**5. Discussion**

zation as nearly equivalent in case of rural and urban as well as for male and female. Considering education-related inequality, we found that the predicative probability of full immunization among the mothers belonging to higher education group is 67

*Public Health in Developing Countries - Challenges and Opportunities*

**NFHS-3 (2005–2006) India East West North South Central North-East**

Poorest 0.35 0.38 0.39 0.29 0.56 0.27 0.15 Poorer 0.39 0.48 0.45 0.45 0.56 0.29 0.25 Middle 0.49 0.50 0.55 0.57 0.67 0.33 0.41 Richer 0.53 0.59 0.64 0.62 0.64 0.35 0.41 Richest 0.61 0.57 0.72 0.66 0.71 0.43 0.61

No education 0.37 0.38 0.51 0.44 0.49 0.24 0.27 Primary 0.47 0.49 0.59 0.50 0.67 0.37 0.32 Secondary 0.57 0.60 0.64 0.68 0.66 0.46 0.43 Higher 0.65 0.69 0.71 0.74 0.82 0.55 0.45

Urban 0.46 0.41 0.62 0.52 0.64 0.37 0.33 Rural 0.49 0.51 0.61 0.59 0.66 0.30 0.38

Male 0.49 0.47 0.63 0.57 0.67 0.33 0.37 Female 0.48 0.48 0.60 0.57 0.63 0.31 0.35

Poorest 0.54 0.66 0.42 0.54 0.71 0.48 0.40 Poorer 0.61 0.73 0.55 0.62 0.66 0.55 0.52 Middle 0.65 0.76 0.55 0.69 0.68 0.59 0.58 Richer 0.67 0.74 0.63 0.68 0.71 0.61 0.58 Richest 0.69 0.71 0.66 0.73 0.73 0.64 0.57

No education 0.56 0.65 0.48 0.62 0.66 0.49 0.41 Primary 0.62 0.74 0.52 0.65 0.73 0.57 0.53 Secondary 0.65 0.73 0.61 0.69 0.70 0.60 0.56 Higher 0.67 0.72 0.58 0.72 0.71 0.62 0.60

Urban 0.61 0.64 0.54 0.65 0.70 0.55 0.52 Rural 0.63 0.71 0.60 0.68 0.70 0.56 0.53

Male 0.62 0.70 0.57 0.65 0.69 0.57 0.52 Female 0.63 0.70 0.59 0.69 0.71 0.54 0.54

*Predicated probabilities of full immunization coverage by wealth status, education of mother, place of*

*residence, and sex of the child in India and its region in 2005–2006 and 2015–2016.*

**Wealth status of household**

**Education of mothers**

**Place of residence**

**Sex of the child**

**NFHS-4 (2015–2016) Wealth status of household**

**Education of mothers**

**Place of residence**

**Sex of the child**

**Table 5.**

**182**

The present study has made an effort to revisit the temporal change and differential access in immunization coverage in regions of India. In the line of previous literature, the present study using the last two rounds of NFHS studied the richpoor inequality, rural–urban inequality, and gender-related inequality to understand the equity gap in immunization among regions of India. The latest round of NFHS found that there was a substantial increase of 18 percent in coverage of full immunization as compared to earlier rounds. Expect the polio vaccine, all other vaccines had improved over time. The full immunization coverage, as well as DPT and measles vaccines, had improved for more than 40 percent in the period 2005– 2016. The improvement in the immunization program can be attributable to the national immunization policies in India.

In India, immunizations are provided free of cost in public health facilities. Irrespective of this, 91% of children were vaccinated against BCG, while DPT and measles are lower compared to it. By convention, a newborn is immediately vaccinated by a dose of BCG, after his entry into this world, whereas, at a later point in time, it becomes little difficult for some parents to let their child receive the doses further signifying the importance of getting immunized at birth. A study found that 40 percent of children in India are left out before completing the series of DPT [17]. The burden of work on mothers, commuting to the public health facility, can be attributed for witnessing an increase in dropouts in further doses of vaccinations. However, a very astonishing picture gets reflected from the observed decline in polio vaccination. Though it is cost-free and has widespread coverage, the figures fell a little from 78 to 73 percent in a decade. The reasons may be ascertained that the present population does not consider polio as a severe and threatening disease [28].

