Inequalities in Childhood Vaccination Across India: Understanding the Root Causes and Potential Solutions

Timely immunization among children has been recognized as an essential intervention to improve child survival outcomes. India shares the highest burden of unvaccinated children in terms of headcount numbers. These children being vulnerable to vaccine-preventable diseases, are also at higher risk of poor health and nutritional outcomes, leading to a high risk of morbidity, and poor growth trajectories over the life course. In developing countries like India, unvaccinated children are also an important marker of vulnerability. Studies have suggested that unvaccinated children are concentrated among poor and marginalized sections. A higher concentration of these unvaccinated (zero-dose) children among poor and marginalized sections has been observed in previous studies and disadvantages pertaining to geographical, religious, political, gender, and health system factors further contribute to such inequality. Importantly, children born in rural and Muslim households in India and mothers with low education are more likely to miss the vaccination shots.

Inequalities in Childhood Vaccination Across India 

A recent study by Rajpal et al 2023, “Regional inequalities in zero-dose (unvaccinated) children in India: A temporal analysis of 29 years, 1993 to 2021” published in JAMA Open, unravel inequality in unvaccinated children across Indian states. The study finds that the prevalence of children with no routine immunization declined in absolute terms by approximately 27 percentage points, reaching 6.6 per cent – equivalent to approximately 1.37 million zero-dose children – in 2021. Such tremendous progress corroborates the importance of major national government initiatives like National Rural Health Mission and Mission Indradhanush. This was evident from the findings that declines have been most important in the two most recent policy periods.

Across states, north-eastern parts of the country (except Assam) have relatively higher prevalence of kids with zero-dose immunization status. However, in absolute terms, Uttar Pradesh, Bihar, Maharashtra, Madhya Pradesh, Gujarat, Rajasthan, and Jharkhand, which together account for 70 per cent of unvaccinated children In India. Importantly, the uptake of antenatal (postnatal) maternal care is also low in these north eastern states with a high incidence of vaccine-preventable diseases. Potential solutions are linked to greater awareness among parents, higher male and female literacy levels, and proactive health-seeking behaviour. Further, in states with high absolute burden, it is imperative to shift the focus to target and strategize the interventions to smaller geographical units (villages, blocks, clusters) against the current strategy of targeting districts. The Intensified Mission Indradhanush have undertaken increasingly fine-tuned targeting approaches for these smaller geographies, which will be critical to ensure that we do not miss high-burden villages (blocks) within low-prevalence districts or states.

Covid-19 pandemic affected routine vaccination

Between 2016 and 2021, some states experienced a rise in the prevalence of unvaccinated children. Surprisingly, low-prevalence states like Kerala, Punjab, Andhra Pradesh, and Telangana have experienced such trends. One of the plausible explanations for such trends is the negative impact of pandemic-induced disturbances on routine vaccination. Therefore, it is crucial to promote sustainable efforts that can maintain vaccination coverage over time, even in lower burden states. The Government of India announced IMI 4.0 in 2022 in 416 districts and 33 states and UTs across the country to avoid backsliding effects of Covid-19 pandemic.

Reaching unvaccinated children is a first critical step against child mortality. Sustained efforts are required to target the northeastern parts of the country and populous states like Uttar Pradesh, and Bihar. Most importantly, prioritizing small administrative units such as village (blocks) when designing targeting strategies will be critical to further India’s efforts to ensure that every child has timely access to these life-saving, life-shaping vaccines.

The article is contributed by Prof. Sunil Rajpal, Economics Department, FLAME University. Additionally, he is also a research fellow at Harvard Geographic Insights La.  

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