Nudges to Increase Routine Immunization

Our Organization

Suvita

What is the name of your solution?

Nudges to Increase Routine Immunization

Provide a one-line summary of your solution.

Using evidence-based combination of SMS technology and systematically identified local influencers to improve uptake of routine immunisation in India

Film your elevator pitch.

What specific problem are you solving?

In 2020, 23 million children failed to receive their basic vaccinations (WHO, 2021). Vaccination coverage varies widely between and within countries, so certain regions bear a much greater load than others when it comes to vaccine-preventable diseases. India has around half of these world’s undervaccinated children and suffers the death of one child every four minutes as a result of a vaccine-preventable disease (WHO, 2020). Around 10 million children born in India each year do not receive their full recommended set of vaccinations by their first birthday. Of these undervaccinated children, over 7 million receive their first basic vaccinations, but fail to complete the rest of the course by the recommended age. 

This “drop-off” is the key problem that Suvita aims to address to improve immunisation coverage. Analysis indicates that root causes of this drop-off in India are primarily demand-side challenges (where parents do not access the services available to them) rather than supply-side challenges (where services are unavailable). For example, a survey of nearly 40,000 parents in low-immunisation districts found that the most common reason for missing a vaccination appointment is an awareness gap. Other analysis has identified that caregivers also commonly drop-off because they forgot to attend their appointments, or because they are worried about or inconvenienced by side-effects (if the baby gets a fever, it might stop the caregiver from working or strain family relationships). In a nationwide survey, caregivers were four times more likely to identify demand-side barriers than supply-side ones when explaining why their child had missed a vaccine dose. Furthermore, roughly 70% of undervaccinated children in India have received at least one vaccine, indicating that missed appointments are a major barrier to full vaccination. Banerjee and others note in their study in India that while vaccines are free and available, a combination of relative indifference, inertia, and procrastination results in children dropping out. 

With the current pandemic, this number of drop-offs has increased. A side effect of India’s tough stance on COVID-19 has been that millions more children are missing out on vital vaccines they should receive in the first year of their life. The Indian government’s expansion of immunisation since 1990 cut the deaths in India from these diseases by 450,000 every year. As a result of COVID-19, we are at risk of losing that progress. Without targeted solutions, disruption of routine vaccination across India could lead to new outbreaks and new epidemics in a few short years.

What is your solution?

Our work is focused on India which has 7 million children not completing their routine vaccination schedule every year. Suvita implements two rigorously-tested models to increase uptake of vaccinations and protects infants and communities from future pandemics. Our work is based on research by Nobel-Prize-winning economist Abhijit Banerjee and colleagues. In their high quality RCT conducted in Haryana, India, these economists found that these two programmes when implemented together increased immunisation rates by about 20%: 

1. Sending personalised SMS reminders to parents in their local language every time their child is due for a vaccination.  They encourage mothers to take the first, critical step of talking to their ASHA, a government appointed community health worker,  or going to see a nurse when it is time for their children to be vaccinated. In this way, reminders can directly reach mothers with critical health information, even where the ASHA is unable to. While our personalised SMSes emphasise and repeat that vaccination prevents deadly diseases, our automatic classification and data extraction process for birth record documents ensures that the immunisation SMS reminder program can be scaled up to different cities  without the need of onboarding more data entry personnel.

2. Building a network of carefully selected volunteer immunisation ambassadors, who share information with new parents in their community about local vaccine clinics and schedules. In each community where we work, we establish a network of immunisation ambassadors who are nominated by their community members for their ability to spread information. We chose a remote rather than in-person survey approach to identifying these ambassadors because we expect it to be more scalable and cost-effective, and it has also proven highly adaptable to the current pandemic. These local ambassadors are regularly motivated (using SMS messages and phone calls) to spread information to caregivers about the importance of getting their children vaccinated, using whatever approach they believe to be most appropriate for their own community. They then mobilise caregivers to bring infants to routine immunisation sessions. 

Ambassadors apply their knowledge of the local context to choose a targeted strategy to address local barriers to vaccine uptake, while SMS reminders provide a behavioural nudge at the optimum moment. This flexibility combined with personalisation and the use of  advanced technology such as AI and machine learning enables the programmes to meet complex and varied needs at scale.

Who does your solution serve, and in what ways will the solution impact their lives?

Our end users are the parents of the 7 million children every year in India who start but do not complete their vaccination schedule. We work primarily in Bihar and Maharashtra states, where over 1 in 4 children do not complete their full vaccination schedule (NFHS-5, 2021). Studies indicate that these families are more likely to have certain demographic characteristics such as having low income and low education levels; being less well-connected to the health system in general (e.g. having had fewer or no antenatal care appointments, and being more likely to have given birth at home rather than in hospital); and belonging to minority religions and historically oppressed castes and tribes. 

