Intended for healthcare professionals


Improving immunisation coverage in rural India

BMJ 2010; 340 doi: (Published 17 May 2010) Cite this as: BMJ 2010;340:c2553
  1. Jishnu Das, senior economist
  1. 1World Bank Main Complex, 1818 H St NW, Washington DC, USA
  1. jdas1{at}

    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 government’s 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 don’t 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


    • Research, doi:10.1136/bmj.c2220
    • Competing interests: The author has completed the Unified Competing Interest form at (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.


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