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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Response to: ‘Improving Immunisation coverage in Rural India:
clustered randomized controlled evaluation of immunization campaigns with
and without incentives” ( 17th May 2010) issue of BMJ.
I have three critical issues to raise with such a study.
1. What is the notion of governance existing for the researchers. Their
attempt to run down the idea of existing government policies thru the
presentation of such data and also the idea of introduction of incentives,
aims to vilify and squander existing government policies and offer
solutions (which governments may have thought of themselves) but did not
choose the path of.
2. This study not only presents itself in a disrespect towards welfare
government and their policies but also treats people in the country with
a certain notion of disrespect. The introduction of incentive based
solutions in places of extreme poverty offer ‘quick fix’ solutions but are
also markers of dire and desperate existence of the people. This too is
taking away from the dignity of those who have been served. This is
besides the point that they have been used as rats in poverty lab ( which
seems to present itself easily to these researchers in a third world
country), and been experimented upon. The presence of a control area, only
adds to the unethical dimension of this study.
3. My third point is located at the design of the RCT and the grave
violations it represents. At one level the RCT, the systematic review seem
to be coming from the purely secular, scientific and objective domain ,
which Is equalizing everyone under the rubric of its ‘method’ on the other
hand the ‘method’ itself beholds within it a political economy of research
and research foundations. With its foundations set in Logical positivism
it addressess people as if they were without nation, a history, a race,
without poverty and also without gender. They are removed from all
contextualization’s and their dreams, demands, dignity and desperations
are played upon to satisfy the vily production factories of western
researchers. There is nearly an methodological irreverence, towards issues
of historical deprivation, poverty of races and nations and their policies
at the core of even such a study.
Bibliography
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Competing interests:
None declared
Competing interests: No competing interests
On going through the study “Improving immunisation coverage in rural
India: clustered randomised controlled evaluation of immunisation
campaigns with and without incentives” in 17th May 2010 issue of BMJ (1),
one is left with a sense of déjà vu as also disquiet; déjà vu with regard
to its claim to be a pioneering study, and disquiet, over its violation of
ethical norms for biomedical research with human participants set down by
the Indian Council of Medical Research (2).
Research studies published earlier have already established the
efficacy of incentives, whether they be in the form of food or conditional
cash transfers, in improving the utilisation of preventive health services
(3,4,5,6,7). Institutional deliveries have increased in India after the
introduction of the Janani Suraksha Yojana (JSY) scheme which provides a
monetary incentive for delivery in a hospital (8).
The ethical dimension lost sight of by the study, was the use of a
control group, in a situation that didn’t warrant a control group. Even
though cluster randomised controlled trial study designs are considered
the best suited to study the effect of public health interventions, there
are ethical issues in such designs that are still being debated (9). The
study population was divided into 3 study groups. Study group A had once
monthly reliable immunisation camp, Study group B had once monthly
reliable immunisation camp with an incentive and no study intervention in
the control group(1). According to the National Family Health Survey
(NFHS-3), in India, 38.6% of children aged between 12-23 months in rural
areas received full immunisation under the Universal Immunisation
Programme (10). In the state of Rajasthan (where the study was conducted),
the percentage of full immunisation in rural areas was 22.1% (11). The 134
villages selected in the study which included 74 control villages had full
immunisation coverage of only 2% in spite of the additional services of
the facilitating Non-Governmental Organization (NGO), Sewa Mandir (1). As
this study involved looking at life-saving basic immunisation services,
the children enrolled in the control group could have been at risk of
dying of a vaccine preventable disease during the period of study since
the vaccine coverage was very poor in the study area. Conducting a study
on utility of incentives to enhance immunization with a control group in
our opinion violates the spirit of General Principle(s) number 3 of the
Indian Council for Medical Research (ICMR) Ethical guidelines for
Biomedical Research on Participants: non-exploitation (2). It is also
violative of the norm that all participants should be beneficiaries in
such a research (2), since most children enrolled in the control group
lost their chance of getting vaccinated on time as compared to the other
groups. Offering of enhanced immunization services in the control area by
the researchers directly or through the partner NGO after study completion
would be too late for these children.
It’s surprising that there are no authors involved in the manuscript
from the partner NGO (Sewa Mandir) or Vidhya Bhawan which is mentioned as
being the university hosting the study in Rajasthan. Involving personnel
from these institutions in the analysis and writing of the manuscript
would have led to local capacity-building of institutions working in the
study area. Also, we feel that the authors at the least should have
thanked their study partners and the study communities without whom the
study would not be possible, but the manuscript does not have such an
acknowledgment section.