We design our programmes to be accessible to our users by sending all messages in local languages using the ubiquitously available technology of SMS messages. Whereas almost every family in India has access to a mobile phone, only around ⅔ of people have access to smartphones. This means that SMSs can reach many of our users where e.g. WhatsApp could not. We are also currently exploring the alternative of recorded voice messages in addition to SMSs, as these are similarly accessible on basic phones, while also overcoming the literacy barrier faced by communities with fewer years of education. Families also do not need to spend any mobile credit to enrol for the programme (this is carried out through either automatic enrolment when they give birth at a healthcare facility, or via a missed call mechanism that costs them no money). 

We identify natural influencers in a community network through the magic question: “If there was a fair in town, who is most likely to tell you about it.” The people who are nominated tend to be active and well-connected in their community, meaning that they have a much better idea of key barriers to immunisation within their own networks, so they can take whatever approach they expect will be most effective in their local area. We expect that this also means the ambassador programme is robust to variation in specific needs and barriers if delivered at scale, because in any community it is led by those who know the community best.

How are you and your team well-positioned to deliver this solution?

In India, one child dies every 4 minutes from a vaccine preventable disease. This is unacceptable. I grew up in India and am a mother of two young children. I can relate to the sense of being exhausted, disorganised and overwhelmed with infants and can intuitively see the value of such nudges in improving uptake of routine immunisation. 

We are a sharp and agile team of 28 generalists and experts committed to solve the problem for good through a relentless focus on impact and scale and a culture of constant iteration and learning. We see this approach as a highly promising route to impact - taking programmes that have been shown to work and helping them reach as many families as possible. Our leadership team spent thousands of hours reviewing the literature on the most cost-effective and evidence-based global health interventions to select and refine our focus. We are confident in our solution and relentlessly dedicated to saving and improving as many lives as we can. 

Our solution depends on the people in the communities we serve. We talk with them to find quality immunisation ambassadors, whose feedback allows us to refine our approach based on personal experiences and deep community ties.

In Saran district, Bihar, where we undertook our initial study this year, we conducted Receipt & Understanding surveys with SMS enrollees and interviews with immunisation ambassadors to better understand their motivation and impact. We are also tracking parents’ and caregivers’ responses to ambassadors by giving out a phone number to ambassadors to share with their networks. Our monitoring suggests that more than 98% of text messages are delivered successfully and at least 50% of the users recall the information at a later date. Overwhelmingly ambassadors are enthusiastic and sharing information with their networks, we received about 30 missed calls within one week of sharing a missed call phone number with 45 ambassadors. 

We also use qualitative research methods such as interviews routinely to get a deeper and better understanding of the program’s benefits (and problems) on ground. For example, one of the interviews with a parent we work with, Sonu, in Bihar state, India stated: “This is your very good initiative, everyone who receives this SMS should go to vaccination. Whatever your organisation is doing is commendable - keep doing this - this will secure the future and health of many children.” 

Which dimension of the Challenge does your solution most closely address?

Build fundamental, resilient, and people-centered health infrastructure that makes essential services, equipment, and medicines more accessible and affordable for communities that are currently underserved;

Where our solution team is headquartered or located:

Our solution's stage of development:

How many people does your solution currently serve?

405,000

Why are you applying to Solve?

I do not know of any other similar opportunity to engage with entrepreneurs, investors, governments, and academics, all focused on sharing ideas and building relationships to increase social impact.  I look to harness the collective and individual wisdom of colleagues to inform our strategy on approaching scaling of our operations in India and abroad. We at Suvita have been in the startup ideation mode for the last two years and believe this year is pivotal in order to chart our exponential scale up plans. Specifically, helping me think through different models of scale, how to think through evaluation of our programming, and how to focus more on external communication would be crucial for us to reach our goals this year. 

As members of the Solve community, we would like to work with experts in technology, data security, monitoring and evaluation, scaling, and the implementation of immunisation ambassador programmes in India (an area in which MIT’s J-Pal team has unique experience). We also hope that a Solve grant would help us reach our short-term budget targets and introduce us to partners who could strengthen our long-term financial outlook, either through direct funding, coaching or connections with other funders and government partners.

Organizations and individuals experienced in maximizing the cost-efficiency of public health outreach programmes could help us reduce our cost per fully immunized child from $64 to $36, and identify other opportunities for increased efficiency.

Financial: Since all of our goals are dependent on funding and we are still in the pilot stage, we stand to gain more from financial coaching and assistance than we do in any other area. Fundraising support could include introductions to investors (especially those with some connection to health efforts in India) and preparation for investment discussions. We would also benefit from  coaching to build stronger financial and accounting systems, and strategic planning to build a sustainable long-term funding model. 

Monitoring and evaluation: We would like to increase operational efficiency, measure and demonstrate our solution’s impact, and drill down on the  mechanisms that most contribute to its success. For example, we would like to partner with third party evaluators to learn more about how our general SMS reminders and immunisation ambassador nudges interact to make better use of this unique model. This would help us answer questions like, “To what extent are ambassadors reaching parents and caregivers that our general messages don’t, and how does that impact immunisation rates in each village?"

In which of the following areas do you most need partners or support?

Technology (e.g. software or hardware, web development/design, data analysis, etc.)

Who is the Team Lead for your solution?

Varsha Venugopal