A child missing a vaccine is often framed as an awareness problem. Did the family know the date? Did the mother understand the importance of the dose? Did the frontline worker remind her? 

These are important questions. But they are not enough. 

Recent field insights from the Community of Practice on Demand (CoP-D), an initiative of the Ministry of Health and Family Welfare supported by UNDP, UNICEF, Gavi and other partners, point to a more complicated reality. CoP-D works to understand the social and behavioural drivers of immunization, address vaccine hesitancy, and strengthen community demand for vaccines.

In many households, immunisation is not a simple decision taken by one informed caregiver. It is shaped by power, permission, money, time, trust, fear and the quiet distribution of care work. To understand why children are missed, we need to ask a sharper set of questions: who decides, who takes on the work, who pays, and who is blamed? 

The answers are rarely straightforward and often gendered. 

Mothers are usually expected to remember vaccination dates, carry the Mother Child Protection (MCP) card, take the child to a health centre,  manage side effects like fever, calm the child, answer the family’s doubts and return for the next dose. Yet they are not always the primary decision-maker. Fathers, grandmothers and other elders can strongly influence whether the child is vaccinated at all. A mother may believe in vaccination but still wait for permission, negotiate family objections or defer to the authority of an elder. 

The CoP-D field studies illustrate how these household dynamics play out.  In Bhiwandi, for instance, one mother explained that the final decision rested with her mother-in-law (Saas): if the Saas approved, the child would be vaccinated; if not, the vaccination could get delayed or refused. In Bhind, another mother identified her father-in-law as the primary decision maker, followed by her husband. 

These power dynamics intersect with other social and structural barriers. In Nuh, for example, CoP-D's assessment found that vaccine hesitancy was shaped not only by strong patriarchal control and limited communication between spouses, often exacerbated by male migration, but also by distrust of health workers and fears that vaccines could cause infertility or result in children receiving duplicate doses. 

This creates a familiar but deeply unfair arrangement: the decision is collective, but the burden is individual. 

CoP-D's household playbook field testing reflected this imbalance. Fathers were identified as decision-makers in 66.7 per cent of families, Grandmothers in 45.5 per cent, and mothers in 27.6 per cent. These findings do not diminish mothers' role; rather, they highlight why expecting mothers alone to ensure complete immunisation is both unrealistic and inequitable. 

The Hidden Costs of a ‘Free’ Vaccine  

 Vaccines under India's Universal Immunisation Programme are provided free of cost. Getting to the vaccination session, however, is often anything but free.  Across CoP-D's qualitative and quantitative research, families repeatedly described the costs that accompany routine immunisation: lost wages, transport expenses, long travel distances, waiting times and the practical challenges of reaching vaccination sessions, particularly for migrant families, dispersed settlements and hard-to-reach communities. 

In Bhojpur, frontline workers described families missing vaccination because they could not afford to lose a day’s income. In Sahibganj, a father explained that taking the child for vaccination meant losing wages. In Bhadohi, an ASHA captured the trade-off bluntly: some families depended on daily home-based work such as rolling bidis (handmade cigarettes) for income, and worried that time spent attending a vaccination session would cost them that day’s earnings. 

Yet another, less visible challenge begins after the vaccination is given. Fever, swelling and crying are medically expected, but for many families these reactions can lead to anxiety, blame and uncertainty. A mother left alone to manage a distressed child may also have to manage concerns.  If fever follows, the need for the next dose may be questioned. In Mumbai, one mother who had completed her elder child’s vaccination schedule described losing courage after a difficult post-vaccination experience with the younger child. 

This is why communication cannot stop at “please vaccinate your child.” Families also need help preparing for what follows: Who will take the child? Who will accompany the mother? Who will manage work that day? Who will remember the next date? What is the plan if the child develops fever? Who will reassure the family? 

These practical conversations are as important as explaining the benefits of vaccines. 

Beyond messaging: Supporting Frontline Workers 

This also means frontline workers cannot be treated only as message carriers. ASHAs, ANMs and AWWs are expected to persuade families, build trust, address rumours, manage resistance and ensure children return for subsequent doses.  

At the same time, since most frontline workers are women, they shoulder their own domestic responsibilities alongside demanding workloads, navigating fatigue, community dynamics and chronic time poverty. A system that relies so heavily on their emotional labour without providing adequate supervisory support, time and recognition is fragile by design.  

Trust-building is also shaped by caste, religion and community relationships. In Nuh, rumours about infertility and duplicate vaccinations continued to influence household decisions. In East Khasi Hills, understandings of illness and prevention were often shaped by religious beliefs, including the view that some illnesses were divinely ordained or part of life's natural course. In parts of Bihar, caste also influenced access. Mahadalit hamlets in Bhojpur, East Champaran and West Champaran were physically segregated from other settlements, and in Bhojpur some community members reported that perceived discriminatory treatment affected whether frontline workers visited them and how they were treated. 

Frontline workers, therefore, do far more than communicate vaccination dates. They navigate household hierarchies, community norms, social exclusion, misinformation and logistical barriers simultaneously. When systems fail to support this work, trust becomes harder to sustain, and immunisation coverage suffers. 

Toward Household Readiness & Shared Accountability  

The way forward is not to move responsibility from mothers to fathers, or from families to frontline workers.  It is to recognise that protecting a child requires shared responsibility across the household and stronger support from the health system. 

This approach calls for a shift in focus, from reminders to preparation, from mother-focused counselling to family engagement, from counselling mothers alone to engaging the entire family, and from viewing vaccination as a single event to supporting the complete journey of care.  

For programmes, this means three shifts: redesigning interpersonal communication to include fathers or patriarchs of the family in pre-visit planning; addressing practical barriers such as transport and wage loss and equipping frontline workers to facilitate family discussions rather than simply deliver health messages. Understanding who decides, who acts, who pays and who bears the consequences can transform vague notions of "hesitancy" into concrete, addressable barriers. 

Because the last mile is not only about reaching the child.  It is also about understanding the household around the child. 

Anjori Agrawal is Project Specialist, CoP-D, UNDP India and Sneha Pathak is Gender Analyst at UNDP India.