Improving Immunisation Coverage in Rural India: Clustered Randomised Controlled Evaluation of Immunisation Campaigns with and without Incentives

"...offering modest incentives to families in resource poor settings can significantly increase uptake of immunisation services..."

In India, immunisation services are offered free in public health facilities, but the immunisation rate remains low in some areas. Previous studies have assessed the effectiveness of financial and non-financial incentives to encourage immunisation and other preventive health behaviours. Conducted in rural Rajasthan, India, the present study sought to assess the efficacy of improving the supply of infrastructure for immunisation only compared with improving supply and simultaneously increasing demand through the use of modest non-financial incentives. Partners in the effort included the Abdul Latif Jameel Poverty Action Lab (J-Pal) at the Massachusetts Institute of Technology (MIT) and Seva Mandir, a non-governmental organisation (NGO) in Udaipur district.

Participants in the clustered randomised controlled trial were 1,640 children aged 1-3. The main sample comprised 134 villages randomly selected from a Seva Mandir catchment area in Udaipur. The villages were randomised to 1 of 3 groups:

1. A once-monthly reliable immunisation camp (intervention A; 379 children from 30 villages) - The idea was that the unreliability of the auxiliary nurse midwives (ANMs) might deter families from taking their children to the public health centre for the 5 visits needed to complete the full immunisation schedule. So, the intervention consisted of a mobile immunisation team, including a nurse and assistant (both hired by Seva Mandir), who conducted monthly immunisation camps in the villages at a fixed time. In addition, in each village, a social worker informed mothers about the availability of the immunisation camps and educated them about the benefits of immunisation.
2. A once-monthly reliable immunisation camp (as above) with the addition of small incentives (raw lentils and thalis (metal plates) for completed immunisation; intervention B; 382 children from 30 villages) - Notably, the thalis were chosen as a tangible sign of achievement, while also being of immediate use.
3. Control (no intervention, 860 children in 74 villages).

At the first immunisation, every child was given an official immunisation card indicating their name, the name of their parent/s, and the date and type of each immunisation performed. The nurse also kept a detailed logbook.

Surveys were undertaken in randomly selected households at baseline (between June 2004 and February 2005) and about 18 months after the interventions started (between July 2006 and February 2007). The main outcome measured was the proportion of children aged 1-3 at the end point who were partially or fully immunised.

Immunisation rates were less than 2% among 1-3 year olds at baseline. Compared with the control group, immunisation rates more than doubled in intervention A villages and increased by more than 6 times in the intervention B villages.

Specifically, among children aged 1-3 in the end point survey, rates of full immunisation were 39% (148/382, 95% confidence interval (CI) 30% to 47%) for intervention B villages (reliable immunisation with incentives), 18% (68/379, 11% to 23%) for intervention A villages (reliable immunisation without incentives), and 6% (50/860, 3% to 9%) for control villages. The relative risk of complete immunisation for intervention B versus control was 6.7 (4.5 to 8.8) and for intervention B versus intervention A was 2.2 (1.5 to 2.8). Children in areas neighbouring intervention B villages were also more likely to be fully immunised than those from areas neighbouring intervention A villages (1.9, 1.1 to 2.8).

The average cost to Seva Mandir of fully immunising a child was $27.94 (1,102 rupees, about £16 or €19) in the reliable camp with incentives and $55.83 (2,202 rupees) in the reliable camp without incentives. The difference comes from the fact that camps had to be open from 11 am to 2 pm, regardless of the number of children present. Thus, the higher average number of children in the camps with incentives spread the daily fixed cost (mainly, the salary of the nurse and assistant) over more children. Moreover, while the lentils represented a cost to Seva Mandir, their distribution could have led to improved nutrition for the family in an environment where malnutrition and anaemia are endemic.

The researchers note that, despite that fact that the family received a set of metal plates for the last immunisation, the biggest increase between intervention A and intervention B villages was for the third and fourth immunisation. This might indicate that parents are more sensitive to the fact that there is an incentive than to the level of the incentive.

One implication of the study's findings is that even a fully reliable supply system has a relatively modest effect on uptake of immunisation. In intervention A, even when access was good and a social worker reminded parents of the benefits of immunisation, more than 80% did not get their children fully immunised. Nevertheless, more than 75% obtained the first injection without the incentive and stopped attending the camps only after 2-3 injections. This indicates that the parents seemingly do not have strong objections or fears about immunisation, but that they are not persuaded enough about its benefits to overcome the natural tendency to delay a slightly costly activity (immunisation is free, but it takes some time and effort to go to the centre and get the child immunised, and the child might have a fever afterwards).

In conclusion, improving reliability of services improves immunisation rates, but the effect remains modest. Small incentives were found to have large positive impacts on the uptake of immunisation services in this resource-poor area and was more cost effective than purely improving supply.