The Last Mile Vaccination

Photograph by Pradeep Baisakh

A small team started from Junagarh block head quarter of Kalahandi district of Odisha province in India by 3 bikes to the Gobar Gola hills to see how Covid vaccination has been done in the remote Lakhnapada village by the volunteers of an NGO. After traveling around 15 kilometers the team reached the foothill. From there started the difficult journey to reach the hilltop village which is about 5-6 kilometers away. A narrow bumpy laterite road cuts across the hill taking several twists and turns traversing through stiff heights up and down till it reaches the village. The journey was tougher that day as the area received some rain the previous night. Somewhere the bikes would slow down due to a stiff height and somewhere the pillion rider had to get off the bike to trek the hills; and still, in some places the rider would barely be able to manage it from skidding back or fall off the sharp edges of the hill! After traveling for about an hour and a half, the team finally reached the village!

Cut off from the mainland, mostly populated by the indigenous community (Kutia Kondhs) and a few families from scheduled caste (Dalit people) and other backward classes (OBCs). Illiteracy level among the adult population is very high. We could barely find any literate adult person in the village except probably the ASHA (Accredited Social Health Activist) worker and a few youths who have passed 5th standard. There is a school where children study. A volunteer from the plane area teaches the students there. Some youths have migrated out of the place to cities and towns to work in the informal sector. The village has no regular electric connection. Two solar panels are there to supply power to a few electric bulbs at night. One cannot get mobile connectivity there though some people carry mobiles. To fetch connectivity, they have to come down to the plane area.

It may be noted that Kalahandi district is among the most backward districts of the country with a huge population from the indigenous communities having low awareness levels. The district is also covered by hills which are not well connected with the plane areas. Such areas are likely to be left behind in the process of vaccination.

COVID vaccination was done in the remote village by social activists of Rupayaan NGO in a GO-NGO partnership under the government initiative of Har Ghar Dastak, where vaccination was done by house to house visits covering the most neglected section of the society who would otherwise not make to the nearest health centers to take vaccines.

The volunteers of Rupayaan traveled to such interior pockets and set up several vaccination camps there to vaccinate men, women, young, old – all adult population. Some villagers from Lakhnapada had earlier taken the first dose of vaccination from the nearest Community Health Centre (CHC) at Chiliguda, 15 kilometers away from the village situated in the plane area. The ASHA (Accredited Social Health Activist) worker (The government health worker at the village level) of the village Ms. Anadi Majhi had helped take people by auto rickshaws after reaching the plane area foot to the health center or people themselves walked the distance to fetch the vaccines. Ramanidei Majhi, 70, Mukta Majhi, 65 are some old women, Gajendra Majhi, 22, Guni Majhi, 35 and Bada Majhi, 55 are some men who were vaccinated with 2nd dose by Rupayaan in three camps set up in the Lakhnapada village during the period from January to April 2022. The remote village is currently nearly 100 percent vaccinated (adult population) with some rare exceptions who were either not present during the camps or have migrated.

Rupayaan took responsibility for fully vaccinating the Junagarh block (Junagarh-Rural) which is predominantly a hilly area inhabited by indigenous and Dalit people. Junagarh Rural has a total of 43918 households and 188848 population (Figure provided by Block Programme Manager of National Health Mission of Junagarh block), minus the NAC (Notified Area Council) area, which is Junagarh small town itself. The NGO worked there from November 2021 to April 2022. Before their intervention, 64 percent of adult population were vaccinated with the first dose and 21.1 percent were vaccinated with the second dose in Junagarh Rural. But in six months with intense intervention, in the block, 98.83 percent adult population were vaccinated with 1st dose and 97 percent with 2nd dose. This makes the vaccination process almost complete.

In some cases, the NGO also vaccinated children above 12 by visiting the schools.

The process of identification of the left behind

An intense planning process by the NGO preceded the actual vaccination. A dedicated team was formed who did household surveys to know the vaccination status of every adult. Line-listing was done based on the survey. The social workers were assigned different village panchayats to approach people and vaccinate them. The qualified ANM (Auxiliary Nurse Midwifery) were hired by the NGO as part of such teams to inject the vaccines. Perfect coordination was maintained by the NGO team with the government community health center (CHC) situated in the Junagarh block head quarter to procure vaccines and update the information on the CoWIN system of the government etc.

Rajkishor Mishra of Rupayaan said, “When we approached the district project manager of National Health Mission (NHM) of Kalahandi district, he assigned us this block for vaccination. We got full cooperation from the government in getting vaccines in time and updating the data. The team we had was extremely dedicated to take the hardship to reach each house in every village in the hills and the plane area and persuade people to take vaccines. We received adequate training before starting the work. It was not easy for the team to persuade people to take vaccines as vaccine hesitancy was high among them. But with effective counseling by the team, the people gradually agreed to take vaccines.”

