health infrastructure & immunization coverage in rural india

8/10/2019 Health infrastructure & immunization coverage in rural India

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Health infrastructure & immunization coverage in rural India

Ashlesha Datar, Arnab Mukherji* & Neeraj Sood

Economics & Statistics Group & *Pardee RAND Graduate School, RAND Corporation

Santa Monica, CA, USA

Received September 1, 2005

Ba ck gr ou nd & ob je ct iv es : Immunization coverage in India is far from complete with a

disproportionately large number of rural children not being immunized. We carried out this study

to examine the role of health infrastructure and community health workers in expanding

immunization coverage in rural India.

Methods: The sample consisted of 43,416 children aged 2-35 months residing in rural India from

the National Family Health Surveys (NFHS) conducted in 1993 and 1998. We estimated separate

multinomial logit regression models for polio and non polio vaccines that estimated the probability

that a child would receive no cover, some cover or full age-appropriate cover. The key

measure of health infrastructure was a hierarchical variable that assigned each child to categories(no facility, dispensary or clinic, sub-centre, primary health care centre, and hospital) based on

the best health facility available in the childs village. We also included variables capturing the

availability of various types of community health workers in the village and other health

infrastructure.

Results: While there was under-provision of rural health infrastructure, our results showed that

the availability of health infrastructure had only a modest effect on immunization coverage. Larger

and better-equipped facilities had bigger effects on immunization coverage. The presence of

community health workers in the village was not associated with increased immunization coverage.

Interpretation & conclusion : Our findings suggest that expanding the availability of fixed health

infrastructure is unlikely to achieve the goal of universal coverage. Reforming community outreach

programmes might be better strategy for increasing immunization coverage.

Key wordsCommunity health workers - health infrastructure - immunization - India - polio

Roughly 3 million children die each year of

vaccine preventable diseases (VPDs) with a

disproportionate number of these children residing

in developing countries1. Vaccines remain one of the

most cost-effective public health initiatives2, yet the

cover against VPDs remains far from complete;

recent estimates suggest that approximately 34

million children are not completely immunized with

Indian J Med Res 125, January 2007, pp 31-42

31


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almost 98 per cent of them residing in developing

countries3. Vaccination coverage in India is also far

from complete despite a longstanding commitment

to universal coverage. A recent evaluation of VPDcoverage in India found that 18 million children did

not receive any coverage in 2001-20024.

In India, immunization has been a central goal

of the health care system from the 1970s, first through

the Expanded Programme on Immunization (EPI) in

1978, and later with the universal immunization

programme (UIP) since 1985. Constitutionally,

health care is on the States list of responsibilities

and is financed by the State. The UIP is an exception;

it is one of the few 100 per cent centrally sponsored

family welfare programmes and provides support for

vaccine storage, training of medical and paramedical

staff, and all infrastructure needs specific to

delivering immunization to infants at the village

level5.

Throughout the 1980s, gains in immunization

coverage proved to be rapid for all VPDs; some

VPDs showed gains from below 20 per cent

coverage to over 60 per cent coverage by the early1990s6. Pulse polio immunization (PPI) campaign

initiated in 1995, was successful in significantly

increasing first-dose polio immunization coverage,

however, there were limited gains in complete

coverage for polio vaccines7. Moreover, coverage

of non-polio vaccines seemed to have remained

unaffected by the PPI campaign. This limited

success in expanding full coverage for VPDs has

renewed the search of ways to expand coverage

effectively. A natural place to start was by studying

the strengths and weakness of the current vaccine

delivery system through the rural health

infrastructure in India.

Indias rural health care system has a strong

dependence on community health infrastructure and

outreach, particularly in remote villages. Community

health infrastructure has been shown to be an

important correlate of health outcomes in other

developing countries8-11. In the Indian context, two

studies have examined the role of health

infrastructure on the utilization of maternal health

care using national data 12,13 while others have

examined the relationship between healthinfrastructure and child and maternal health at the

State level14,15. These studies have mixed findings.

For example, one study used multivariate regressions

to control for individual and household

characteristics and found that distance to a health

facility did not predict health services utilization13.

Others have used a similar analytic strategy, but

different data, and the results indicated that presence

of a health facility in the village significantly

increased the likelihood of maternity care

utilization10,14. In this study, we examined the role of

rural health infrastructure and community health

workers in expanding immunization coverage in rural

India.

