Introduction
Himachal Pradesh is a landlocked state in northern India that shares a border with Jammu and Kashmir in the north; Punjab, Haryana, and Uttarakhand in the south and west; and China in the east. The state’s population of 6.9 million (according to the 2011 census)1 lives in some of the harshest terrain and climate regions of the world, including Komic village, the highest village in the state and in the world, located at an altitude of 4,724 meters.2 The state’s territory is mountainous except for few pockets that border Punjab and Haryana, which have sub mountainous topography. The state is part of the Himalayan system. Altitudes of different regions of the state range from 350 to 7,000 meters.3
While the state is not as densely populated as Uttar Pradesh, Haryana, or Punjab, Himachal Pradesh’s unforgiving terrain and severe weather events, like snowstorms and seasonal rains that hinder access to entire districts at a time, make inoculating people difficult. Moreover, the task of convincing people who live in remote villages to be vaccinated limits the reach of vaccination drives.4 Despite these challenges, the state emerged as a champion when it became the first state in India to achieve 100 percent vaccination of its eligible population (those over 18 years of age) with both doses of the COVID-19 vaccine; it surpassed its target of the 5.38 million eligible population and inoculated more than 5.39 million people on December 4, 2021.5 As of December 7, 2021, a total of 11.2 million COVID-19 vaccines were administered across the state: 5,839,658 people were inoculated with the first dose of the vaccine, and 5,400,354 people were fully vaccinated.6
How can you replicate or adapt this promising practice?Adopt a holistic approach to vaccinationHimachal Pradesh adopted a blended approach to create awareness about vaccination. The state used technology to map residents and their vaccination status, and recruited community health care workers, such as accredited social health activists, who went door to door to raise awareness and encourage more residents, including those in the remotest villages, to get vaccinated.4
Conduct back-end planning and managementThe state administration accelerated the vaccination rollout with almost zero wastage of vaccines through back-end planning and management. This included completing groundwork, such as enhancing the capacity of the cold chain storage in the state, transportation facilities, and human resources, and encouraging people to get vaccinated.4,8
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How was this promising practice implemented?
Established near-to-home COVID-19 vaccination center strategy
To make vaccines more accessible for the elderly and differently abled citizens, who were unable to reach existing COVID-19 vaccination centers, Himachal Pradesh implemented the near-to-home COVID-19 vaccination center strategy. This was a community-based approach, in which the state conducted vaccination sessions at community centers, resident welfare association centers, group housing society centers, panchayat buildings, and school buildings, among other places in the community.10
Revised COVID-19 vaccination strategy
To address the needs of the people and ensure zero vaccine wastage, the National Health Mission in Himachal Pradesh revised the statewide vaccination strategy; this revised strategy went into force on July 19, 2021. The earlier strategy involved holding a separate vaccination session for each age group—18 to 45 years, 46 to 60 years, and over 60 years. As part of the revised vaccination strategy, the state created a single session for all three age groups, which was held on all working days. It was prescribed that all sessions on the CoWIN vaccination portal be marked as regular rather than special, except for sessions in near-to-home COVID-19 vaccination centers and in tribal and hard-to-reach areas, to ensure greater visibility of sessions on the app.11,12
Other salient features of the revised vaccination strategy include the following:
- Hybrid approach to vaccination registration: The district administrations had the freedom to determine the proportion of vaccination slots that people could register for online, based on previous experience with vaccination slot booking. There was no prescribed limit for online slots in rural COVID-19 vaccination centers; in urban areas, however, 50 percent of the slots had to be reserved for online registration when creating sessions in CoWIN. If the slots available online in urban areas were not fully reserved, on-site slots could be increased to cover the number of on-site registrants on a given day.
