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Research

Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2220 (Published 17 May 2010) Cite this as: BMJ 2010;340:c2220

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  1. Abhijit Vinayak Banerjee, Ford foundation international professor of economics1,
  2. Esther Duflo, Abdul Latif Jameel professor of poverty alleviation and development economics 1,
  3. Rachel Glennerster, executive director2,
  4. Dhruva Kothari, medical student3
  1. 1Department of Economics, Massachusetts Institute of Technology, 50 Memorial Drive, E52-391, Cambridge, MA 02142, USA
  2. 2Abdul Latif Jameel Poverty Action Lab, Massachusetts Institute of Technology, Cambridge, MA
  3. 3630 West 168th Street, Columbia University Physicians and Surgeons Mailbox #67, New York, NY 10032, USA
  1. Correspondence to: E Duflo eduflo{at}mit.edu
  • Accepted 11 April 2010

Abstract

Objective To assess the efficacy of modest non-financial incentives on immunisation rates in children aged 1-3 and to compare it with the effect of only improving the reliability of the supply of services.

Design Clustered randomised controlled study.

Setting Rural Rajasthan, India.

Participants 1640 children aged 1-3 at end point.

Interventions 134 villages were randomised to one of three groups: a once monthly reliable immunisation camp (intervention A; 379 children from 30 villages); a once monthly reliable immunisation camp with small incentives (raw lentils and metal plates for completed immunisation; intervention B; 382 children from 30 villages), or control (no intervention, 860 children in 74 villages). Surveys were undertaken in randomly selected households at baseline and about 18 months after the interventions started (end point).

Main outcome measures Proportion of children aged 1-3 at the end point who were partially or fully immunised.

Results Among children aged 1-3 in the end point survey, rates of full immunisation were 39% (148/382, 95% confidence interval 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 per immunisation was $28 (1102 rupees, about £16 or €19) in intervention A and $56 (2202 rupees) in intervention B.

Conclusions Improving reliability of services improves immunisation rates, but the effect remains modest. Small incentives have large positive impacts on the uptake of immunisation services in resource poor areas and are more cost effective than purely improving supply.

Trial registration IRSCTN87759937.

Footnotes

  • We thank Jennifer Tobin for her help in editing this manuscript for publication. She was funded by the Abdul Latif Jameel Poverty Action lab.

  • Contributors: AVB, ED, and RG participated in the study design. ED and DK completed the data analysis. All authors participated in data collection, data interpretation, and drafting of the manuscript. ED is guarantor.

  • Funding: This study was funded by the Mac Arthur Foundation. All researchers declare that the research was entirely independent from the funders. The funders had no involvement in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. The intervention was funded by the Evangelischer Entwicklungdienst (Germany), Inter Church Cooperation for Development Cooperation (Netherlands), and Plan International, through Seva Mandir comprehensive plan. None of the funding organisations participated in the design of the study (although the MacArthur Foundation reviewed the design before making the funding decision), the data collection or analysis, or the decision to submit the paper for publication.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that they have no competing interests relevant to this work.

  • Ethical approval: This study was approved by the health ministry of the government of Rajasthan, the office on the use of human subjects at Massachusetts Institute of Technology, and the ethics committee of Vidhya Bhawan, the university which hosted the project in Udaipur. Informed consent was first obtained orally at the community level from the research villages through village meetings to which all adult members of the village were invited. Individual level informed consent was then obtained orally from every family participating in the study.

  • Data sharing: Statistical code and full dataset available from the corresponding author at eduflo{at}mit.edu. Consent was not obtained, but the presented data are anonymised and risk of identification is extremely low.

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