We built on this prior research in four important

ways. First, by characterizing the availability of

rural health infrastructure in more detail than prior

studies we were able to discuss the effectiveness of

different levels of health infrastructure in expanding

coverage. Important differences in both the natureof services provided and the staffing at different

levels of care are likely to have different effects on

immunization coverage (Table I). We constructed

a hierarchical measure of health infrastructure that

captured the highest level of health facility available

in the village, and thus we were able to examine

whether it matters if the best available health facility

in the village is a hospital, or a less equipped,

smaller facility.

Second, we also examined whether the

availability of community health workers (CHWs)

such as village health guides (VHG), Anganwadi

workers (AWW), and trained birth attendants (TBA)

affects immunization coverage.

Third, we classified the set of vaccines under the

UIP into polio and non-polio vaccines to identify the

effect of different mechanisms of immunization

delivery. Since the PPI campaign was initiated

32 INDIAN J MED RES, JANUARY 2007


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between the two National Family Health Survey

(NFHS) waves, it is important to examine changes

in coverage for polio and non-polio immunizations

separately.

Finally, in addition to the usual household and

individual covariates we included village level

variables as well as indicator variables for each State

(state fixed effects) in our regression models to

control for variations across areas in unobserved

factors such as policy environment and governance

that are correlated with health infrastructure as well

as immunization coverage. Given that States differ

markedly in terms of development and health related

measures, it was important to adequately control for

these differences.

Material & Methods

Rural health care system: The health care delivery

system in rural India relies on a combination of

primary health care infrastructure and community

outreach. Table I provides details about various levels

of government funded rural health infrastructure, the

intended and actual populations that each level

serves, the medical staff available at each level, and

the shortfall for each level. Community health centres

(CHC) are the largest facility and are the most

endowed in terms of medical staff and equipment,followed by primary health centres (PHC), and

subsequently, subcentres (SC). CHCs are designed

to serve a much larger population, followed by PHCs,

and then SCs. However, there are substantial

shortfalls at each level of health infrastructure; as of

2005, there were 10 per cent fewer PHCs and SCs

than needed and 50 per cent fewer CHCs than needed

(Table I).

From an immunization delivery perspective, one

key problem in expanding coverage is the demanding,

temperature-controlled environment needed to store

vaccines before they are administered. Most CHCs

and many PHCs, though not all, are currently a part

of the Cold Chain and are technically able to maintain

a stock of vaccines at recommended temperature

zones. While stock-outs at these levels have been

reported, they are rare15. Thus, the key area of concern

is how effectively the immunization delivery system

administers vaccines to infants in villages away from

these cold chain facilities.

Table I. State of rural health care system in India

Sub centre Primary health centre Community health centre

(SC) (PHC) (CHC)

Population capacity:

Plain area 5,000 30,000 1,20,000

Hilly/tribal area 3,000 20,000 80,000

Actually serving:

Average population 4,579 27,364 214,000

Average area (sq. km) 22.81 136.31 1,067.10

Specified manpower 2 multi-purpose workers 1 Medical officer + 4 Medical officers (surgeon,

and asset strength (1 male & 1 female 14 Para medical staff; medicine, gynecologist medicine,

(ANM*) + 1 lady health 4-6 beds; acts as a gynecologist and paediatrician)

visitor supervising 6 SCs referral unit to 6 SCs + 21 paramedical staff;

30 beds + 1 OT + X-ray facilities +

Labour room and Lab facilities;

serves 4 PHCs

Requirement (Census 2001) 1,58,792 26,022 6,491

Number functioning as of 2005 1,42,655 23,109 3,222

Shortfall (%) 10.16 11.19 50.36

Sources: Ref. 5 : (1) Chapter 3, Section 8, Annual Report 1997-98, Ministry of Health and Family Welfare, http://mohfw.nic.in/

reports/1997-98Er/Contents.pdf (accessed January 31, 2006). (2) Ministry of Health and Family Welfare website.

http://mohfw.nic.in/dofw%20website/about%20us/infrastructure%20frame.htm#a2 (accessed January 31, 2006) and Ref. 15

*ANM, Auxiliary nurse midwife

DATAR et al: RURAL HEALTH INFRASTRUCTURE IN INDIA 33


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In villages with just a SC, vaccination delivery

is done with the help of para-medical staff and

community outreach workers. The para-medical staff

consists of the lady health worker (LHV) stationedat the PHC, and the auxiliary nurse midwife (ANM)

stationed at the SC. The community health and

outreach workers consist of the male health workers

stationed at the SC, Anganwadi workers (AWW)

stationed at an Anganwadi centre that provides day

care for children, village health guides (VHG) who

provide first-aid and act as outreach workers, and

trained birth attendants (TBA) who help with child

birth as well as outreach.

