New Delhi: A child born to a household in the richest wealth bracket in India is 2.26 times more likely to receive the critical, three-dose vaccine against diphtheria, pertussis (whooping cough) and tetanus (DPT3) than one born to the poorest, according to a new study.

The study titled ‘Explorations of Inequality: Childhood Immunisation’ was launched by the World Health Organization (WHO) on July 1, 2018. Its aim was to examine how socioeconomic, demographic and geographic factors affect a child’s likelihood of being vaccinated.

In 2015-16, 78.4% of Indian children aged 12-23 months received DPT3 vaccine, up from 55.3% a decade ago, according to the National Family Health Survey 2015-16 (NFHS). The WHO study analysed data from the NFHS and found that birth order, mother’s education and household economic status are the most influential factors in determining a child’s chance of being vaccinated. Sex-related inequality was non-existent, as male and female children presented the same level of coverage (79%).

WHO researchers analysed data from 10 countries which are classified as vaccine-priority countries--Afghanistan, Chad, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Kenya, Nigeria, Pakistan and Uganda. These nations are identified as the highest priority for childhood immunisation by the Global Alliance for Vaccine and Immunisation (GAVI).

These findings are critical because in October 2017, India launched Intensified Mission Indradhanush, a campaign which aims to increase immunisation coverage in select districts and cities to more than 90% by December 2018. Under the first Mission Indradhanush, launched in December 2014, immunisation coverage up to at least 90% was to be achieved by 2020.

In 2015-16, 62% Indian children aged 12-23 months received basic vaccinations, up from 44% a decade ago in 2005-06, according to the latest national health data, as IndiaSpend reported on February 13, 2018.

As can be seen in the table above, as mother’s education level increases, the chances of a child getting immunised increases.

“We must realise that every health system has its own inequities,” public health physician and social innovator Chandrakant Lahariya told IndiaSpend. “Once a health programme reaches 80-90% of coverage, the challenge is to reach the last-mile users, who are the poorest and most vulnerable. This is where the role of data comes in, to design specific interventions which target such populations.”

In India, there are 1,403 females who have never attended any educational institution for every 1,000 males who have not done so. The ratio increases sharply from 17 years till the 30-34 year age group where it is 2,009--which means for every man who has never attended an educational institution, there are two women who haven’t, IndiaSpend reported on November 28, 2015.

“More educated and literate mothers can read newspapers, watch TV and understand advertisements,” says Lahariya. “If any immunisation/health programme is launched using these mediums, educated mothers became aware of them and get their child immunised.”

Children from richest households most likely to be immunised

A child belonging to the richest quintile of wealth is 2.26 times more likely to be immunised than a child from the poorest quintile, indicating the link between economic status and immunisation. A quintile is one of five equal groups into which a population can be divided according to the distribution of values of a particular variable, in this case wealth.

However, immunisation among rich households in India has decreased overall. Vaccinations grew by 29% among the poorest one-fifth of the population, while full immunisation among the wealthiest one-fifth fell slightly, according to this January 14, 2018, analysis of NFHS 2015-16 data by Scroll.in.

“Increased immunisation coverage in more educated mothers and financially better-off sub-groups is indicative of better reach and comprehension of information about the need for vaccination schedule adherence in these sub-groups,” said Anant Bhan, a global health and policy researcher. “It also suggests that the national vaccination programme needs to put more effort into communicating and reaching out to the educationally and financially disadvantaged sub-groups. Innovations need to also be explored to remove the barriers to vaccination adherence in these sub-groups.”

Parents are more vigilant about the health and immunisation requirements of their older children, especially the first born. “(But) the effect wears down as the family size expands. In large families, conformity to the vaccination schedule for younger kids can go low in the parental priority list,” said Bhan.

Lahariya holds the health system accountable for this neglect. “Based on anecdotal experience, I would say that if it is the first child, a mother is more excited and willing to suffer the deplorable quality of our health system to get the child vaccinated,” she said. “However, with later children, she may not be very willing to stand in long queues and spend several hours getting them vaccinated.”

Lack of trust in the health system and misinformation about vaccinations could prevent families from getting their children immunised, according to this 2017 paper in the Indian Journal of Medical Ethics.

More than seven in ten Indians are not covered by insurance--Indians are the sixth biggest out-of-pocket health spenders in the low-middle income group of 50 nations, as IndiaSpend reported in May 2017. Out-of-pocket (OOP) health expenses drove 55 million Indians--more than the population of South Korea, Spain or Kenya--into poverty in 2011-12, and of these, 38 million (69%) were impoverished by expenditure on medicines alone, according to a new study, IndiaSpend reported on July 19, 2018.

Nagaland, Arunachal Pradesh and Dadra & Nagar Haveli perform worst

Among states, Nagaland performed the worst on immunisation--just 35% children were vaccinated in 2015-16, according to NFHS data cited by IndiaSpend in this report on February 13, 2018. Rajasthan (55%), Madhya Pradesh (54%), Uttar Pradesh (51%), and Gujarat (50%) were among the worst 10 performers, along with five of eight north-eastern states.

The WHO study took Nagaland as a reference because of its bad performance. It found that children in Chandigarh children are 14.56 times more likely than those in Nagaland to receive the DTP3 vaccine.

(Saha is a media & policy communications consultant with the Policy & Development Advisory Group, Delhi. In September 2018, he will be starting his PhD in International Development from the Institute of Development Studies, University of Sussex, UK.)

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