was established to provide strategic direction and editorial

oversight over the case study methods and development, and to synthesize the cross-case findings. The

country teams and Global Steering Committee were supported by the PMNCH secretariat in overall

project management. The BMJ coordinated the journal peer review and publication of the papers.

Indicative key tasks for developing the country case studies are set out in table 2. The semi-structured

questionnaire was used to develop a working paper on the collaborative process. Relevant programme

data, reports and evaluations, and other peer-reviewed and grey literature were used as data sources,

and key informant interviews were conducted to fill identified data gaps.

Table 2. Key tasks for developing the country case studies

ESTABLISH COUNTRY-LEVEL COORDINATION TEAM AND PLAN

• Lead organization brings together a country working group to review the case study process and

timelines (and agree dates for key deliverables and events), develop the plan and budget, and secure

national consultancy support if required

• Coordination with the international consultant to set up and support the process, including organizing

the multistakeholder review meeting

• Collation of relevant programme data, reports and evaluations, and other peer-reviewed and grey

literature, as well as identification of further information and key informant interviews required

DEVELOP THE WORKING REPORT USING THE GUIDING QUESTIONS TO COLLATE DATA

• Development of the working report using the questions from the methods guide and a synthesis of

relevant programme data, reports and evaluations, and other peer-reviewed and grey literature

• Country visit by international consultant

CONDUCT MULTISTAKEHOLDER REVIEW MEETING

• Organization of a multistakeholder review meeting, following the methods guide, including preparation,

planning and inviting participants,

• Holding the multistakeholder review meeting to review and update the working report and resolve any

remaining issues

• Country visit by international consultant for the multistakeholder review

DEVELOP JOURNAL ARTICLE BASED ON THE WORKING REPORT AND MULTISTAKEHOLDER REVIEW

• Drafting of 3000-word journal article, based on the working report developed for internal editing

• Submission of the article to The BMJ

• Revision and completion of the article in response to comments from peer reviewers and The BMJ’s

Editorial Committee

• Working with The BMJ’s technical editors on copy-edited manuscript and checking pdf proofs

ACTIVITIES LEADING UP TO THE PARTNERS’ FORUM

• Publication of journal articles, contingent on approval by The BMJ’s peer review, editorial, and

publication process

• Contributing to the Partners’ Forum programme, especially the communications materials and learning

sessions that will be agreed between the lead organization and the Forum Organizing Committee as the

agenda develops

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Country teams conducted a multistakeholder review of the working paper and the factors leading to

successful collaboration. The multistakeholder review processes drew on both the methods used in the

first Success Factors study series1 6

and the PMNCH guide for multistakeholder dialogues.7

Multistakeholder reviews were used together with the semi-structured questionnaire in Phase 1 to

ensure that the case studies were evidence-based, with triangulation of information and perspectives,

and were representative of a collaborative exercise. The multistakeholder dialogues commonly involved

face-to-face meetings of health and development stakeholders engaged in, benefiting from, or

influencing the specific collaboration, including from civil society or community/target population

groups.

In Phase 4 the working paper and the outputs from the multistakeholder dialogue informed the drafting

of the 3000-word journal articles on the factors leading to successful collaboration across sectors.

Detailed outlines and/or drafts of the journal articles were reviewed by PMNCH and at least one

member of the Steering Group. Phase 3 also included a synthesis of all the case studies to identify

common factors, with the findings published in this paper. The methods for that process are described

in the next section.

PART 2. METHODS FOR DEVELOPING THE SYNTHESIS PAPER

Selection and quality of the synthesis methods

The selection of the synthesis methods for this study series was informed by a review of methods for

analysing qualitative and quantitative research for management and policy.2 8

It also drew on the

methods tested in the first Success Factors study series.1

The choice of synthesis methods was contingent on the research question and methods used, and the

nature of the available evidence. The research question (i.e. what works in collaboration across sectors)

and the methods (i.e. case studies across countries) were best matched with a cross-case analysis. The

synthesis began by organizing the findings from the different case studies in a standard format using a

matrix or text-table.2 Most of the evidence in the case studies was qualitative and descriptive. The

quantitative data used were context-specific and derived from varying sources and methods, and so

were not readily comparable between countries. The method deemed most suitable was therefore a

thematic analysis, identifying and bringing together the main, recurrent, or most important issues or

themes across the case studies.2 The aim of the synthesis was to recognize and make sense of patterns

across the case studies in order to build up a meaningful picture without compromising their richness

and diversity. A multi-grounded theory approach was then used to synthesize the emerging patterns

using a theoretical model that could be applied and tested in other contexts.9 All these methods are

detailed below.

Quality considerations

Recognizing that many in the study and synthesis teams were less familiar with qualitative methods than

with quantitative methods, it was necessary to explicate the differences between quality criteria in

qualitative and quantitative methods (see table 3). Using some of the key strategies outlined in table 3,

we aimed for rigour in the methods used, credibility in the interpretation of results, and generalizability

based on theoretical transferability.

