“As a doctor, I understood the significance of receiving (a) vaccine shot, but the villagers in this area were not showing any interest. Our accredited social health activist (ASHA) workers were doing their best, but villagers could not be convinced,” recalled Jain.

“Eventually, I decided to step out of the PHC and go out on the ground (sic) to bring about a change in people’s behaviour,” Jain added.

This decision—motivated by a “feeling of unrest she felt within,” Jain says—dramatically changed the nature of her workday. Door-to-door house calls had to be made. Effective science communication had to be learnt on the go. Jain’s daily routine from 9am to 4pm, largely inside an office, now stretches up to 8pm sometimes. It all depends on her field visit on any particular day.

In many parts of the country, doctors such as Jain have begun to step out. The results of this outreach are already visible. Over the last two weeks, India’s daily vaccination clip has risen sharply. More covid-19 vaccine doses were administered in the first week of September than in the entire month of May. Rural areas have led this mini surge. And PHC doctors are a key cog in the system that is falling into place.

The motivations are varied—with an improvement in vaccine supply, some states have imposed district-level targets that doctors have to meet; many rural doctors also want to prevent a third wave because the second wave pushed them to the brink; some consider it a duty to the village or the town they serve.

“The average per day dose administered has increased from 2 million in May to 7.8 million in September. This number is expected to climb even higher,” said Rajesh Bhushan, Union health secretary.

View Full Image

What has aided this effort is the fact that the PHC doctor, in many parts of rural India, is a trustworthy figure. That doesn’t mean abuse or even threats of violence are non-existent.

For instance, Jain recalled a recent incident during a visit to a waterlogged area in Chindwara district to convince a family that had four elderly members. “The eldest family member was angry with me since I had visited (their home) for two consecutive days,” she said. “He threatened to attack me with a chisel if I ever went back to his house. But I persisted and continued visiting them till I found an emotional connect with the family and told them that the risks of vaccination are far less than the disease. Two days later, the whole family turned up at the PHC and got vaccinated.”

“I wanted them to live, so I counselled them,” Jain said. “We are gradually attaining success. And that’s my reward.”

Vaccination targets

Dr Raj Kumar, the district immunization officer (DIO) of Amroha, a district in Uttar Pradesh, is hoping to attain 100% vaccination coverage in his district within the next 50 working days.

According to Kumar, 50% of Amroha’s adults have received both doses of the vaccine. That figure, he said, hasn’t come easily. He had to spend many sleepless nights before the district managed to meet the daily vaccination target imposed by the state government.

“Uttar Pradesh is a state that had major vaccine hesitancy. Our target was to administer 14,000 vaccine doses every day,” Kumar said.

“Religious beliefs and misinformation played a major role in keeping people away from the vaccines. I have to give credit to my field workers, but there were times also when I have had to intervene. I have visited temples and mosques to motivate people to get vaccinated so that we can prevent (the spread of the) severe covid-19 disease,” Kumar added.

It’s important to craft outreach strategies based on the understanding that immunization programs have never been easy, Kumar said. “Whether it was for polio or smallpox, it took years to make people understand the significance of vaccination. And this (ongoing effort) is an adult vaccination program. It is all the more difficult.”

“It seems people have a phobia about vaccines. But, to an extent, villagers respect doctors and (do) listen. After teams of doctors started visiting the villages, we (have) gained traction at the vaccination centres,” added Kumar.

In Virat Nagar in Jaipur, Rajasthan, Dr Sunil Kumar Meena went through a similar experience. “In my area, people even refused covid-19 testing. Vaccination was a distant dream,” Meena said.

“Eventually, all the healthcare workers—from doctors to the nursing staff—conducted village-level meetings, door-to-door surveys, and announcements via speakers with the involvement of the local ward sarpanch or teacher. Now, people are coming forward,” he added.

This month, on average, the rural vs urban vaccination ratio has stood at 2.3:1. “That means, for every person who gets vaccinated in an urban area, at least 2.3 people are being vaccinated in rural areas. If this trend continues, the rural population will get vaccinated in about half the time,” said Balaji S. Reddie, assistant professor of operations at Pune’s Balaji Institute of Modern Management.

As per Reddie’s calculations, the rural vs urban ratio is less than 1 only in a handful of states—Delhi, Chandigarh, Mizoram, Puducherry and Telangana. In states such as Arunachal Pradesh, Nagaland and Tamil Nadu, the current ratio is roughly 1:1. In every other state, rural areas are pushing ahead of urban centres in terms of vaccination coverage.