The key role in immunization delivery is that of

the ANM; she is responsible for not only administering

vaccines, but also for monitoring immunization

coverage4. Her primary duty is to conduct monthly

immunization sessions at the SC, and at other villages

in the SCs catchment area that have more than a 1000

individuals. In smaller villages, she is expected to co-

ordinate immunization sessions with the help of the

AWW, once every 3 months. The AWW is responsible

for bringing the children to the Angwanwadi where

the immunization session is held. The ANM is alsoresponsible for (i) maintaining data on immunization

delivery; (ii) writing monthly reports on the state of

immunization in her catchment area with input from

the LHV and the Medical Officer at the PHC;

(iii) physically carrying vaccines in from the nearest

CHC or PHC on a weekly basis; and (iv) scheduling

each of her immunization sessions at each of the

villages in the SCs catchment area. The male health

worker helps the ANM with some of the logistics,

while the AWW plays an important support role in

the scheduled immunization session, many of which

take place in an Anganwadi centre. Thus, by and large,

parents are expected to bring their children to

immunization sessions run by the ANM, if fixed

facilities are not available, or directly to PHCs or

CHCs4,5,15.

Study hypotheses: For our statistical analyses, we

used this knowledge about the health infrastructure

and the ways in which each facility and individual

contributed to the immunization effort to develop our

study hypotheses. We expected to see the presence

of each level of health care infrastructure, such as

the CHC, or the PHC, or the SC, or the availabilityof community health workers like the TBA, VHG or

AWW would expand immunization coverage,

particularly when compared to villages without

access to any of these. We also expected that

availability of health facilities that are directly linked

to the cold chain (CHCs & PHCs) to have larger

effects. Among community health workers, we

expected AWWs to have the largest effect on

immunization coverage due to their relatively well-

defined role in immunization delivery.

In addition to the public health infrastructure, the

UIP provides vaccines free of cost to private sector

medical practitioners who can use them on their

patients to further expand immunization coverage4.

Therefore, apart from public health facilities, we also

expected the private health facilities such as

dispensaries, clinics, and pharmacies to play a

positive role in expanding coverage. Approximately

7 per cent of mothers in our data reported using a

private facility for their childs vaccination.

Data: We used data from the 1993 and 1998 waves of

the NFHS. The NFHS surveyed a representative

sample of households from 26 major States in India.

Data were collected using structured interviews with

women in the 13-49 yr age group who are, or have

been, married. Interviews were conducted using a

questionnaire designed specially for mothers, and this

was also used to collect data on immunization for

children. In addition, for women residing in rural areas

information was also collected on the availability of

village infrastructure through a village questionnaire.

Our analysis sample consisted of 43,416 children

sampled from rural primary sampling units, including

22,473 children in wave 1 and 20,943 children in wave

2. By matching the mother level data files with the

village level data files we got information on each

childs immunization status, their personal attributes,

their maternal and household attributes, and the village

infrastructure that they have access to.



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Immuniza tion: Mothers were asked about

immunizations received by each of her eligible

children, and when possible, this information was

verified by cross-checking against the childsvaccination card. Specifically, the survey asked

whether the child had received BCG, DPT (all doses),

polio (all doses) and measles vaccinations. Since we

do not observe the frequency with each dose is

administered, a child was classified as receiving all

doses of the polio vaccine if the survey reported

that the child had received at least one dose (oral or

otherwise) of each of polio1, 2, and 3 vaccines (all

doses is similarly defined for DPT). Our definition

of immunization distinguished across vaccine types

to identify immunization coverage rates for two

categories of VPDs - polio and non-polio. This

categorization was considered useful since the two

waves of NFHS straddled the PPI.

