Decline in immunization coverage across well-performing districts in India: an urban conundrum?

Abstract

Inequities in immunization persist in India in spite of the established importance of the national immunization program in preventing deaths, disability and morbidity arising from vaccine preventable diseases (VPDs) [1]. The role of programmatic complexities, political and social contexts as determinants of immunization has been explored in understanding why these inequities exist [2]. The DLHS3 reported a decline in the proportion of fully immunized children (12–23 mo) in several states which had been reporting high overall state level immunization coverage [3]. Possible explanations include the adverse impact of the polio eradication campaign, and social resistance in some states such as Tamil Nadu and Kerala due to reports of deaths and Adverse Events Following Immunization (AEFI) [4]. These explanations seem inadequate as the states reporting declines in full immunization coverage were nonendemic for polio and had only one or two pulse polio rounds annually, while the scale of AEFI is not large enough [5]. In this study the authors apply an alternative methodological approach, namely, the area effects framework, to analyze a combination of individual and socio-economic factors that can effectively explain the variations in the observed decline in district-level immunization coverage. The area effects framework, consisting of compositional, collective and contextual factors was applied to explain variations in immunization coverage observed at the district level between the two rounds of the DLHS survey (rounds 2 and 3) [6]. The factors selected were (i) household factors: educational attainment and poverty status; (ii) factors that influence local physical and social environment: distance from nearest town, availability and accessibility of health infrastructure, and urbanization; (iii) community-level contextual factors: religion, caste and tribe. The empirical analysis uses a logistic regression to identify the significant explanatory factors that can explain the observed decline in coverage. Empirical district level data on explanatory factors was taken from DLHS3 (2007–8). Good governance at state level is expected to play a key role in successful implementation of the immunization program. Consequently, nine states were selected for the analysis where several districts have reported declines, despite being states deemed to have good governance in terms of their performance in several socio-economic aspects such as infrastructure availability, law and order, judicial services, and educational achievements [7]. These states are Punjab, Haryana, Andhra Pradesh, Tamil Nadu, Gujarat, Karnataka, Maharashtra, Kerala, and Himachal Pradesh. The analysis was done for all the districts (206 districts) in these nine states. Districts which report a decline in immunization coverage between DLHS2 (2002–04) and DLHS3 (2007–08) were defined as decline districts and the rest served as the control districts in each selected state. The proportion of fully immunized children as per the Government of India’s national immunization program was the indicator used for judging the coverage achieved in each district. Nearly 58 % (119) districts of a total of 206 districts in these nine states reported a decline in coverage of fully immunized children in DLHS3 as compared to DLHS2.Within a state, the highest proportion of districts reporting a decline was from Tamil Nadu at 87 %, where 26 out of the 30 districts covered in the survey reported a decline (Fig. 1). In two of the nine states, Punjab and Maharashtra, disparity in coverage across districts increased between DLHS2 and 3. The extent R. Dasgupta (*) Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi 110067, India e-mail: dasgupta.jnu@gmail.com