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Ratna M, Singh SK, Sinha NK, Kannure M, Bhatia M, Aggarwal MK, Dalpath SK, Sharma S, Shah V. Developing a roadmap to reach and sustain 90% full immunization coverage through a cross-sectoral system strengthening strategy in Bihar, India. BMC Health Serv Res 2024; 24:933. [PMID: 39143542 PMCID: PMC11325628 DOI: 10.1186/s12913-024-11380-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 07/30/2024] [Indexed: 08/16/2024] Open
Abstract
INTRODUCTION Reducing childhood mortality by curtailing the incidence of vaccine preventable diseases is contingent upon a robust and high-performing routine immunization system. According to the available data, the full immunization coverage (FIC) in the state of Bihar (India) has reached ~ 71%. While the government aspires to reach 90% FIC, a systematic evidence-based investigation of the reasons behind underimmunization as well as the identification of drivers and enablers to reach and sustain 90% FIC is critical. This study aimed to review the factors leading to underimmunized children in the state of Bihar and develop a forward-looking roadmap to reach and sustain 90% FIC by adopting a system strengthening approach. METHOD We conducted a desk review, followed by extensive stakeholder interviews and field visits to document and analyze the data and evidence relevant to routine immunization system performance in the state of Bihar. The stakeholders included the State Immunization Officer, District Immunization Officers, Block-level health officials, representatives from development agencies, healthcare workers, and caregivers. A total of eighty-six structured interviews were conducted, which included qualitative and quantitative parameters. RESULT While positive results were observed from the assessment of Bihar's immunization system, the implementation of targeted strategies for supply, service delivery and demand can provide a means to achieve FIC of 90%. The roadmap developed by the Government of Bihar enlists 40 + interventions across key thematic areas and has been prioritized over a 5-year time horizon as short, medium, and long-term milestones to achieve 90% FIC. These interventions include strengthening the data availability and quality, improving the governance and review mechanism, augmenting the capacity of health workers involve with immunization programme, and initiatives to increase demand for immunization services. CONCLUSION The Bihar's Immunization Roadmap development project work follows a methodical approach to assess and identify intervention to improve immunization coverage and can provide information and reference to other states and countries that are aiming to formulate similar action plans.
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Affiliation(s)
- Manish Ratna
- William J. Clinton Foundation, New Delhi, India.
| | | | | | | | | | | | | | | | - Vama Shah
- William J. Clinton Foundation, New Delhi, India
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Clarke-Deelder E, Suharlim C, Chatterjee S, Portnoy A, Brenzel L, Ray A, Cohen JL, Menzies NA, Resch SC. Health impact and cost-effectiveness of expanding routine immunization coverage in India through Intensified Mission Indradhanush. Health Policy Plan 2024; 39:583-592. [PMID: 38590052 PMCID: PMC11145919 DOI: 10.1093/heapol/czae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 03/24/2024] [Accepted: 04/02/2024] [Indexed: 04/10/2024] Open
Abstract
Many children do not receive a full schedule of childhood vaccines, yet there is limited evidence on the cost-effectiveness of strategies for improving vaccination coverage. Evidence is even scarcer on the cost-effectiveness of strategies for reaching 'zero-dose children', who have not received any routine vaccines. We evaluated the cost-effectiveness of periodic intensification of routine immunization (PIRI), a widely applied strategy for increasing vaccination coverage. We focused on Intensified Mission Indradhanush (IMI), a large-scale PIRI intervention implemented in India in 2017-2018. In 40 sampled districts, we measured the incremental economic cost of IMI using primary data, and used controlled interrupted time-series regression to estimate the incremental vaccination doses delivered. We estimated deaths and disability-adjusted life years (DALYs) averted using the Lives Saved Tool and reported cost-effectiveness from immunization programme and societal perspectives. We found that, in sampled districts, IMI had an estimated incremental cost of 2021US$13.7 (95% uncertainty interval: 10.6 to 17.4) million from an immunization programme perspective and increased vaccine delivery by an estimated 2.2 (-0.5 to 4.8) million doses over a 12-month period, averting an estimated 1413 (-350 to 3129) deaths. The incremental cost from a programme perspective was $6.21 per dose ($2.80 to dominated), $82.99 per zero-dose child reached ($39.85 to dominated), $327.63 ($147.65 to dominated) per DALY averted, $360.72 ($162.56 to dominated) per life-year saved and $9701.35 ($4372.01 to dominated) per under-5 death averted. At a cost-effectiveness threshold of 1× per-capita GDP per DALY averted, IMI was estimated to be cost-effective with 90% probability. This evidence suggests IMI was both impactful and cost-effective for improving vaccination coverage, though there is a high degree of uncertainty in the results. As vaccination programmes expand coverage, unit costs may increase due to the higher costs of reaching currently unvaccinated children.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Allschwil 4123, Switzerland
- University of Basel, Basel 4001, Switzerland
| | - Christian Suharlim
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
- Management Sciences for Health, Medford, MA 02155, United States
| | - Susmita Chatterjee