In each of the NFHS waves we categorized a child

as having either no coverage, some coverage or

full age appropriate coverage using Government

of Indias Recommended Immunization Schedule

(Table II). Thus, for example, a child who is 3 months

old, and has BCG, DPT1 and 2, and Polio1 vaccineswould be classified as having fully age-appropriate

coverage under the non-polio vaccine category, but

would only be classified as having some cover for

the polio vaccine. Since many diseases require

multiple doses to provide full coverage across a range

of strains of the disease (e.g., polio) we used this

three-fold classification of immunization status.

While some prior studies have used a similar three-

fold classification (no coverage, partial coverage, full

coverage), they restricted their sample to children

12-25 months in a subsample of States in India7,13.

Our characterization of immunization coverage

differed from such studies by defining immunization

cover on the basis of its appropriateness at every ageof the infant. This approach had two advantages over

prior studies. First, it allowed us to include all

children in the 2 to 35 months age group in our

analysis. Second, it allowed us to distinguish children

who received age-appropriate coverage from children

who were immunized at an older (or younger) age

and were therefore exposed to the risk of VPDs for a

longer duration of time (or receive vaccinations prior

to being physiologically ready).

Measure s of rura l he alth infrast ru cture an d

community health workers: The NFHS collected

village level information in each wave regarding the

presence of rural health infrastructure and community

health workers relevant for immunizations. First, we

constructed a categorical variable that captured the

hierarchy of primary health infrastructure, where a

dispensary or a clinic was the smallest facility,

followed by SC, PHC and the largest facility being a

hospital. Specifically, we assigned each village to

one of five mutually exclusive categories thatcaptured the highest level of public or private health

facility available in the village (i) no health facility

present, (ii) best facility was a dispensary or a clinic,

(iii) best facility was a SC, (iv) best facility was a

PHC, and (v) best facility was a hospital. While it

was rare for SC, PHC, and hospitals to be co-located,

we found that NFHS data did not report these to be

mutually exclusive (about 2% of all children lived

in villages which had both a hospital and a PHC, and

9 % of all children lived in villages with both a PHC

Table II. Recommended immunization schedule

Age Vaccine BCG DPT Polio Measles Age appropriate coverage

(wk) (months) for all India

Birth 0 X X BCG

6 1.5 X X BCG + DPT1 + Polio1

10 2.5 X X BCG + DPT1-2 + Polio1-2

14 3.5 X X BCG + DPT1-3 + Polio1-3

36 9.0 X BCG + DPT1-3 + Polio1-3 + Measles

Source: Ref. 16



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and SC). We were unable to distinguish between

private and public hospitals due to the nature of the

survey questions. As a result, our definition of

hospital included CHCs, government hospitals, NGOhospitals, and private hospitals.

Second, we constructed indicator variables for

various community health workers present in the

village who did not provide immunizations to

children but played an important role in community

mobilization. These included (i) whether a VHG was

present in the village, (ii) whether a TBA was present

in the village, and (iii) whether an AWW was present

in the village. We also included an indicator for

whether there was a pharmacy or medical shop

present in the village. We expected this variable to

proxy for the availability of private health care in

the village. The survey also asked about visit from a

MHU. We included a separate indicator for whether

a MHU visited the village.

Many households did not have a health facility

in their village, but a facility was available in a

neighboring village. Therefore, we constructed

alternative measures of infrastructure availability thatcaptured the highest level of facility available within

2 and 5 km from each childs village of residence.

Analysis approa ch: For each category of

immunizations (polio vaccines and non polio

vaccines), we estimated a multinomial logit

regression model, which estimates the conditional

probability that a child with a specific set of

characteristics (at the child, household and village

levels) was likely to receive no cover, some

cover or full age-appropriate cover. The key

explanatory variables of interest in our models were

the village health infrastructure and health personnel

variables.

Since placement of health facilities and

community health workers was likely to be

influenced by other population and village

characteristics that might also be correlated with a

childs likelihood of being immunized, controlling

for these factors was important in order to assess the

independent impact of health infrastructure on

immunization coverage. The NFHS survey data

allowed us to include a rich set of covariates, atvarious levels, that related to a childs likelihood of

being immunized - child-level (age, sex, birth order),

mother-level (age, education, cohabiting, work status,

and if working for a salary), husband-level (age and

occupation), household-level (religion, tribal status,

household size, wealth index17). In addition, we also

included a number of village-level variables that were

likely to influence the placement of health facilities

(access to roads, distance to a major town, availability

of post office, schools, and electricity).