“Most urban dwellers seem to be suffering from vaccination hesitancy. This could be attributed to over-thinking by the educated and informed class. The hesitation seems to be waning, but it’s still there. As against this, the rural population seems to have unquestionable faith in the medical practitioners in their area,” said Reddie.

Challenges remain

On 1 September, India administered over 10 million vaccine doses on a single day for the first time. Subsequently, the country breached that mark on two other days. Both walk-ins (at the vaccination centre) and assisted registrations via the 1075 helpline are on the uptick. But challenges remain.

Several villagers are technically challenged and do not want to undergo the hassles of registration, said Dr Mehul Mehta, anchor, maternal and child health and nutrition, at Tata Trusts.

“Also, at MGNREGA sites, people would disappear once they hear that a frontline worker has come to promote vaccination. In the evening, they would visit the frontline worker’s house and tell them not to visit their house for the vaccination drive. So, many frontline workers would avoid home visits,” Mehta said.

“Tribal areas in southern Rajasthan have many myths about vaccination—that people will die after vaccination; that they will develop a fever; their population will be reduced if they get vaccinated; or the vaccine is not good,” Mehta said, while adding that earlier no one was getting vaccinated in certain villages, but the pace is picking up now.

A study published in the latest issue of the Indian Journal of Public Health has noted that the immunization programme in India has matured over the last couple of decades and has demonstrated considerable resilience. Programme strategies dealing with vaccine hesitancy and social resistance based on the experience of the pulse polio and measles-rubella campaigns may not prove to be sufficient for the covid-19 vaccination drive, which encompasses both vaccine optimism and vaccine scepticism, the study titled Covid-19 vaccination and the power of rumours said.

“Risk communication and community engagement strategies need to account for both psychological responses and social contexts under which misinformation spreads,” researchers involved in the study noted further.

“The responsibility at the systems level lies in being able to amend the information ecosystem to reduce selective exposure and opinion polarization. (On the one hand), this calls for an interdisciplinary team of social scientists, psychologists, computer scientists and public health professionals, and on the other, an ‘IT war room’ (that has) to be in constant engagement with industries and internet consumers—during and beyond the campaign,” the researchers added.

Drone deliveries

As the pace of India’s vaccination drive expands, apart from hesitancy, reliable supply would also be a key factor—particularly in harder-to-reach rural areas. In an effort to fix the latter concern, the Indian government is now planning to leverage the use of drones to enable steady access to covid-19 vaccines, even in remote rural hamlets. The pilot drone delivery programme kicked off last week.

The ‘medicine from the sky’ project will undergo trials in the southern state of Telangana. It would involve beyond visual line of sight (BVLOS) drone flights for the delivery of vaccines. And the trials would take place over a period of 28 days.

Apollo Hospital’s HealthNet Global is the founding partner in these trials, along with the World Economic Forum, government of Telangana and NITI Aayog. With the country focused on achieving 100% adult vaccination, reliable vaccine supply will be a key hurdle that needs to be surmounted.

“The pandemic has highlighted that healthcare supply chains ought to be further strengthened and drones offer a robust value proposition, especially when it comes to remote areas and emergencies,” said K.T. Rama Rao, Telangana’s minister for information technology, industries, municipal administration and urban development. “Medicine from the sky is the first of its kind initiative in the country to generate insights that shall benefit the entire ecosystem,” he added.

If the drone delivery trials turn out to be a success, the model could be used even for the commercial delivery of emergency medicines and vaccines. After the initial trials, plans are in place to expand the network within the state before partnering with other states.

The initiative will also outline the several challenges that the drone delivery service could potentially solve—how to oversee operations and implement such a program. “The use of drones could make (the) delivery of critical medicines, vaccines and other essential medical supplies more widespread and faster. The technology will strengthen India’s (existing) universal immunization programme,” Vikram Thaploo, chief executive officer of HealthNet Global and Apollo TeleHealth, said.

“Drones would be best-suited for hilly and tribal terrains where stock-outs are experienced frequently. This can also help bolster India’s ongoing efforts to control mortality and morbidity as the country battles the pandemic. The ‘medicine from the sky’ initiative will generate key insights that can drive future adoption strategies as well as policy interventions for (the) inclusion of drones in (the) healthcare supply chain,” he said.