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Table 3. Quality criteria – illustrative differences between quantitative and qualitative methods2 10-13

Quality criteria Quantitative Qualitative

Generalizability Statistical generalizability Analytical/ theoretical generalizability;

transferability within and across contexts

Validity Accuracy of measurement

Validity: face; construct; and criterion

Appropriateness of methods and expertise

and experience of researchers

Validity: democratic (all perspectives

accurately represented); dialogic (review

and deliberation of findings); process

(cogent and dependable); outcome

(resolution of research question)

Reliability Precision

Replicability: inter-observer, test-retest,

triangulation

Auditability and documentation of

research methods

Consistency in applying methods

Achieving theoretical saturation

Credibility Triangulation of data sources

Counterfactual analysis and causal

inference

Triangulation of data sources

Expertise and experience of researchers

Diverse perspectives to test and refine the

findings, including consideration of

alternative interpretations

Context for

application of

quality criteria

Embedded in a broader understanding of

and expertise in quantitative research

design, data analysis, application, and

limitations

Embedded in a broader understanding of

and expertise in qualitative research

design, data analysis, application, and

limitations

In-depth understanding of context of

analysis from different perspectives

Methods for synthesizing the findings

A multidisciplinary team conducted the evidence synthesis, led by the co-chairs of the Global Steering

Committee, who are experienced in research and synthesis methods and multi-country studies.

Together the synthesis team members brought a wide range of expertise and perspectives to the

synthesis process: from policy science, public health and epidemiology, multisectoral collaboration,

political philosophy, anthropology, health economics, and narrative analysis. The Global Steering

Committee members contributed to the synthesis, based on their reviews of the country case studies,

and reviewed the synthesis findings. Country case study leads and international consultants also

reviewed the synthesis findings. These diverse perspectives enabled the robust testing, corroboration,

and/or refining of findings. Country case study leads and international consultants also reviewed the

synthesis findings.

As described below, the evidence synthesis involved both induction and deduction, the former from the

country case studies, the latter from the themes identified in the case studies and then integrated into a

higher-order theoretical model. However, the analysis was primarily based on the data reported in the

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country case studies. The dependability of the findings was confirmed when the main themes were

discussed by the synthesis team and shared with the country teams, who agreed that they reasonably

reflected their experience. Further confirmation will be achieved if peer reviews and other readers find

the conclusions and interpretations to be valid and useful for guiding action and analysis. An audit trail

of analytical decisions further strengthens the credibility and reliability of the findings and the

triangulation.

To synthesize the findings across the case studies, the synthesis team used a multi-grounded theory

approach9 (fig 3).

Fig 3. Multi-grounded theory approach used to synthesize the studies’ findings

Adapted from Goldkuhl & Cronholm (2010)

9

The deductive analysis required an underpinning theoretical framework. The evidence review preceding

this study highlighted the paucity of strong evidence, best practices, and theoretical frameworks on

effective collaboration across sectors.3,4

The lead author on the synthesis paper had previously co-

authored peer-reviewed publications with a theoretical model, based on policy science and philosophy,

on best practices in decision-making and achieving transformative change, including through

collaboration.14 15

The synthesis team discussed how this theoretical model, having informed the

methods guide,4

could also be used for the deductive analysis. Other theoretical models could have

been used, but no alternatives were identified in the evidence review for this study3,4

or in the synthesis

team’s discussion. One of the country case studies referred to the Kindgon model; this had been

considered in the policy science and philosophy theoretical model but it did not cover the full range of

issues under consideration. A transformative change model,14

based on policy science and political

philosophy theory, was selected for use as a deductive/ theoretical framework for the evidence

synthesis. To facilitate analysis and practical application by a wide range of stakeholders, some of the

more technical policy science and political philosophy terms were adapted, including the title of the

model.

The data extraction matrix was tested on two case studies by members of the synthesis team to check

the reliability of data extraction and resolve any issues or ambiguities. The data extraction for each case

Multi-grounded theory synthesis

• Synthesis of findings across the case studies based on

deductive and inductive analyses

• Testing of the transformative change model to accommodate

the synthesis findings

• Generation of key principles of success for collaboration

across sectors

Deductive analysis/ theoretical framework

• Transformative change model used to

categorize and analyse study findings on

effective collaboration across sectors

Inductive analysis

• Cross-case analysis of findings

• Thematic analysis with theoretical

saturation

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study was then conducted by one team member and reviewed and discussed with the other team

members. Each case study also was reviewed by a Global Steering Committee member who highlighted

key issues for the synthesis.

The inductive analysis was based on the empirical findings from the 12 country case studies and 65

eligible proposals. It was based on a triangulation of the following methods.

Cross-case analysis.2 The main findings and related examples from each country case study were

presented in a matrix format, structured by the guiding questions in the methods guide. These findings

were then categorized by the transformative change model14

that informed the development of the

conceptual framework for the case study methods guide.