We included dummy variables for each State in

our models to control for time invariant unobserved

differences across States that were related to

immunization coverage. We also included a dummy

variable for wave, which controlled for any general

time trend in immunization coverage (e.g., improved

efficiency in providing health care). We estimated

our models using Stata for Windows, Version 8 (Stata

Corp, College Station, Texas, USA). All estimates

were weighted to adjust for the multistage samplingdesign. Robust standard errors were estimated to

adjust for clustering at the village level. The variables

in our analysis had extremely low rates of missing

data; on average the variables had a less than 1 per

cent missing rate, with the maximum missing rate

for any one variable being 3 per cent.

Results

Polio and non-polio vaccine coverage: Data on

distribution of age-appropriate immunization

coverage for polio and non-polio vaccines in each

wave in both urban and rural India showed that in

1993, a significant proportion of children in rural

India did not have any vaccination coverage. Between

1993 and 1998 there was a significant decline in the

proportion of children with no coverage for both polio

and non-polio vaccines (Table III). However, the

decline in no-coverage was much more pronounced

for polio vaccines (21 percentage points) compared



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to non-polio vaccines (11 percentage points). The

reduction in no-coverage for polio vaccines translated

into a roughly equal increase in partial and full

coverage. In contrast, the decline in no-coverage fornon-polio vaccines increased full coverage almost

twice as much as partial coverage. Immunization

rates for polio and non polio vaccines in urban areas

were much higher than corresponding rates in rural

areas (Table III).

Avai labil ity of rural heal th in fras truc ture and

community health workers: Data on the distribution

of rural health infrastructure in each wave of the

NFHS showed three salient trends (Table IV). First

was the limited availability of health infrastructure

in rural India in the early 1990s. For example, in 1993

as many as 43 per cent of children lived in villages

with no health facility and roughly half did not have

a PHC or hospital within a 5 km radius. Second, the

data showed substantial improvements in the

availability of health infrastructure across the two

waves that mimiced the trend of higher immunization

coverage. Third, the data suggested that the

improvement in health infrastructure was

concentrated in areas that already had a health

facility. For example, across all our hierarchical

measures of health infrastructure, the proportion with

no health facility remained relatively stable whilethe proportion with PHC or hospital increased across

the two waves. Finally, as expected, the best available

facility in the village improved as we examined

availability within larger distances. Most notably,

there was a significant drop in the percentage of

children who had no dispensary/clinic, SC, PHC or

hospital in their village (only 28% within 2 km, and

just under 9% within 5 km), and an increase in the

percentage of children living in villages where the

best health facility was a hospital (Table IV).

Table III. Age appropriate coverage (%) for polio and non-

polio vaccination, By wave

NFHS I (1993) NFHS II (1998)

Rural sample

Polio age appropriate coverage:

No cover 47.3 26.0

Some cover 13.8 25.7

Full cover 38.9 48.3

Non-polio age appropriate coverage:

No cover 45.3 34.0

Some cover 27.4 31.5Full cover 27.4 34.5

Urban sample

Polio age appropriate coverage:

No cover 29.2 14.3



Non polio age appropriate coverage:

No cover 25.5 14.8



NFHS, National Family Health Survey

Estimates are based on weighted NFHS I and II data

Table IV. Availability of rural health infrastructure in the childs

village, By Wave

NFHS I (1993) NFHS II (1998)

(%) (%)

Best health facility in the village:

None 42.9 46.6

Dispensary or clinic 20.7 10.0

Subcentre 20.2 21.9

Primary health centre 5.1 6.5

Hospital 11.2 14.9

Best health facili ty within 2 km of the village:None 28.1 29.5


Subcentre 24.3 28.2


Hospital 18.5 22.2

Best health facili ty within 5 km of the village:

None 8.8 9.7


Subcentre 21.8 26.1


Hospital 38.8 40.7

Other health infrastructure in the village:

Mobile health unit in

the village 16.2 11.3

Pharmacy or medical

shop in the village 26.9 23.9

Community health workers in the village :

Village health guide 45.0 33.2

Trained birth attendant 50.1 57.8

Anganwadi worker 46.2 62.1

Estimates were based on weighted NFHS I and II data

Sample consists of children between the age of 2-35 months

of age whose immunization records were complete for each

category of immunization

NFHS, National Family Health Survey



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The availability of other health infrastructure was

also relatively scarce in wave 1. Less than one in

three children lived in villages that had a pharmacy

or medical shop. Visits by a MHU were even lesscommon. In contrast, the availability of community

health workers in the village was relatively more

common. As many as one in two children lived in

villages that had a TBA, 45 per cent lived in villages

with a VHG, and 46 per cent lived in villages that

had an AWW.

