The Effectiveness of Technology-Aided Monitoring for Early Childhood Vaccination Coverage: Evidence from a Natural Experiment

Abstract

Achieving population-wide vaccination coverage against vaccine-preventable diseases (VPDs) remains a challenge across the globe. A promising solution involves technology-aided monitoring and accountability, which has promised to improve vaccination rates. The current study estimates the impact of a similar intervention on early childhood vaccination rates in the province of Punjab, Pakistan. During late 2014, E-VACCS (an Electronic Vaccine Registration System) was implemented across the province of Punjab, one of the four provinces in Pakistan. We use yearly data (2010-2019) from Pakistan Social and Living Standards Measurement Survey (PSLM) in a difference-in-differences framework to exploit the natural across-province over-time variation offered to us by Punjab’s adoption of E-VACCS. We analyze the impact of E-VACCS on complete vaccination coverage as well as antigen-specific vaccination rates. Our analysis suggests that E-VACCS did improve vaccination coverage but these increases are largely driven by specific sub-populations. The intervention led to a 2.2% increase in the instance of a child having received at least 1 dose of vaccination. Across urban households, we find a 6.2% increase in vaccination coverage on the intensive margin. However these treatment effects within urban areas are limited to mid-high income households. Our estimates for antigen-specific rates of vaccination coverage confirm similar trends. Among urban mid-high income households, improvements occurred in the antigen-specific coverage rates for vaccines administered towards the end of the childhood vaccination cycle (.e.g D-Tap-3 or Hep-B-3). However for rural low-income households, we find negative treatment effects for antigen-specific vaccine coverage rates, particularly for the three hepatitis doses. The results suggest that the increase in vaccination coverage across urban mid-high income households came at the expense of a significant decrease in coverage across low-income rural households, signaling redirection of critical resources. Our estimates remain robust to several variations in the specifications. Further robustness checks are provided through event study plots and synthetic control methods.