Excerpts from the World Health Organization report “Explorations of inequality: childhood immunization”, released in July 2018:
India has a population of 1.309 billion, with 9.3% under 5 years of age. The country consists of 29 states and 7 union territories, including the National Capital Territory of Delhi. The under-5 mortality rate in India has fallen from 125.9 deaths per 1000 live births in 1990 to 43.0 deaths per 1000 live births in 2016. The high burden of childhood mortality and morbidity in India reflects the poor quality of public health care in India, with uneven progress between subnational regions, and on the basis of socioeconomic status and sex.
In 1978, India launched its Expanded Programme on Immunization, which was renamed as the Universal Immunization Program in 1985. The Universal Immunization Program is embedded as part of India’s National Health Policy, and the National Vaccine Policy of 2011 provides broad policy guidelines and frameworks to guide decision- making in areas such as research and development, vaccine quality assessment, institutional processes, vaccine introduction issues and regulatory issues.
The Government of India launched Mission Indradhanush in 2014 as a campaign to accelerate progress towards achieving 90% full immunization coverage by 2020. Initially targeting 201 low-performing districts, the campaign has subsequently been expanded to over 350 districts, and has been successful in improving coverage in underserved areas.
Immunization coverage in India demonstrates multidimensional types of inequality, with variation across subgroups defined by social class, parental education, religion, wealth status, place of residence, and other individual and family characteristics. Key challenges related to immunization activities include: weak health information systems and low capacity for monitoring and evaluation (resulting in a lack of evidence for planning and research activities); and human resource shortages in management, research and operations at all levels.
Disaggregation by background characteristics According to the 2015 National Family Health Survey (NFHS), the DTP3 immunization coverage among one-year-olds in India was 79%.
Sex-related inequality was non-existent, as male and female children presented the same level of coverage (79%). There was a gradient in coverage according to birth order, with higher order births showing lower coverage.
Looking at mother’s characteristics, the coverage of DTP3 immunization was the same for the 15–19 years and 20–34 years subgroups (79%), while coverage was lower in the 35–49 years subgroup (70%). A gradient in immunization coverage was observed across mother’s education level, with increasing coverage in more-educated subgroups. The gap between the no education subgroup and the subgroup with more than secondary education was 18 percentage points.
There were small differentials in DTP3 coverage by mother’s caste/tribe: coverage was higher among those in the scheduled caste, other backward class or other subgroups (coverage around 80%), whereas coverage was lower in the scheduled tribe subgroup (74%).
There was no difference in coverage on the basis of the sex of the household head. A gradient was observed across wealth quintiles, with the gap in coverage between the richest and poorest quintiles amounting to 16 percentage points (86% and 70%, respectively).
Inequality by place of residence in India was minimal, with a 3 percentage point difference between coverage in urban (81%) and rural areas (78%). Coverage across subnational regions varied markedly. Nagaland and Arunachal Pradesh had the lowest coverage at 53%, whereas 9 out of the 36 regions reported coverage of 90% or higher.
The wealth-related inequality in DTP3 immunization coverage in India amounted to a positive ECI value of 0.130. While small, this value indicates that coverage is more concentrated among wealthier households. The education-related ECI in India had a value of 0.150, suggesting that coverage was more concentrated in children with more-educated mothers. Both ECIs were largely statistically significant.
There was large variation in the odds of childhood immunization coverage across regions. Compared to the reference region of Nagaland, which had the lowest DTP3 immunization coverage in the country, several states/union territories demonstrated more than 10 times higher odds of coverage, including Chandigarh, Chhattisgarh, Lakshadweep, Puducherry and West Bengal.
Immunization coverage was positively associated with economic status and mother’s education, adjusting for other factors. A one-year-old child in the richest quintile had a 2.3 times higher chance of being covered than a child in the poorest quintile. Compared to the no education subgroup, the odds of DTP3 immunization coverage were 1.4 times higher in the primary school subgroup, 1.6 times higher in the secondary school subgroup, and almost double in the more than secondary school subgroup.
There was a weak, although statistically significant, association between mother’s age at birth and childhood immunization: the 20–34 years subgroup and the 35–49 years subgroup were 1.2 and 1.3 times more likely, respectively, of being covered than the 15–19 years subgroup. Birth order had a negative association with DTP3 immunization coverage: relative to children 6th born or higher, the odds of coverage were significantly higher in all lower order birth subgroups.
The chance of being covered by DTP3 immunization among 1st born children was nearly twice as large. Compared to those of mothers in the scheduled tribe subgroup, those in the scheduled caste subgroup had 1.2 times higher chance of being covered. Place of residence also demonstrated a significant association, as children living in urban areas had a lower chance (0.75) of being covered than those in rural areas.
The sex of the child and the sex of the household head showed non-significant associations with DTP3 immunization coverage after adjusting for other factors.
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