Before a camp was organised in a village/area, prior information about time and place of the vaccination camp was given to the villagers to stay in the village on the day and come to the camp at their convenience. Otherwise, people would be out in their agricultural fields. The volunteers took vaccine kits with them procured from the community health center and go to the village by a vehicle or by bike or in some cases by walking long distance! In order not to leave anyone left out of the process, the team also did ‘tele calling’ to the people who had taken the first dose to inform them to take the second dose by inviting them to the camps.

Similar to the Lakhnapada village, Dunda, a hilltop village was also challenging where social workers had to walk long distance to reach there.

Narayan Jena of the NGO sums up the types of vaccine hesitancy among the people. “The first reason for vaccine hesitancy was lack of proper communication to the indigenous communities in their own language. Indigenous people speak Kui language in the district. Most communications from the state government were in Odia, the official language of the province, which was not conducive to the indigenous people. The reluctant category includes old people, pregnant and lactating mothers, people with comorbidities etc. The people thought that the fetus may be destroyed if a pregnant lady is vaccinated and in case of a lactating mother, the baby may die.” During an interaction with some youth in the Lakhnapada village, they told they were of the false belief that they would lose potency after being vaccinated!

The volunteers made effort to dispel the false belief of people. Krishna Patra, a ANM associated with the NGO says, “We told the pregnant lady that if you take the vaccines, you will not get Corona and thus saving your and your child’s life in the womb.” People also had superstitions. They thought they would not be able to worship their Gods if they take the vaccines. There were news reports of people dying after being inoculated in the initial period of vaccination. That also had scared the people.

The first dose of vaccination was taken by these people in August 2021 out of fear. In April – June 2021 the country was engulfed with second wave of Covid and witnessed rapid spread of virus and an insurmountable number of deaths. In this wave, the country reported above 400000 for some days. Some Covid related fatalities were also reported from the Kalahandi district that time. This had prompted people to go to the nearest health centers to take vaccines. It was not easy to take vaccines in the health center then. Due to a mad rush, said some people, they would have to reach the place at 2 am to be in queue and get the vaccine at 4 pm afternoon, a 14-hour waiting period! However, this process did not cover all the neediest like the old people and persons with disabilities etc. who could not leave the villages due to obvious reasons.

Door to door campaign: Bedridden and person with disabilities vaccinated

Sangita Kabir and Himadri Meher, both ANM working with the NGO, narrate their experience of vaccinating a person with mental disabilities in Charbati village Panchayat. “When we reached the village, we approached the ASHA to help us introduce to the villagers. We found a person with mental disability (name hidden) who was not vaccinated. The ASHA feared to go to his house. But we could persuade her. It was really a challenge to vaccinate the person. He was aggressive. The ASHA ran away from the house once we were there. Somehow, we persuaded him and inject the vaccine.” Taking pride in the work, the ANMs told, “That is one of our big achievements!”

In the Charbati village, Jayamani Nayak, 70-year-old lady, who has been on bed for last 5 years got two doses of vaccines from the team through home visits. Similarly, Kushuma Nayak, 65 who is also bedridden got two doses of vaccines. Said Kushuma, “I could not have taken vaccine if these people had not come to my home to vaccinate me.” There are several such cases in the area.

A charitable donor organization, Azim Premji Foundation which supported Rupayaan with funds also supported some other NGOs to undertake last mile vaccination in 29 difficult blocks in the country.

Scale of vaccination in the country

In a review meeting on 3rd November 2021 with District Magistrates of over 40 districts with low inoculation, Prime Minister Narendra Modi cautioned against any slackness and urged to go to the doorsteps to vaccinate people. The government launched the ‘HarGharDastak’ campaign in November 2021 that helped reaching the most marginalized group of people. The government sent teams to do door to door vaccination under the campaign. The phase 2 of the campaign was undertaken for two months in June & July 2022 to cover the old age homes, prisons etc. and also the children above 12. “The initiative contributed immensely towards the success of the programme by reaching out to the last mile beneficiaries including the old-aged, differently-abled and even the vaccine hesitant populations.” states a press release by the Ministry of Health and Family Welfare released on June 1, 2022.

In July India became the second country to cross the 2 billion mark in vaccination after China. By September 3, 2022 India has administered more than 2.13 billion vaccines (1.02 first dose, 0.94 billion second dose and 0.16 billion booster does), suggest the CoWIN portal of the government. In terms of percentage, by August 1, 2022, 94% of eligible population (above 12) have been given first dose, 86% second dose. Various vaccines those have been used are Covishield, Covaxin, Sputnik V, Cobervax and Covovax among which first two constitute the major percentage. In Odisha province, above 35 million first dose, 32.6 million second dose and 8.2 million booster doses have been given by September 3, 2022.