Thematic analysis. Within each category of the transformative change model, the synthesis team

conducted a thematic analysis of the cross-case matrix of findings to identify the main, recurrent, or

most important issues or themes (based on whether the findings addressed the specific study questions

and were highlighted by the country teams as a key finding contributing to, or hindering, success) across

the country case studies. The themes were then refined iteratively through discussions by the synthesis

team to reach a shared understanding of and agreement on the emerging themes. The synthesis team

also ran through a number of ways of interrogating the data by displaying it graphically in charts. The

synthesis and thematic refinement continued until there was theoretical saturation:2 that is, when

existing themes could accommodate new findings and no adjustments or new themes were required to

categorize the data.

Multi-grounded theory synthesis. Through the deductive and inductive analyses, the transformative

change model was tested based on whether its categories could accommodate the case study findings,

or if there were findings that fell outside the model (a qualitative process analogous to hypothesis

testing). The transformative change model was found to be a robust theoretical framework to

synthesize and accommodate the findings from the case studies on effective collaboration across

sectors to achieve transformative change. A higher-order synthesis to identify overarching principles of

success was developed against the main synthesis findings across different thematic categories. Future

programmes and research could apply, test, and further develop these principles on successful

collaboration across sectors to achieve health and sustainable development goals.

To ensure the quality of the findings, a triangulation of qualitative synthesis methods and reviews from

multidisciplinary perspectives was used—with the synthesis team, steering committee, and external

reviews. Synthesis findings were validated by the country teams. The theoretical validity and reliability

of the analytical framework were assessed as described above, and an audit trail of synthesis steps and

working documents was maintained. The synthesis paper was reviewed by all the authors from the

global synthesis and country case study teams and by external experts and journal peer reviewers.

References

1. PMNCH. Success Factors for Women’s and Children’s Health: Multisector Pathways to Progress. 2014.

http://www.who.int/pmnch/knowledge/publications/successfactors/en/.

2. Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform

management and policy-making in the health field. J Health Serv Res Policy 2005;10 Suppl 1:6-

20. doi: 10.1258/1355819054308576 [published Online First: 2005/08/02]

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3. Global Health Insights. Working report. Case Study Development based on a rapid review of the

evidence: Collaborating Across Sectors for Women’s, Children’s, and Adolescents’ Health. 2017.

http://www.who.int/pmnch/knowledge/working-report-case-study-development.pdf.

4. PMNCH. Methods guide for country case studies on successful collaboration across sectors for health

and sustainable development. 2018. http://www.who.int/pmnch/knowledge/case-study-

methods-guide.pdf.

5. WHO, Alliance for Health Policy and Systems Research. Programme reporting standards for sexual,

reproductive, maternal, newborn, child and adolescent health. 2017.

http://apps.who.int/iris/bitstream/handle/10665/258932/WHO-MCA-17.11-

eng.pdf;jsessionid=1689105592DC13C497459EA1A2AB07F1?sequence=1.

6. Frost L, Hinton R, Pratt BA, et al. Using multistakeholder dialogues to assess policies, programmes and

progress for women's, children's and adolescents' health. Bull World Health Organ

2016;94(5):393-5. doi: 10.2471/BLT.16.171710 [published Online First: 2016/05/06]

7. PMNCH and WHO. Multi-Stakeholder Dialogues for Women’s and Children’s Health: A Guide for

Conveners and Facilitators. 2014.

http://www.who.int/pmnch/knowledge/publications/msd_guide.pdf.

8. Dixon-Woods M, Agarwal S, Jones D, et al. Synthesising qualitative and quantitative evidence: a

review of possible methods. J Health Serv Res Policy 2005;10(1):45-53. doi:

10.1177/135581960501000110 [published Online First: 2005/01/26]

9. Goldkuhl G, Cronholm S. Adding Theoretical Grounding to Grounded Theory: Toward Multi-Grounded

Theory. International Journal of Qualitative Methods, 2010.

10. Patton M.Q. Qualitative Research & Evaluation Methods. 3rd ed: Sage 2002.

11. Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the

dog? BMJ 2001;322(7294):1115-7. [published Online First: 2001/05/05]

12. Creswell J.W. Research design: Qualitative & quantitative approaches. Thousand Oaks, CA: Sage

1994.

13. Denzin N.K. Handbook of qualitative research. London: Sage 1994.

14. Kuruvilla S, Dorstewitz P. There is no “point” in decision-making: a model of transactive rationality

for public policy and administration. Policy Sciences 2010;43(3):263-87.

15. Dorstewitz P, Kuruvilla S. Revieiwing rationality: a pragmatist perspective on policy & planning

processes. Philosophy of Management 2007;6(1):35-61.

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BMJ · 2017-08-18 · launched Mission Indradhanush (MI) in 2014, a strategy targeting underserved, vulnerable, resistant and inaccessible populations.8,9 MI ran between April 2015

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