[Answered] The high prevalence of zero-dose children, especially among the poor, reflects critical gaps in India’s vaccination efforts. Analyze the socio-economic and governance challenges hindering universal immunization and suggest policy reforms for equitable health outcomes.

Introduction

Despite India’s vast immunization infrastructure, the persistence of zero-dose children among the poorest reflects systemic inequities. Addressing socio-economic barriers and governance bottlenecks is essential to achieving universal immunization goals.

Magnitude of the Problem

1. According to The Lancet (2024), India had 1.44 million zero-dose children in 2023 — second only globally — accounting for 6.2% of the 23 million annual births.
2. India is among the eight countries that comprise over 50% of global zero-dose children.
3. This marks a reversal from earlier progress: India reduced zero-dose prevalence from 33.4% in 1992 to 10.1% in 2016, yet COVID-19 disruptions caused a spike to 2.7 million in 2021 before partially recovering.

Socio-Economic Challenges

1. Poverty and Maternal Education: A majority of zero-dose children belong to poor households, especially those with low maternal literacy. Poor families often prioritize daily subsistence over health-seeking behavior due to opportunity costs and wage loss.
2. Marginalized Communities: Zero-dose prevalence remains high among Scheduled Tribes (STs), Muslims, and migrant families, especially in urban slums and remote tribal belts. States with the highest burden include Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Maharashtra, and Gujarat.
3. Geographical and Infrastructural Gaps: Immunization coverage is low in Northeast India (e.g., Nagaland, Meghalaya, Arunachal Pradesh) due to difficult terrain, poor connectivity, and understaffed health facilities.
4. Vaccine Hesitancy and Misinformation: Cultural and religious hesitations — particularly in Muslim-dominated households — remain a major barrier despite outreach efforts. Misinformation during the COVID-19 pandemic further eroded trust in vaccines.

Governance and Programmatic Challenges

1. Underutilization of Mission Indradhanush: While Mission Indradhanush aimed to achieve 90% full immunization, its progress has been uneven and coverage stagnated at around 76% as per NFHS-5 (2019–21).
2. Fragmented Urban Health Governance: Urban slums often fall under overlapping jurisdictions of municipal and state health bodies, creating accountability gaps and poor outreach.
3. Data and Monitoring Deficiencies: Weak surveillance systems limit real-time tracking of zero-dose children. The eVIN system for cold chain logistics exists but doesn’t ensure child-level follow-up.
4. COVID-19 Setback: Immunization drives were halted or diverted during the pandemic, disrupting routine services and contributing to a surge in missed vaccinations.

Policy Reforms and Solutions

1. Equity-Focused Targeting: Prioritize geographic and community-specific micro-planning, especially in high-burden districts under Intensified Mission Indradhanush (IMI) 5.0. Use social behavior change communication (SBCC) to counter vaccine hesitancy.
2. Strengthening Frontline Workforce: Empower ASHAs, ANMs and Anganwadi workers with incentives, mobility support, and training to target hard-to-reach populations.
3. Integrated Urban Health Strategy: Implement the National Urban Health Mission more effectively with robust community linkages for slum populations.
4. Technology and Innovation: Utilize AI-enabled dashboards, Aadhaar-linked real-time immunization records, and mobile vaccination vans in remote zones.
5. Community-Based Interventions: Leverage Self-Help Groups (SHGs), religious leaders, and civil society organizations to build trust and increase awareness.
6. Global Best Practices: India can learn from Bangladesh’s door-to-door immunization and Rwanda’s mobile health clinics that successfully reached underserved populations.

Conclusion

India’s universal immunization goal hinges on addressing persistent socio-economic and governance challenges. Targeted, inclusive, and data-driven policies can ensure equitable access to vaccines and healthier futures for all children.