Seminar
Immunization and economic development
BIBEK DEBROY
THE 1993 World Development Report (WDR) was subtitled ‘Investing in Health’ and advanced the argument that better health outcomes facilitate economic development.1Even if one contests the direction of causation, correlation between better health outcomes and higher levels of economic development is not in doubt. In achieving better health outcomes, immunization is a cost-effective strategy. WHO estimates that immunization is globally capable of preventing between two and three million deaths a year. WHO’s original Expanded Programme on Immunization (EPI) covered diphtheria, whooping cough, tetanus, measles, poliomyelitis and tuberculosis and it was hoped that all children would be immunized against these diseases by 1990. Subsequently, with some country-level variations, hepatitis-B, Haemophilus influenza type b (Hib), pneumococcal conjugate and rotavirus have occasionally been added.
Health outcomes, and some immunization indicators, have also entered the MDG (Millennium Development Goal) system. The MDG system has eight goals, plus 21 targets and 60 indicators. Under Goal four and Target six, there is Indicator 18, on the proportion of one-year olds who have been immunized against measles. Despite this, progress has been short of expectations. In the developed world, arguments have been advanced against possible side effects, though developed countries are beneficiaries of past immunization efforts.2
For children under one, WHO/UNICEF estimates are that BCG coverage has increased from 19% in 1980 to 93% in 2009.3DTP3 coverage has increased from 26% in 1980 to 89% in 2009. HepB3 coverage has increased from 1% in 1990 to 79% in 2009. Hib3 coverage has increased from 0% in 1990 to 41% in 2009. MCV1 coverage has increased from 13% in 1980 to 92% in 2009. Polio3 coverage has increased from 25% in 1980 to 89% in 2009. And so on. Specifically for India, the infant mortality rate (per 1000 live births) is now estimated to be 50 and the under-5 mortality rate (per 1000 live births) is estimated to be 66. In 2009, WHO/UNICEF estimates of vaccination coverage were 87% for BCG, 83% for DTP1, 66% for DTP3, 21% for HepB3, 71% for MCV, 67% for Pol3 and 86% for PAB.4To state the obvious, India performed better in some forms of vaccination coverage than in others.
In 2009, a status report was produced on India’s progress towards the MDGs.5In 2005 and 2007, there were two earlier reports on progress towards the MDGs. Of specific interest is MDG Goal no.4, that of reducing child mortality, the specific target being one of reducing the under-5 mortality rate by two-thirds between 1990 and 2015. Within this target, we have indicators like the under-5 mortality rate, the infant mortality rate (IMR) and the proportion of 1-year-old children immunized against measles. The under-5 mortality rate declined from 125 (per thousand live births) in 1990 to 74.6 in 2005-06. Though we don’t have data later than 2005-06 yet, a two-thirds reduction would have required an under-5 mortality rate of 42 by 2015, a target impossible to reach if present trends are extrapolated.
Under-5 mortality is high because infant mortality rates are high. Neo-natal deaths, deaths within the first month of birth, are particularly high among children. The IMR (per thousand live births) was 80 in 1990. Given the two-thirds reduction target, it should have become 26.7 by 2015. But given present trends, it is more likely to be something like 46 by 2015. In general, India performs better on poverty reduction and education goals of MDGs than the health-related goals. Roughly two-thirds of infant deaths are because of neo-natal deaths.6It is no one’s case that infant deaths and neo-natal deaths can be prevented by immunization alone. However, two points need to be made. First, the Indian track record is better for immunization against measles than for other kinds of immunization. Perhaps one should mention that the eleventh five year plan (2007-12) had a target of reducing the IMR to 28 by 2012.
Second, there are great variations in health indicators, immunization and health care delivery across states. ‘The rural-urban divide in incidence of infant mortality is quite glaring. There are 10 states in 2007, among those for which data are available, which had more than 20 point difference between rural and urban incidence of infant deaths, rural incidence being higher. The difference is maximum for Rajasthan, followed by Assam, Madhya Pradesh, Gujarat, Himachal Pradesh. Incidentally these states have also bigger female-male gap in IMR. Among the states/UTs, which are particularly lagging in increasing their coverage of immunization against measles, the states of Bihar, Rajasthan and UP are particularly long way behind universal coverage, and had low coverage in 1998-99. Other states which were similarly placed in 1998-99 are Assam, Jharkhand, Madhya Pradesh and Meghalaya.’7
The point is a simple one. There is a rural/urban divide and a male/female one and backward states on delivery are Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Rajasthan and Uttar Pradesh, and even Gujarat, Himachal Pradesh and Assam. But the bulk of the problem is concentrated in the Hindi heartland, so to speak. It was partly to address such issues that the National Rural Health Mission (NRHM) was launched in 2005.