Regres sion results : In regression analyses, we

estimated a series of multinomial logit models for

non-polio and polio vaccine coverage. Panels A to C

(Table V) reported estimates of the effect of village

health infrastructure and community health workers

on non polio vaccination coverage for the three

hierarchical measures of health infrastructure. The

estimates in all three panels showed that availability

of a dispensary/clinic, SC, PHC or hospital in the

village reduced no-coverage for non polio vaccines.

The estimates also showed that larger and better-

equipped facilities such as PHCs or hospitals had a

larger effect on non polio vaccine coverage compared

to dispensaries or SCs. For example, children livingin villages where the best available health facility

was a hospital are 4 percentage points less likely to

have no-cover for non-polio vaccines compared to

children that have no health facility in their village.

This decrease translated into an almost equal increase

in some-cover and full-cover. By contrast, children

living in villages where the best available health

facility was a dispensary or clinic are 3 percentage

points less likely to have no-cover for non polio

vaccines and this decreased translates mostly into an

increase in some-cover. The effect of a MHU on

immunization coverage appeared to be weak. One

of the reasons could be that MHUs typically served

very remote populations of whom we saw very little

of in the data. In villages that reported a MHU visit

the mean distances to the nearest SC, PHC, and

hospital were 4, 10 and 11 km, respectively.

Data showed that more restrictive measures of

the lack of health infrastructure had a stronger effect

on vaccination coverage (Table V). For example,

children who resided in villages with no health

facility within 2 km were 4.8 percentage points more

likely to have no vaccination coverage compared tochildren where the best facility within 2 km radius

was a hospital. By contrast, children who resided in

villages with no health facility within 5 km were 7.1

percentage points more likely to have no vaccination

coverage compared to children in villages where the

best facility within 5 km was a hospital. Thus, the

results suggested that the likelihood of having some

or full immunization coverage decreased with

increasing distance to rural healthcare infrastructure.

While these gains were important, and statistically

significant, the increase in coverage from health

infrastructure was at best a small fraction of the gap

between current coverage levels and universal

immunization.

The results for other health facilities and

community health workers variables showed that

these factors had little or no influence on

immunization coverage. The availability of MHU

was not associated with changes in non-polio vaccine

coverage. However, the availability of a pharmacyor medical shop in the village was associated with

an increase in some-cover (2.2 percentage points),

although the effect was smaller than that of hospitals

and PHCs. Among community health workers,

presence of VHGs and TBAs in the village was not

associated with increased immunization coverage.

However, as expected, the presence of an AWW

reduced the likelihood of no-coverage (-1.8

percentage points).

In contrast to the results for non polio coverage,

the association between the best health facility

available in the village and polio vaccine coverage

was smaller, and not statistically significant (Table VI).

For the more restrictive measures, such as having

a PHC or hospital within 2 or 5 km of the

respondents village, the likelihood of full-cover

for polio vaccine increased and was statistically

significant but was also substantively small in

terms of realizing full immunization coverage



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(4.6 percentage points and 5.7 percentage points

increase in full-cover for PHC within 2 and 5 km;

4.3 percentage points and 4.4 percentage points

increase in full-cover for hospital within 2 and 5km). In contrast to what we found for non-polio

coverage, MHU visits in the village were associated

with a statistically significant decline in no-cover

for polio vaccination (-3.2 percentage points). The

availability of a pharmacy or a medical shop, VHG,

or AWW in the village was not associated with

coverage for polio vaccines. Presence of a TBA in

the village, while not associated with changes in

non polio coverage, reduced the likelihood of some-

cover.

