Immunization coverage under national programs is an important indicator to track advancement towards child health-related SDGs.
By Shalini Rudra
As a signatory of the Sustainable Development Goals (SDGs) agenda, India is committed to ensure healthy lives and promote well-being for all, at all ages. To foster the global efforts, India is expected to make rapid headway in achieving universal health coverage, particularly in the provisioning of essential health care services. Immunization coverage under national programmes is an important indicator to track advancement towards child health-related SDGs, and the National Family Health Survey 4 (NFHS 4) results gives us an opportunity to compare the distance covered over the last decade.
The slow progress in full immunization coverage in India during 2005-06 to 2015-16 needs discussion, particularly when compared to the dramatic improvements in institutional deliveries, and lessons learned should inform our way forward.
An NFHS based trend comparison shows that prior to the NRHM, full immunization coverage in India improved at a sluggish pace from 35.4% in 1992-93 to 42% in 1998-99 and 44% in 2005-06. The most recent wave of NFHS finds that immunization coverage has now increased to 62% in 2015-16. Although post-NRHM, the pace of improvements has accelerated but it leaves much to be desired when compared to achievements in institutional births that improved from a similarly low level of 39% in 2005-06 to 79% in 2015-16. This raises a fundamental policy question: why does immunization coverage continue to be low despite decades of publicly financed universal immunization programme?
However, before discussing the key concerns, some stylised facts from NFHS 2015-16 need to be looked at (Table 1). We note that between 2005-06 and 2015-16, immunization coverage in India increased by 18% points (from 44% to 62%). Much of the progress comes from rural areas (from 39% to 61%) whereas urban areas witness surprisingly low improvements (from 58% to 64%). Figure 1 shows that improvements in coverage are better among the poorest households (those in the lowest wealth quintiles) compared to those from the better-off sections (higher wealth quintiles). In fact, there is a worrisome stagnation in coverage (at 70%) among households in the highest wealth quintile. Notwithstanding the progress dynamics, it is discernible that the rural-urban hierarchies as well as the socioeconomic gradients in terms of wealth and social group affiliations are fully intact.
Table 1: Percentage levels of full immunization in India, 2005-06 and 2015-16
|NFHS||Full immunization (%)|
|Place of residence|
|Other backward classes||41||62||21|
|None of them||54||64||10|
Source: National Family Health Survey Report/Fact Sheet (2005-06, 2015-16)
A decline in immunization or more appropriately lack of progress in richer households does also raise concerns about the outreach activities around full immunization. Also, are the surveys capturing this information accurately with consistent definitions consistent and valid comparisons? It may be reminded that eliciting immunization-related information involves considerable recall ability or possibility of households to have safely kept an updated record of vaccines usually provided by health care facilities in the form of an immunization card (Mother-Child Protection Card). In this regard, NFHS 2015-16 results seem to be valid, as more or less similar findings emerged from the Rapid Survey on Children conducted in 2013-14 with immunization coverage of about 65% for all India.
Given the pace of progress revealed through NFHS 4, policymakers should be concerned about India’s performance on the immunization front. The SDG commitment warrants universal immunization coverage by 2030. As Figure 2 shows, currently India has a gap of 38% from achieving universal coverage. This implies that every year India has to ensure full immunization of about 2.7 crore new born under the UIP.
Given the enormous challenge, it is important to explore the determinants of immunization coverage that NRHM had limited impact on. As such, full immunization is determined by multiple factors and not merely by availability of health facility and promoters (the supply-side). For instance, demand-side issues such as awareness regarding number and types of vaccines, the sequence, importance of immunization, and suspicions around immunization, etc. have a role to play. Maternal education is an important factor as children belonging to mothers with secondary or higher education have high coverage (67%) than those without formal education (52%). Clearly, there are both demand and supply side factors that need equal policy attention.
Given the enormous challenge, it is important to explore the determinants of immunization coverage that NRHM had limited impact on.
A worrisome record in urban areas and even among the better-off sections of the society does call for re-examining the broad policy direction. Under NRHM, although Mission Indradhanush was launched to capture the left-behind children but in light of the NFHS 4 findings, the Mission has to rework the strategies for greater effectiveness. Perhaps, there is a case for of providing or increasing financial incentives for households and for health workers as an effective strategy to promote immunization coverage.
Besides, urban centres also pose the problem of continuous in-migration who may find it difficult to locate, go and seek health care for various reasons in an urban health centre or hospital. Many of the unauthorised slums, construction work sites, brick-kiln sites etc. are hotspots where children are less likely to have received full immunization. In this context, what strategies will be needed to provide health care services to the growing migrant population in urban areas who usually reside in non-serviceable areas such as construction sites and similar workplaces?
Strengthening of health management information systems, including data recording and registration systems, called Mother and Child Tracking System (MCTS). The linking of already available systems with the unique identification like Aadhaar can facilitate tracking of the beneficiaries. Furthermore, development of universal health cards and electronic record maintenance for maternal and child health care is highly desirable. This can facilitate careseeking by the migrant population in urban areas and can be used to decide resource allocations.
Devoting greater financial resources towards immunization coverage with concerted efforts to improve social mobilization for immunization is warranted. In particular, strengthening a network of community health workers in urban and peri-urban areas to contribute towards progress in immunization coverage by reaching out to both slum as well as non-slum populations is of utmost priority.
Facilitating improvement in knowledge and awareness regarding child immunization can be intensified with the use of mass media, mid media, interpersonal communication (IPC), school and youth networks and corporates, building on Mission Indradhanush. Reaching out to communities and areas with poor immunization coverage with well-articulated strategies for community awareness will be key to success.
The draft National Indicator Framework (NIF) for SDGs prepared by the Ministry of Statistics and Programme Implementation (MoSPI) should outline full immunization coverage as a basic tracking indicator for SDG 3 on health, and particularly under Target 3.8 related to achievement of universal health coverage for all. Additionally, the Ministry of Health and Family Welfare (MoHFW) and the NITI Aayog should streamline greater inter-sectoral coordination to facilitate immunization coverage among communities and regions with poor performance.
In conclusion, it is worth reiterating that the NFHS 4 findings on full immunization coverage should trigger policy action to improve the situation. At this point in time, India seems to be far away from the Mission Indradhanush goal of achieving and sustaining 90% full immunization coverage by year 2020. Nevertheless, it is only reasonable to expect that with enhanced financial incentives as part of maternity benefits, as announced by the Prime Minister and in the union budget speech for 2017-18, progress towards universal immunization coverage will soon pick up pace.