**Abstract**

Since 1978, India through its various health policies target to achieve the universal immunization, but profound progress is yet to be seen. This paper examine the trend in immunization coverage and differential access among the population subgroups. Data for the analysis was extracted from the two recent rounds of the National Family Health Survey (NFHS) conducted in 2005–2006 and 2015–2016. Descriptive statistics were used to understand the level of coverage, whereas the ratio method and concentration index was used to understand the inequality. The study identified immunization coverage had improved from 44 percent in 2005– 2006 to 62 percent in 2015–2016. However, considerable variation was observed among the regions and various wealth quintiles. In the Southern region, 63 percent of children from the poorest wealth quintile were fully immunized compared to 36 percent in North Eastern region. The coverage of full immunization among richest children was found to be 1.5 times higher than that of the poorest. The concentration index remains positive showing the pro-rich inequality. A positive result was found in the Northern and Northeastern region, where the poorest were showing an impeccable improvement over the period. Moreover, the study found the gap by place of residence and gender was close to convergence. 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 essential ingredient in achieving the sustainable development goals.

**Keywords:** inequality, immunization, India, NFHS, temporal

## **1. Introduction**

Socioeconomic inequalities in a child health is a major policy concern to achieve the Sustainable Development Goals (SDGs) framed by the United Nations in 2015 [1]. However, progress toward reducing these inequalities in child health indicators is not noteworthy among and between the countries [2]. Irrespective of the continued global effort to reduce the infant and child mortality rates, the targets of Millennium Development Goals (MDG) remained unattainable in many developing countries [3]. Nearly, 5.6 million of under-five death occurs worldwide [4], out of which quarter of death are due to vaccine-preventable diseases. Moreover, an estimated 19.9 million infants worldwide stay absent for routine immunization services. Around 60 percent of these children live in 10 countries, mainly from Africa and South Asia including India [5]. Though the Global Vaccine Action Plan (GVAP) has been endorsed by 194 countries in 2012, to ensure the equitable access to immunization by the year 2020, profound progress is yet to be seen [6].

Immunization coverage is given high priority globally and nationally especially for developing countries like India. The Indian immunization program started in 1978 after the Alma-Ata declaration aimed at immunizing all children [7]. To accelerate this, appropriate policy measures were put in place during those times, but the task of attaining these were quite arduous. The Government of India recently launched the *Mission Indradhanush* (UIP) in 2014 with the target of achieving universal immunization coverage https://www.nhp.gov.in/mission-indradhanush1\_ pg. Irrespective of these attempts, nearly one-third of the children remain to be far away from vaccinations in India [8–12].

used. These surveys were conducted in 2005–2006 and 2015–2016 by International Institute for Population Sciences (IIPS) under the stewardship of the Ministry of Health and Family Welfare (MoHFW), Government of India, with technical support from ICF International. The survey is designed in line with Demographic and Health Surveys (DHS) conducted worldwide. Both the surveys were large-scale surveys that provide state- and national-level estimates on fertility, infant mortality and child mortality, and other family welfare and health indicators. The survey uses a multi-stage stratified random sampling to select the households. Using the appropriate sampling weight, the survey provides estimates for various geographical regions. More about the survey design, sampling procedure, and questionnaire

The unit of our analysis is the regions of India. The two rounds of National Family Health Survey have followed a uniform pattern in segregating the states qualifying them for a particular region. In our study, the composition of regions based on the state is guided by the NFHS report. As uniformity is maintained in

Full immunization among children aged 12–23 months is the primary outcome variable in this study. Children are considered as fully immunized only when they receive vaccination against tuberculosis (BCG), three doses of diphtheria, pertussis (whooping cough), and tetanus (DPT) vaccine; three doses of poliomyelitis (Polio) vaccine; and one dose of the measles vaccine by the age of 12 months. In India, BCG should be given at birth or first clinical contact; DPT and polio require three vaccinations at approximately 4, 8, and 12 weeks of age; and the measles vaccine should be given at age 12 months or sooner after reaching 9 months of age. Information on vaccination coverage was collected from the child's health card and direct reporting from the mother. We have used the kid's file for analysis; the survey has selected only those households that had childbirths in the last 5 years prior to the survey. The sample size of the children is 49,284 in 2015–2016 and 9559 in