- Advance planning of vaccination sessions: The district administrations published information about sessions between noon and 1 p.m. at least a day in advance. The number of sessions and their capacity were scheduled based on vaccine availability. District wise, daily limits were established based on the number of beneficiaries eligible for each dose. Ongoing sessions could be extended beyond the scheduled capacity to minimize wastage of vaccine in open vials.11
Achieved minimal wastage of vaccine
Himachal Pradesh set an example for other states by reporting negative wastage of COVID-19 vaccine. As of June 11, 2021, the vaccine wastage factor was reported as −2 for government-procured vaccines and −1 for state-procured vaccines.13 The state health department used its resources optimally to prevent vaccine wastage at all possible stages. Vaccinators in the state were meticulously trained to load vaccines for transport and administer doses to ensure minimal wastage of vaccine, per the health department guidelines. The vaccinators were also trained to fully use extra doses that were available in most vials.14,15
“We don’t waste a single dose of vaccine at our center. Our motto is ‘one dose-one life’. We request people to wait and they cooperate with us. One vial only works for 4 hours. We extract over 10.5 doses from one vial because there is an extra dose in the vial.” —Dr. Saad Rizvi, in-charge of the vaccination center at the Indira Gandhi Medical College, Shimla13
“To minimise the vaccine wastage, the facilitated Cohort Mobilization was done by the Health Workers, ASHAs [accredited social health activists] and AWWs [Aanganwadi workers] to maintain a staggered and continuous movement to the COVID vaccination Centre in Himachal Pradesh.” —Dr. Nipun Jindal, Director, National Health Mission, Himachal Pradesh15
Addressed vaccine hesitancy
Residents of some regions of Himachal Pradesh, such as Malana, initially refused vaccination, citing cultural reasons. This became a roadblock to the state government achieving its target of 100 percent vaccination with the first dose.
“Various development works like construction of school building, roads etc. are also started by the department only after permission of the local deity Jamlu Rishi. However, convincing them to take the vaccine shots was a challenge as they had lot of reservations about the vaccine.” —Ashutosh Garg, Deputy Commissioner, Kullu district16
The deputy commissioner of Kullu district, Ashutosh Garg, traveled to Malana, along with the district chief medical officer and other medical staff, to encourage residents to get vaccinated.4 The team met with villagers and addressed all of their queries in a 2-hour discussion with pujaris (priests)—a council of 11 members considered to be representatives of the local spiritual deity. The team shared various data points, case studies, and research papers to show the benefits of COVID-19 vaccination. At the same time, the team conveyed that the government of India may make it mandatory for everyone to be fully vaccinated.16
A team of state officials carrying out a discussion on the benefits of COVID-19 vaccination with villagers.16
“We told them that vaccines are safe and don’t have any major side-effects. And if tomorrow, the government of India starts doling out certain benefits only for people who have received Covid-19 vaccination, they will regret it. These benefits may include entry at certain places, freedom to roam out freely and benefits in government schemes.” —Ashutosh Garg, Deputy Commissioner, Kullu district16
The last thing that probably had the biggest impact on villagers’ decision to take up vaccine was the safety of tourists and villagers, as the locals depended on tourism for income and livelihood. The officers told the villagers that they could resume the entry of foreign tourists by vaccinating themselves so that tourists would not hesitate to come to the village and locals would not fear catching COVID-19 from tourists. Eventually, the team was able to receive permission to begin a vaccination drive.
Arranged transportation to difficult-to-reach areas
The state government authorized the commissioner of Kangra district, Nipun Jindal, to use the state’s helicopter to fly health workers, medical teams, and district officials for the vaccination of residents of the Bara Bhangal area, which could not be reached easily due to its terrain. An alternative plan was to send the health care teams on foot if the monsoon rains disrupted the helicopter flight. However, weather did not disrupt the first plan.4
Supplementary material