The findings show that inequality in specific vaccination coverage as well as in full immunization coverage had shown substantial prorich inequality. The inequality in full immunization coverage was found to be higher among the richer classes also followed to be in the regions. The result was consistent with other studies in India and abroad [18, 26]. But the temporal variation in each vaccination witnessed a significant decline in the gap among the poorest and richest wealth quintile. The ratio in full immunization coverage almost halved over the intersurvey period. This can be thought of as an improvement in the coverage of vaccination among children from the poorest wealth quintile. DPT coverage among children from the poorest wealth quintile doubled, while measles improved 1.5 times over the period, which is instrumental in doubling the full immunization coverage. A positive pattern can be witnessed in the Northern and Northeastern region, where the poorest are showing an impeccable improvement over the period. This can be accredited to advancement in the coverage of immunization, dedicated, well-trained, and sensitive ASHA workers, or community health workers.

Children from urban areas were reported to be better immunized as compared to their rural counterparts. These findings were in tune with studies done in the regional context. In 2015–2016, we found a very marginal rural–urban gap among the regions except for the Northeastern region. The reasons can be due to low

urbanization and inadequate or unfit health facilities. The previous literature has highlighted the male advantages in obtaining the vaccination [13, 27]. This study found that the gap in immunization was close to convergence. These achievements can be attributed to an increase in female education, effective gender sensitization programs, and improved communication between health workers and the community.

This study is an attempt in understanding the changes in coverage and inequality among the regions of India dealt with some limitation. The sample size of the children in the NFHS-3 was very less, so it is misleading to find the estimates by different wealth quintiles among the smaller states. Estimates of vaccination coverage in India are based on the vaccination card or the parental recall, but the accuracy and validity of the response are critical. In India, vaccination card is not universal, and the use of parental recall against the absence of vaccination card can sometimes be incomplete or inaccurate.

### **6. Conclusion and policy implications**

Our analysis shows that a significant variation can be observed in the region-wise distribution of a child's immunization. With an aim to increase the immunization coverage among children, the government has initiated several programs, targeted at achieving universal immunization. Though the initiation of new programs gets underway, the achievement of desired targets to be met is often confronted with the lack of community health workers, inadequate infrastructure and human resource, and majorly political will. The study suggests that the immunization programs have to be inclusive, with widespread reach, leaving no stones unturned. These steps can be beneficial in diminishing inequalities, acting as an important ingredient in achieving the Sustainable Development Goals.

#### **Acknowledgements**

The author likes to thank the editor of the book as well as the reviewer.

#### **Competing interests**

The author declared that he does not have any competing interest.

**Author details**

**185**

Basant Kumar Panda

International Institute for Population Sciences, Mumbai, India

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: basantpanda99@gmail.com

*Temporal Trend and Inequality in Immunization Coverage in India*

*DOI: http://dx.doi.org/10.5772/intechopen.88298*

provided the original work is properly cited.

#### **Funding**

The author had not received any funding for this work.

#### **Ethics approval and consent to participate**

As the study is based on the secondary data and available in public domain, it needs no prior approval.

*Temporal Trend and Inequality in Immunization Coverage in India DOI: http://dx.doi.org/10.5772/intechopen.88298*

urbanization and inadequate or unfit health facilities. The previous literature has highlighted the male advantages in obtaining the vaccination [13, 27]. This study found that the gap in immunization was close to convergence. These achievements can be attributed to an increase in female education, effective gender sensitization

programs, and improved communication between health workers and the

*Public Health in Developing Countries - Challenges and Opportunities*

This study is an attempt in understanding the changes in coverage and inequality among the regions of India dealt with some limitation. The sample size of the children in the NFHS-3 was very less, so it is misleading to find the estimates by different wealth quintiles among the smaller states. Estimates of vaccination coverage in India are based on the vaccination card or the parental recall, but the accuracy and validity of the response are critical. In India, vaccination card is not universal, and the use of parental recall against the absence of vaccination card can

Our analysis shows that a significant variation can be observed in the region-wise distribution of a child's immunization. With an aim to increase the immunization coverage among children, the government has initiated several programs, targeted at achieving universal immunization. Though the initiation of new programs gets underway, the achievement of desired targets to be met is often confronted with the lack of community health workers, inadequate infrastructure and human resource, and majorly political will. The study suggests that the immunization programs have to be inclusive, with widespread reach, leaving no stones unturned. These steps can be beneficial in diminishing inequalities, acting as an important ingredient in achieving the Sustainable

The author likes to thank the editor of the book as well as the reviewer.

The author declared that he does not have any competing interest.

As the study is based on the secondary data and available in public domain, it

The author had not received any funding for this work.

**Ethics approval and consent to participate**

community.

Development Goals.

**Acknowledgements**

**Competing interests**

needs no prior approval.

**Funding**

**184**

sometimes be incomplete or inaccurate.

**6. Conclusion and policy implications**