This study used two summary indexes to measure inequality in immunization coverage. The first measure is a simple ratio of the threshold of the population characteristics. The ratio measure is considered as a crude measure as it does not consider the estimates except the threshold. Despite its limitation, the measure is considered as a crucial relative measure of inequality and provides a clear idea of discrepancy in health indicators among the population subgroup. Wealth inequality ratio (WIR), rural–urban inequality ratio (RUIR), and gender-related inequality ratio (GIR) were calculated to quantify the inequality based on these attributes. The formula for these measures as guided by the other studies [26, 27] are as follows:

<sup>¼</sup> %of fully immunized children in the richest wealth class

Urban � Rural Inequality Ratio <sup>¼</sup> %of fully immunized urban children

%of fully immunized children in the poorest wealth class <sup>∗</sup> <sup>100</sup>

%of fully immunized rural children <sup>∗</sup> <sup>100</sup>

framing the geographical region, it is comparable over time.

*Temporal Trend and Inequality in Immunization Coverage in India*

**3.1 Measuring inequality in immunization coverage**

Rich � Poor Inequality Ratio

are provided in the national report [8].

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

**3. Methods**

2005–2006.

**177**

India, known for its multifaceted society and social hierarchy, dealt with higher social, economic, and regional inequality. A growing number of studies in India examined inequalities in child health status including full immunization coverage [9, 13, 14]. The studies found significant gap in wealth-related, rural–urban, and gender-related inequality in immunization coverage [15–18]. Some studies also observed large differentials among the economic groups, caste, and religion of the household [11, 19, 20]. Among the other factors, maternal education, proximity to a health facility, place of delivery, and pre- and postnatal checkup of mothers are among the leading factors affecting immunization coverage in India [21–24]. Apart from that, appropriateness of the timing of the vaccination is lagging in India and many states [25]. In order to reduce the disparity in immunization coverage, countries must adopt proequity programs aimed at reducing the gap in immunization coverage.

The present study is conceptualized under the following rationale. Firstly, in terms of immunization, India is one of the major contributor of unimmunized children in the world [5]. So, it is essential to understand the pattern of full immunization coverage in general and specific vaccinations in particular among various geographies of India. Secondly, many literatures suggest the pervasiveness of economic inequality among children in various health indicators. Therefore, it becomes imperative to study the pattern of inequality among the better off and worse off population subgroups. Thirdly, the WHO Commission on social determinants of health positioned strategically to reduce health inequalities and considers gender as one of the main determinants. It is widely established that pronounced gender bias still exists in India, favoring males over females. In this concern, understanding gender segregation in immunization practices is critical for policy formulation. In the same line, this study is a revisit to understand the temporal variation and inequality in immunization coverage among the regions of India. The present study will deliver the dynamic pattern of inequality in regions of India and provide guidance to frame policy as per the present challenges at hand.

The main objective of this paper was to document pattern and inequalities in immunization coverage in India over two periods of time (2005–2006 and 2015– 2016). Further, this paper was an attempt to understand inequality patterns in immunization coverage by the wealth quintile at the regional level. We have investigated inequalities in full immunization coverage using various inequality indexes that are related to three characteristics, namely economic status, place of residence, and sex of the child.

### **2. Data and methods**

#### **2.1 Data**

In an attempt to understand the variation in immunization among children, data from the third and fourth rounds of National Family Health Surveys (NFHSs) were *Temporal Trend and Inequality in Immunization Coverage in India DOI: http://dx.doi.org/10.5772/intechopen.88298*

used. These surveys were conducted in 2005–2006 and 2015–2016 by International Institute for Population Sciences (IIPS) under the stewardship of the Ministry of Health and Family Welfare (MoHFW), Government of India, with technical support from ICF International. The survey is designed in line with Demographic and Health Surveys (DHS) conducted worldwide. Both the surveys were large-scale surveys that provide state- and national-level estimates on fertility, infant mortality and child mortality, and other family welfare and health indicators. The survey uses a multi-stage stratified random sampling to select the households. Using the appropriate sampling weight, the survey provides estimates for various geographical regions. More about the survey design, sampling procedure, and questionnaire are provided in the national report [8].

The unit of our analysis is the regions of India. The two rounds of National Family Health Survey have followed a uniform pattern in segregating the states qualifying them for a particular region. In our study, the composition of regions based on the state is guided by the NFHS report. As uniformity is maintained in framing the geographical region, it is comparable over time.
