Published 17 May 2010, doi:10.1136/bmj.

c2553
Cite this as: BMJ 2010;340:c2553

Editorials
Improving immunisation coverage in rural India
Incentives help, but not nearly enough
Despite decades of rhetoric about improving health and two decades of economic growth, vaccination
rates in India remain low. As in Ethiopia, Burkina Faso, and Afghanistan, measles vaccination rates in
India are around 70%, and only 44% of children aged 1-2 years are fully immunised.1 Low vaccination
rates have been alternately blamed on insufficient public funds, poor implementation of vaccination
programmes, and a general apathy towards the health of the poor. Yet, we have remarkably little
evidence to help us separate problems with implementation of vaccination programmes from design
flaws that restrict take-up.
Banerjee and colleagues linked cluster randomised trial (doi:10.1136/bmj.c2220) brings together time
tested methods from public health (randomised trials) with the latest thinking in economics on
incentives and human behaviour to examine fundamental problems of design in the delivery of
vaccinations.2
The authors compared two interventions in a region where vaccination rates are low. In the first
intervention, vaccination camps were held in villages on a monthly basis. The second intervention also
established camps, but the researchers provided households a small food incentive (lentils worth $1;
0.66; 0.78) for every vaccination and a slightly larger incentive for children who completed the full
package (plates, worth just under $2). In the control villages with no interventions, 6% (95%
confidence interval 3% to 9%) of children aged 1-3 years had received the basic package of
vaccinations in the end point survey. This increased to 18% (11% to 23%) in villages that received the
first intervention and to 39% (30% to 47%) in those that received the second intervention. The relative
risk of being immunised was 3.09 (1.96 to 4.21) for the first intervention versus the control and 2.16
(1.54 to 2.78) for the second intervention versus the first intervention.
The difference between the "camp" villages and the "camp plus incentives" villages emerged after the
first two vaccinations. Households therefore seem not to be averse to immunisations but unable to
maintain visits to the vaccination camps over time. The small food incentives "nudged" households into
returning for repeat vaccinations, leading to a large difference in the proportion of fully immunised
children at the end of the trial, with a relative risk of vaccination of 2.16 between the first and second
interventions. Because the fixed cost of setting up and manning a vaccination camp is much higher than
the cost of the vaccine, it was half as expensive to fully immunise a child in the "incentive" villages
relative to the "camp only" villages$28 v $56.
One interpretation of these results is that small food incentives double vaccination rates and lower
immunisation costs. Given that the camp model is a standard component of the Indian governments
vaccination strategy, such food incentives should be immediately incorporated into the delivery of
vaccinations because they increase vaccination rates while decreasing costs. In cost-benefit
calculations, the camp with incentives approach generates an infinite return relative to the camp only
strategy.
But another more pessimistic view is also possible. The best implemented camp and incentives model,
held in a region with low population resistance to vaccination; an established relationship with the
implementing organisation; and enormous mobilisation, with health workers visiting households to
educate them about vaccinations and inform them about camps, only increased the proportion of
children immunised with a basic package to 39%far short of what is needed to achieve herd
immunity.
Further increases using this approach face two obstacles. Firstly, increasing the size of the incentives is
unlikely to have greater impact; studies of similar programmes suggest that the first dollar has the
largest effect.3 4 Secondly, vaccination rates drop off so dramatically with distance that this approach
will work only if camps are held regularly in every village. It is a tall order for the government to
replicate the gold standard conditions that this study operated under, unless vaccination campaigns are
meant to combat high absence rates among rural nurses and public sector doctors in primary healthcare
centres by inducing a greater presence of health worker in periodic vaccination camps.5 How food
incentives would work even when doctors and nurses dont go to work (so no home visits or timely
regular camps) remains an open question.
Under this second view, the study is crucial precisely because the effect is small. Even if the
government, through some remarkable transformation, could get its doctors and nurses to work, camps
with food incentives would increase vaccination rates to 38% at most and cost $27 for each fully
immunised child. While part of the problem may be poor implementation by the government, these
numbers suggest a fundamental design flaw in the entire camp based approach to vaccinations.
This study is then a wake-up call for more experimentation and evaluation on the fundamental design
of vaccination programmes. While public health specialists have been actively engaged in such efforts
around the world, economists can bring to the table an extensive understanding of incentives and
behaviour.6 Combining recent advances in behavioural economics with a long established tradition in
public health on experimentation and evaluation, as this study shows, could rapidly and dramatically
change existing models of vaccination delivery. Ultimately, it could also ensure that two million more
Indian children live to celebrate their 5th birthday.
Cite this as: BMJ 2010;340:c2553
Jishnu Das, senior economist
1 World Bank Main Complex, 1818 H St NW, Washington DC, USA
jdas1@worldbank.org
Research, doi:10.1136/bmj.c2220

Competing interests: The author has completed the Unified Competing Interest form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares:
(1) No financial support for the submitted work; (2) No relationship in the past three years with
companies that might have an interest in the submitted work; (3) No spouse or children with financial
relationships that are relevant to the submitted work; (4) No non-financial interests that may be relevant
to the submitted work
Provenance and peer review: Commissioned; not externally peer reviewed.
References
1. World Health Organization. Immunization surveillance, assessment and monitoring.
www.who.int/immunization_monitoring/data/data_subject/en/index.html.
2. Banerjee AV, Duflo E, Glennerster R, Kothari D. Improving immunisation coverage in rural
India: clustered randomised controlled evaluation of immunisation campaigns with and without
incentives. BMJ 2010;340:c2220.[Abstract/Free Full Text]
3. Thornton R. The demand for and impact of learning HIV status: evidence from a field
experiment. Am Econ Rev 2008;98:1829-63.[CrossRef][Web of Science]
4. Filmer D, Schady N. Are there diminishing returns to transfer size in conditional cash transfers?
Policy Research Working Paper Series 4999. World Bank; 2009.
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and health worker absence in developing countries. J Econ Perspect 2006;20:91-116.[CrossRef]
[Web of Science][Medline]
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[Medline]