Title: Inequalities in routine immunization coverage in primary care: a multi-level mixed methods study from three Indian states

Title: Inequalities in routine immunization coverage in primary care: a multi-level mixed methods
study from three Indian states
Swati Srivastava*
, Sakthivel Selvaraj, Preeti Kumar, Habib Hasan, Maulik Chokshi, Indranil
Mukhopadhyay, Pallav Bhatt, Ravi Kumar
*
Corresponding author
Public Health Foundation of India
ISID Campus, Plot No.4, Institutional Area
Vasant Kunj, New Delhi- 110070, India
Phone: +91-11-49566000 Ext 6055
Fax: +91-11-41648513
Mobile: +91-9015942985
Email: swati.srivastava@phfi.org

Background: Immunization is key to prevent vaccine-preventable disease yet almost half of Indian
children do not receive age-appropriate vaccinations. While individual and family level characteristics
related to immunization uptake have been explored extensively, areas needing investigation include
outreach services, vaccine supply and logistics, human resources issues and training, financing, and
service delivery.

Methods: We conducted an embedded multi-level mixed methods study exploring programmatic and
beneficiary-level constraints in immunization, to understand the roles these factors are playing in
immunization uptake. Methodological triangulation was conducted between a qualitative strand
consisting of data collected from multiple levels of health care providers and beneficiaries, and a
quantitative strand using structured questionnaires. The study was conducted in 11 districts of three
states (Uttar Pradesh, Rajasthan, and Himachal Pradesh) from September-November, 2012.

Results: Overall, vaccine supply was adequate. Mismatch in vaccine demand and supply, poor financial
allocation for supplies and cold chain maintenance, human resource constraints (shortages and poor
competencies), infrequent training and lack of monitoring and supervision, and inconsistent staff
incentives, was hampering progress. Urban areas had special requirements due to lack of infrastructure,
staff, and systematic mechanisms. Novel target setting, beneficiary estimations, and linking
immunization to institutional delivery incentives showed marked improvements. National Rural Health
Mission has contributed to improvement through financial and technical support, supplementing and
supplying vaccines, consumables and cold chain equipment, and utilization of untied and flexible funds.

Discussion: There has been significant progress in immunization in the states. However programmatic,
financial, human resource and infrastructural challenges remain to improve access and quality of
services. At the beneficiary level, societal biases, knowledge gaps, and increasing community's trust in
the system, especially in those not accessing services, are important. Consistently, an increased level of
awareness among the people for immunization and dedication and leadership from health staff were
associated with better coverage.

SOURCE-
http://www.ev4gh.net/wp-content/uploads/2013/09/swati_srivastava_abstract.pdf

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