- Research Department, George Institute for Global Health, New Delhi, Delhi 110025, India
- Department of Medicine, University of New South Wales, New South Wales 2052, Australia
| | - Allison Portnoy
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
- Department of Global Health, Boston University School of Public Health, Boston, MA 02118, United States
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, WA 98109, United States
| | - Arindam Ray
- Bill & Melinda Gates Foundation, New Delhi, Delhi 110067, India
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
| | - Stephen C Resch
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA 02115, United States
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Summan A, Nandi A, Shet A, Laxminarayan R. The effect of the COVID-19 pandemic on routine childhood immunization coverage and timeliness in India: retrospective analysis of the National Family Health Survey of 2019-2021 data. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 8:100099. [PMID: 36285007 PMCID: PMC9584865 DOI: 10.1016/j.lansea.2022.100099] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/27/2022] [Accepted: 10/11/2022] [Indexed: 11/09/2022]
Abstract
Background The COVID-19 pandemic has disrupted health systems globally. We estimated the effect of the pandemic on the coverage and timeliness of routine childhood immunization in India through April 2021. Methods We used data from India's National Family Health Survey 2019-2021 (NFHS-5), a cross-sectional survey which collected immunization information of under-five children from a nationally representative sample of households between June 2019 and April 2021. We used a mother fixed-effects regression model - accounting for secular trends and confounding factors - to compare COVID-affected children with their COVID-unaffected siblings (n = 59,144). Children who were eligible for a vaccine after January 30, 2020 (date of the first COVID case in India) were considered as the COVID-affected group and those eligible for a vaccine before this date were included in the COVID-unaffected group. Coverage of the following vaccine doses was considered-Bacillus Calmette-Guérin (BCG), hepatitis B birth dose (hepB0), DPT1 (diphtheria, pertussis, and tetanus, first dose), DPT2, DPT3, polio1, polio2, polio3, and measles first dose (MCV1). Indicators of vaccine coverage and vaccine timeliness (defined as receiving a dose within 45 days of minimum eligibility age) were separately examined. Findings Immunization coverage was lower in COVID-affected children as compared with unaffected children, ranging from 2% lower for BCG and hepB0 to 9% for DPT3 and 10% for polio3. There was no significant difference in MCV1 coverage. Coverage reduction was greater for vaccines doses given in later age groups. The rate of timely receipt of polio and DPT vaccine doses was 3%-5% lower among COVID-affected children relative to unaffected children. Among population subgroups, COVID-affected male children and those from rural areas experienced the highest reduction in vaccine coverage. Interpretation Children in India experienced lower routine immunization coverage and greater delays in immunization during the COVID-19 pandemic. Funding The Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Arindam Nandi
- One Health Trust, Washington, DC, USA,The Population Council, 1 Dag Hammarskjold Plaza, New York, NY, 10017, USA,Corresponding author. The Population Council, 1 Dag Hammarskjold Plaza, New York, NY, 10017, USA
| | - Anita Shet
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ramanan Laxminarayan
- One Health Trust, New Delhi, India,High Meadows Environmental Institute, Princeton University, NJ, USA
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Feldhaus I, Chatterjee S, Clarke-Deelder E, Brenzel L, Resch S, Bossert TJ. Examining decentralization and managerial decision making for child immunization program performance in India. Soc Sci Med 2023; 317:115457. [PMID: 36493499 PMCID: PMC9870749 DOI: 10.1016/j.socscimed.2022.115457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/03/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022]
Abstract
Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mechanisms of the Intensified Mission Indradhanush (IMI) in India relate to measurable performance of the immunization program. Data on decision space and its related dimensions of institutional capacity and accountability were collected by conducting structured interviews with managers based in 24 districts, 61 blocks, and 279 subcenters. Two measures by which to assess performance were selected: (1) proportion reduction in the DTP3 coverage gap (i.e., effectiveness), and (2) total IMI doses delivered per incremental USD spent on program implementation (i.e., efficiency). Descriptive statistics on decision space, institutional capacity, and accountability for IMI managers were generated. Structural equation models (SEM) were specified to detect any potential associations between decision space dimensions and performance measures. The majority of districts and blocks indicated low levels of decision space. Institutional capacity and accountability were similar across areas. Increases in decision space were associated with less progress towards closing the immunization coverage gap in the IMI context. Initiatives to support health workers and managers based on their specific contextual challenges could further improve outcomes of the program. Similar to previous studies, results revealed strong associations between each of the three decentralization dimensions. Health systems should consider the impact that management structures have on the efficiency and effectiveness of health services delivery. Future research could provide greater evidence for directionality of direct and indirect effects, interaction effects, and/or mediators of relationships.