Sources
- At a glance. Himachal Pradesh: The Official Website. Updated September 7, 2021. Accessed October 25, 2021. https://himachal.nic.in/en-IN/at-a-glance.html
- Komic, world’s highest village in Himachal Pradesh, gets fully vaccinated. The Times of India. May 20, 2021. Accessed November 10, 2021. https://timesofindia.indiatimes.com/travel/travel-news/komic-worlds-highest-village-in-himachal-pradesh-gets-fully-vaccinated/as82801955.cms
- Himachal Pradesh: a profile. In: Planning Commission, Government of India. Himachal Pradesh State Development Report. New Delhi: Planning Commission; 2014. Accessed November 11, 2021. https://niti.gov.in/planningcommission.gov.in/docs/plans/stateplan/sdr_hp/sdr_hpch1.pdf
- Mahajan AS. How Himachal Pradesh achieved a 100 per cent first dose vaccination target. India Today. Updated September 7, 2021. Accessed October 25, 2021. https://www.indiatoday.in/india-today-insight/story/how-himachal-pradesh-achieved-a-100-per-cent-first-dose-vaccination-target-1849855-2021-09-06
- Sharma A. Himachal Pradesh becomes first state to achieve 100% vaccination. Outlook. December 5, 2021. Accessed December 9, 2021. https://www.outlookindia.com/website/story/india-news-himachal-pradesh-becomes-first-state-to-achieve-100-vaccination/403909
- Government of Himachal Pradesh. COVID-19 vaccination. National Health Mission, Department of Health and Family Welfare. Updated October 28, 2021. Accessed January 14, 2022. http://www.nrhmhp.gov.in/content/covid-19-vaccination
- “Himachal emerged champion, 100% adults given 1st dose of covid vaccine”: PM Modi. NDTV. Updated September 6, 2021. Accessed October 25, 2021. https://www.ndtv.com/india-news/himachal-emerges-as-champion-in-covid-vaccination-drive-says-pm-modi-2531280
- Bodh A. Himachal Pradesh emerges as champion of vaccination campaign, says PM Narendra Modi. The Times of India. September 6, 2021. Accessed October 25, 2021. https://timesofindia.indiatimes.com/city/shimla/himachal-pradesh-emerges-as-champion-of-vaccination-campaign-says-pm-narendra-modi/articleshow/85978229.cms
- Himachal Pradesh completes administering 100% first dose of Covid vaccine. Mint. Updated August 29, 2021. Accessed October 26, 2021. https://www.livemint.com/news/india/himachal-pradesh-completes-administering-100-first-dose-of-covid-vaccine-11630237553087.html
- Mission Director of the National Health Mission, Department of Health and Family Welfare, Himachal Pradesh. Regarding Near to Home COVID Vaccination Centres (NHCVC) Drive for Elderly and Differently Abled Citizens. New Delhi: National Health Mission; 2021. Accessed October 25, 2021. http://nrhmhp.gov.in/sites/default/files/files/letter%20dated%2029%20May%202021%20to%20all%20CMO%20reg%20Near%20to%20Home%20COVID%20vaccination%20Centres%20drive%20for%20Elderly%20and%20differently%20Abled%20citizens.pdf
- Punj V. Himachal Pradesh revises Covid-19 vaccination strategy. Here’s what has changed. Mint. Updated July 17, 2021. Accessed October 25, 2021. https://www.livemint.com/news/india/himachal-pradesh-revises-covid-19-vaccination-strategy-here-s-what-has-changed-11626532571225.html
- National Health Mission, Himachal Pradesh revises COVID vaccination strategy; to be implemented from July 19. ANI. July 17, 2021. Accessed November 11, 2021. https://www.aninews.in/news/national/general-news/national-health-mission-himachal-pradesh-revises-covid-vaccination-strategy-to-be-implemented-from-july-1920210717234544/
- Sharma M. Negative Covid-19 vaccine wastage in Himachal Pradesh. Here is how. India Today. Updated June 11, 2021. Accessed November 9, 2021. https://www.indiatoday.in/coronavirus-outbreak/story/negative-covid-19-vaccine-wastage-in-himachal-pradesh-here-is-how-1813650-2021-06-11
- Bodh A. Zero per cent Covid-19 vaccine wastage in Himachal Pradesh. Times of India. May 9, 2021. Accessed November 9, 2021. https://timesofindia.indiatimes.com/city/shimla/zero-per-cent-covid-19-vaccine-wastage-in-himachal-pradesh/articleshow/82498328.cms
- Himachal achieved highest full immunisation coverage & zero vaccine wastage, claims HP NHM. Himachal Watcher. May 10, 2021. Accessed November 9, 2021. https://himachalwatcher.com/2021/05/10/himachal-achieved-highest-full-immunisation-coverage-zero-vaccine-wastage-claims-hp-nhm/
- Chandna H. Holy shot: how the Himachal Pradesh govt convinced the god of Malana village to allow vaccination. News18. Updated September 20, 2021. Accessed November 10, 2021. https://www.news18.com/news/india/holy-shot-how-the-himachal-pradesh-govt-convinced-the-god-of-malana-village-to-allow-vaccination-4223411.html