Finally, the results for other co-variates in the

models (not presented in the Tables) showed that

there were a number of other important predictors

of childhood immunization. The most prominent

predictors in our models included sex of the child,

maternal literacy and whether the child belonged

to a scheduled caste/tribe (SC/ST) household. For

example, a child born to a mother who was literate,

but not completed middle school was 8.6

percentage points less likely to have no-cover fornon polio vaccines compared to an illiterate

mother. Similarly, a child born in an SC/ST

household was 3.0 percentage points more likely

to have no-cover for non polio vaccines when

compared to a child born in a non-SC/ST family;

and a girl child was 4.0 percentage points more

likely to have no-cover for non polio vaccines

when compared to a boy child. Thus, immunization

coverage levels varied systematically across

distributions of socio-economic and demographic

variables and some sub-groups were more at risk

of not receiving immunization coverage than

others.

Discussion

Our results highlighted two salient facts. First,

the immunization coverage in rural India was far

from universal. Second was that expanding the

availability of fixed health infrastructure would


result in only modest gains in immunization

coverage and was unlikely to achieve the goal of

universal coverage. Our results also showed that

immunization coverage in urban India althoughhigher than in rural India was far from universal

despite presumably better access to fixed health

infrastructure.

In principle, community health workers should

play an important role in expanding immunization

coverage to areas that do not have a well-developed

health infrastructure. However, we found that the

effectiveness of community health workers in

expanding immunization coverage was at best

small. It was not immediately obvious from our

study if this poor association was due to weak

mobilization efforts of these community workers,

or due to the ANMs inadequate coverage of the

SC catchment area where these community health

workers operated. Unfortunately, the NFHS does not

provide data on either the location or the time

allocation of the ANM across the many duties she

has. Anecdotal and case-study evidence suggested

that the current job requirements of the ANM may

not be optimally allocating the ANMs time if thegoal is to expand immunization coverage4,18,19. At

the same time, providing better training to and

monitoring of the community health workers has

been identified as an important area for

improvement18,19.

The results also showed that the availability of a

higher level facility like a hospital or PHC in the

village, or within 2 or 5 km, tended to have a larger

effect on immunization coverage than lower level

facilities (SCs, dispensaries). This was not surprising

since hospitals and PHCs were not only better staffed

but were also a part of the cold chain and therefore

had a regular supply of vaccines. In addition, they

conducted weekly scheduled immunization sessions

as opposed to the monthly sessions, which were run

at SCs. But the point of concern was that the spread

of Indias rural health network was the thinnest at

the levels of health infrastructure that we found to

be most effective.


11/12


12/12

13. Das N, Mishra V, Saha P. Does community access affect

the use of health and family welfare services in rural India?

National Family Health Survey Subject Reports. Number

18; May 2001; Indian Institute of Population Sciences,

Mumbai, India.

14. Shariff A, Singh G. Determinants of maternal health care

utilization in India: Evidence from a recent household

survey. 2002. Working Paper Series No. 85. National

Council of Applied Economic Research. New Delhi, India.

15. Government of India. Strengthening of public institution for

health delivery, Technical Report, Ministry of Health and

Family Welfare. 2005. [Accessed on January 31, 2006].

Available from: http://mohfw.nic.in/phi%20

strengthening%2015th%20march.pdf.

16. Universal Immunization Program Division, Department of

Family Welfare, Ministry of Health & Family Welfare, http:/

/cbhidghs.nic.in/hii2003/12.01.htm [Accessed April 18,

2004].

Reprint requests: Dr Neeraj Sood, Associate Economist, RAND Corporation

1776 Main Street, Santa Monica, CA 90407, USA

e-mail: [email protected]

17. Filmer D, Prichett L. Estimating wealth effects without

expenditure data- or tears: An application to educational

enrollments in states of India. Demography 2001; 38 :

115-32.

18. Bajpai N, Dholakia RH, Sachs JD. Scaling up primary health

services in rural India. CSDG Working Paper No.29. The

Earth Institute at Columbia University. 2005 [Accessed on

January 30, 2006]. Available from: http://

www.ear thins t i tu te .columbia.edu/cgsd/documents /

RuralHealthPaper.pdf.

19. Rao KS. Delivery of health services in the pubic sector. In :

PG. Lal and Byword Editorial Consultants, editor.

Ba ckgr ou nd pa pe rs of the Nat ion al Comm is si on on

Macroeconomics and Health. New Delhi: Ministry of Health

and Family Welfare, Government of India. 2005. [accessed

January 30, 2006] Available from: http://mohfw.nic.in

Re po rt %2 0o n%2 0NC MH /B ack gr ou nd %2 0P ape rs %

20report.pdf.


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