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Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | | | | | | | - Stephen Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Thomas J. Bossert
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Pan D, Hong W, He M. Can campaign-style enforcement facilitate water pollution control? Learning from China's Environmental Protection Interview. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2022; 301:113910. [PMID: 34626950 DOI: 10.1016/j.jenvman.2021.113910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/08/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
The effectiveness of campaign-style enforcement (CSE) on water pollution, especially the long-term effectiveness, is controversial, and little knowledge is known about the channels through which the effectiveness happens. We take advantage of China's Environmental Protection Interview (EPI)- a distinguished form of CSE launched in 2014, as a natural experiment to estimate the short-term and long-term effects of CSE on water pollution. Using a time-varying difference-in-differences model based on city panel data from 2006 to 2018, we find that EPI can lead to an average 14.5% reduction in water pollution, and this effect is still persistent in the long term. Mechanism analysis shows that EPI reduces water pollution mainly through the pressure effect on the government, the penalty effect on the firms, and the mobilization effect on the public. Heterogeneity analysis shows that the effect of EPI on water pollution is more significant in cities with high initial pollution, low public complaints, and low economic levels. Further cost-benefit analysis based on the estimated value of water pollution reduction shows that the upper health benefit of EPI is $520.97 billion, which is 4.87 times higher than its estimated cost of $107.05 billion.
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Affiliation(s)
- Dan Pan
- School of Economics, Jiangxi University of Finance and Economics, Nanchang, 330013, China.
| | - Wei Hong
- School of Economics, Jiangxi University of Finance and Economics, Nanchang, 330013, China
| | - Mimi He
- School of Economics, Jiangxi University of Finance and Economics, Nanchang, 330013, China
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Schueller E, Nandi A, Summan A, Chatterjee S, Ray A, Haldar P, Laxminarayan R. Public Finance of Universal Routine Childhood Immunization in India: District Level Cost Estimates. Health Policy Plan 2021; 37:200-208. [PMID: 34522955 PMCID: PMC8826633 DOI: 10.1093/heapol/czab114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/06/2021] [Accepted: 09/14/2021] [Indexed: 12/29/2022] Open
Abstract
India’s Universal Immunization Programme (UIP) is among the largest routine childhood vaccination programmes in the world. However, only an estimated 65% of Indian children under the age 2 years were fully vaccinated in 2019. We estimated the cost of raising childhood vaccination coverage to a minimum of 90% in each district in India. We obtained vaccine price data from India’s comprehensive multi-year strategic plan for immunization. Cost of vaccine delivery by district was derived from a 2018 field study in 24 districts. We used propensity score matching methods to match the remaining Indian districts with these 24, based on indicators from the National Family Health Survey (2015–16). We assumed the same unit cost of vaccine delivery in matched pair districts and estimated the total and incremental cost of providing routine vaccines to 90% of the current cohort of children in each district. The estimated national cost of providing basic vaccinations—one dose each of Bacillus Calmette–Guerin (BCG) and measles vaccines, and three doses each of oral polio (OPV) and diphtheria, pertussis and tetanus vaccines—was $784.91 million (2020 US$). Considering all childhood vaccines included in UIP during 2018–22 (one dose each of BCG, hepatitis B and measles–rubella; four doses of OPV; two doses of inactivated polio; and three doses each of rotavirus, pneumococcal and pentavalent vaccines), the estimated national cost of vaccines and delivery to 90% of target children in each district was $1.73 billion. The 2018 UIP budget for vaccinating children, pregnant women and adults was $1.17 billion (2020 US$). In comparison, $1.73 billion would be needed to vaccinate 90% of children in all Indian districts with the recommended schedule of routine childhood vaccines. Additional costs for infrastructural investments and communication activities, not incorporated in this study, may also be necessary.