References:
1. 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 May 17;340:c2220. doi: 10.1136/bmj.c2220.
2. Indian Council of Medical Research. Ethical Guidelines for
Biomedical Research on human participants [Internet]. New Delhi: Indian
Council of Medical Research; 2006 Oct [cited 2010 Jun 10]. 120p. Available
from:http://www.icmr.nic.in/ethical_guidelines.pdf
3. Loevinsohn BP, Loevinsohn ME. Well child clinics and mass
vaccination campaigns: an evaluation of strategies for improving the
coverage of primary health care in a developing country. Am J Public
Health. 1987;77:1407-11.
4. Lagarde M, Haines A, Palmer N. Conditional cash transfers for
improving uptake of health interventions in low- and middle-income
countries: a systematic review. JAMA 2007;298:1900-10.
5. Fernald LCH, Gertler PJ, Neufeld LM. Role of cash in conditional
cash transfer programmes for child health, growth, and development: an
analysis of Mexico’s Oportunidades. Lancet 2008; 371:828-37.
6. Gertler PJ, Boyce Simon. An experiment in incentive based welfare:
The impact of PROGRESA on health in Mexico. University of California,
Berkley, April 2001.
7. Morris SS, Flores Rafael, Olinto Pedro, Medina JM. Monetary
incentive on primary health care and effects on use and coverage of
preventive health care in rural Honduras; cluster randomised trial. The
Lancet 2004; 364:2030- 37
8. Ministry of Health and Family Welfare. Concurrent assessment of
Janani Suraksha Yojana (JSY) in selected states of India, 2009; May.
http://www.mohfw.nic.in/NRHM/Documents/JSY_Study_UNFPA.pdf
9. Osrin David et al. Ethical challenges in cluster randomised
controlled trials: experiences from public health interventions in Africa
and Asia. Bulletin of the WHO 2009;87:772-79
10. International Institute for Population Sciences. Key Indicators
for India from NFHS-3. National Family Health Survey 2005-2006 (NFHS-3).
http://www.nfhsindia.org/pdf/India.pdf
11. International Institute for Population Sciences. Key Indicators
for Rajasthan from NFHS-3. National Family Health Survey 2005-2006 (NFHS-
3). http://www.nfhsindia.org/pdf/Rajasthan.pdf
Competing interests:
None declared
Competing interests: No competing interests
Re: Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives
Just like India and most countries, immunization services are offered free in public health facilities in Kenya, but often than not, access to and quality of these services is hampered by shortage of health workers especially in rural areas.
The use of community health workers (CHWs) has been identified as one strategy of enhancing the promotion of individual health and can make a valuable contribution to community development and, more specifically, improvement in access to and coverage of communities with basic health services. These services include preventive vaccination in human resource–poor settings. An evaluation using a meta-analysis found evidence in the effectiveness of CHWs in promoting childhood vaccination uptake, though as pointed out in your study, these evidence-based validations are not reported in developing countries
In addition to financial or non-financial incentives, adding other health services to a vaccination platform has been proposed as a way to increase coverage of those services and/or vaccinations. In Kenya for example, “Reaching Every District (RED)” approach strategy was found to be very effective in increasing uptake and coverage of immunization services (78% Diphtheria-Pertussis-Tetanus 3 (DPT3) coverage). RED is a district-focused, comprehensive strategy developed to tackle the common obstacles in improving access to and utilization of immunization services. The integration includes provision of immunisation with other maternal and child health services with outreach sessions for example Vitamin A supplementation, family planning, antenatal care, bed net distribution, deworming, growth monitoring and curative care. DPT1 coverage was a principal indicator of access to immunisation services; while DPT3 coverage measured the utilisation of these services. However, another integration strategy of hygiene interventions with vaccinations only increased vaccine coverage in urban areas while that of rural areas either remained unchanged or increased.
Based on these findings as well as your findings which reported large positive impacts of small incentives on the uptake of immunisation services in resource poor areas, socio-economic status may be an important consideration when designing sustainable strategies for scale up of immunization coverage and utilization.
Rose Kiriinya Kinyua
Project Data Analyst; Emory University Kenya Project
Research Inter, Great Lakes University of Kisumu
Email: rose.kiriinya@emorykenya.org
Competing interests: No competing interests