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Affiliation(s)
- Emily Schueller
- Center for Disease Dynamics, Economics & Policy, Washington DC, USA
| | - Arindam Nandi
- The Population Council, New York, NY.,Center for Disease Dynamics, Economics & Policy, Washington DC, USA
| | - Amit Summan
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Susmita Chatterjee
- George Institute for Global Health, New Delhi, India.,University of New South Wales, Sydney, Australia.,Prasanna School of Public Health, Manipal Academy of Higher Education, India
| | - Arindam Ray
- Bill & Melinda Gates Foundation, India Country Office, New Delhi, India
| | - Pradeep Haldar
- Ministry of Health and Family Welfare, Government of India
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, New Delhi, India.,High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA
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Chatterjee S, Das P, Pinheiro A, Haldar P, Ray A, Brenzel L, Resch S. The incremental cost of improving immunization coverage in India through the Intensified Mission Indradhanush programme. Health Policy Plan 2021; 36:1316-1324. [PMID: 33950262 PMCID: PMC8428614 DOI: 10.1093/heapol/czab053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/02/2021] [Accepted: 04/21/2021] [Indexed: 11/12/2022] Open
Abstract
Intensified Mission Indradhanush (IMI) was a strategic endeavour launched by the Government of India aiming to achieve 90% full immunization coverage in the country by 2018. The basic strategy of this special drive involved identifying missed children and vaccinating them in temporary outreach sites for 1 week over consecutive 4-month period starting from October 2017. This study estimated the incremental economic and financial cost of conducting IMI in India from a government provider perspective. Five states-Assam, Bihar, Maharashtra, Rajasthan and Uttar Pradesh were purposefully selected because of high concentration of IMI activities. The stratified random sample of 40 districts, 90 sub-districts and 289 sub-centres were included in this study. Cost data were retrospectively collected at all levels from administrative records, financial records and staff interviews involved in IMI. The weighted incremental economic cost per dose (including vaccine costs) was lowest in Uttar Pradesh (US$3.45) and highest in Maharashtra (U$12.23). Incremental economic cost per IMI dose was found to be higher than a recent routine immunization costing study by Chatterjee and colleagues in 2018, suggesting that it requires additional resources to immunize children through an intensified push in hard-to-reach areas. Incremental financial cost of the IMI programme estimated in this study will be helpful for the government for any future planning of such special initiative. The reasons for variation of unit costs of IMI across the study districts are not known, but lower baseline coverage, high population density, migration, geography and terrain and vaccinating small numbers of children per session could account for the range of findings. Further analysis is required to understand the determinants of cost variations of the IMI programme, which may aid in better planning and more efficient use of resources for future intensified efforts.
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Affiliation(s)
- Susmita Chatterjee
- Research department, The George Institute for Global Health, Research Department, 308-309, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India
- Department of Medicine, University of New South Wales, 18 High Street, Kensington, New South Wales 2052, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Madhav Nagar, Manipal 576104, Karnataka, India
| | - Palash Das
- Research department, The George Institute for Global Health, Research Department, 308-309, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India
| | - Anita Pinheiro
- Research department, The George Institute for Global Health, Research Department, 308-309, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India
| | - Pradeep Haldar
- Immunization Division, Ministry of Health and Family Welfare, Government of India, Nirman Bhawan, Maulana Azad Road, New Delhi 110011, India
| | - Arindam Ray
- The Bill & Melinda Gates Foundation, Capital
Court, 5th Floor, Olof Palme Marg, Munirka, New Delhi 110067, India
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, 500 5th Ave N, Seattle, WA 98109, USA
| | - Stephen Resch
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston MA 02115, USA
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Summan A, Nandi A, Deo S, Laxminarayan R. Improving vaccination coverage and timeliness through periodic intensification of routine immunization: evidence from Mission Indradhanush. Ann N Y Acad Sci 2021; 1502:110-120. [PMID: 34263929 PMCID: PMC9291841 DOI: 10.1111/nyas.14657] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 01/04/2023]
Abstract
Only an estimated 62% of Indian children under the age of 2 years are fully immunized. We examined the association between India's Mission Indradhanush (MI)-a periodic intensification of the routine immunization program-which was implemented in phases across districts between March 2015 and July 2017, and routine vaccination coverage and timeliness among children. We used data from a 2015 to 2016 national survey of children (n = 29,532) and employed difference-in-difference regressions to examine binary indicators of receipt of 11 vaccines and whether vaccines were received at recommended ages. The full immunization rate was 27% higher among children under 2 years old residing in MI phase 1 and 2 districts (intervention group) as compared with those residing elsewhere (control group). The rate of receiving all vaccines at recommended ages was 8% higher in the intervention group. Receiving doses of oral polio vaccine (OPV) birth dose, OPV dose 1 (OPV1), OPV2, OPV3, bacillus Calmette-Guérin, and hepatitis B birth dose vaccines were 9%, 9%, 11%, 16%, 5%, and 19% higher in the intervention group than the control group, respectively. More research is required on the cost-effectiveness of investing in MI-type programs as compared with routine immunization.
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Affiliation(s)
- Amit Summan
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | - Arindam Nandi
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | - Sarang Deo
- Indian School of Business, Hyderabad, India
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, New Delhi, India.,High Meadows Environmental Institute, Princeton University, Princeton, New Jersey
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