Delivery of health care in rural India is through a structure of community health centres (CHCs), sub-centres (SCs) and primary health centres (PHCs). Compared to the required number of such centres, there is a huge shortage in states like Bihar, Uttar Pradesh, West Bengal and Madhya Pradesh.8Other than physical infrastructure, even if one ignores radiographers, lab technicians, specialists and doctors, there is a shortage of female health workers and auxiliary nurse midwives (ANMs). There aren’t enough accredited social health activists (ASHAs) and many villages don’t yet have health and sanitation committees.
One of the NRHM interventions is immunization against six diseases that can be prevented through vaccination – tuberculosis, diphtheria, pertussis, tetanus, polio and measles. District Level Household Surveys were held in 2002-04 and 2007-08 and these show some improvement between these two time periods. This is shown in Table 1.9More significant than the overall improvement is the improvement in states like Assam, Bihar, Jammu and Kashmir, Jharkhand, Meghalaya, Mizoram, Rajasthan, Sikkim, Uttarakhand and West Bengal.10The concern should be more with the near stagnation in Chhattisgarh, Gujarat, Haryana, Madhya Pradesh, Orissa, Tripura and Uttar Pradesh. In fairness, one should mention that these are on the basis of the surveys held in 2002-04 and 2007-08. There is a delivery monitoring unit in NRHM and this suggests that the percentage of fully immunized children has increased to 70.3% in December 2009.
TABLE 1Per Cent of Children Fully Immunized
State / 2002-04 / 2007-09
Andhra Pradesh / 62.0 / 67.1
Assam / 16.0 / 50.9
Bihar / 20.7 / 41.4
Chandigarh / 53.5 / 73.0
Chhattisgarh / 56.9 / 59.3
Dadar & Nagar Haveli / 84.2 / 57.3
Daman & Diu / 56.1 / 84.5
Delhi / 59.2 / 67.6
Goa / 76.9 / 89.8
Gujarat / 54.0 / 54.9
Haryana / 59.1 / 59.6
Himachal Pradesh / 79.3 / 82.3
Jammu & Kashmir / 31.7 / 62.5
Jharkhand / 25.7 / 54.1
Karnataka / 71.3 / 76.7
Kerala / 78.5 / 79.5
Lakshadweep / 61.0 / 86.1
Madhya Pradesh / 30.4 / 36.2
Maharashtra / 70.9 / 69.1
Meghalaya / 13.5 / 33.7
Mizoram / 32.6 / 54.5
Orissa / 53.3 / 62.4
Puducherry / 89.3 / 83.5
Punjab / 72.9 / 79.9
Rajasthan / 23.9 / 48.8
Sikkim / 52.7 / 77.8
Tamil Nadu / 91.4 / 81.8
Tripura / 32.6 / 38.5
Uttar Pradesh / 25.8 / 30.3
Uttarakhand / 44.5 / 62.9
West Bengal / 50.3 / 75.8
All-India / 45.9 / 54.1
In September 2010, the Ministry of Health and Family Welfare produced an annual report to the people on health.11This stated, ‘Another aspect of the strategy (to reduce under-5 and infant mortality) is in scaling up the universal access to immunization with particular focus on eradicating polio. More effort at micro-planning, mobilization of beneficiaries by ASHAs, improved cold chain management, Vitamin A administration, pediatric anaemia management and periodic deworming is also a part of this programme. Expand training of ASHAs for home-based newborn and child care and develop a policy framework for constituting community-based women empowerment groups under the leadership of the women panchayat members but also consisting of other women networks that may be existing in the village. The aim of such a strategic direction would be to one day ensure that the female functionaries – ASHA, AWW, ANM – become accountable to and work with these groups to help them realize their well-being and rights and more closely, monitor the immunization programme by listing the mothers and the children for tracking their care. Computerization of this data which is underway would enable identifying the missing children and enhancing the timeliness of the coverage. Include in the UIP protocol the second dose for measles and a catch-up campaign for measles so as to reduce the incidence of mortality on account of this disease, which is estimated to be almost four per cent.’
Why is immunization important? There is a reason why one needs to ask this question. At one level, immunization is an end in itself, because it helps to reduce under-5 and infant mortality. However, it is more than an end on its own. Reduced under-5 and infant mortality has correlation with levels of economic development and with India’s promised demographic dividend. A burden of disease has costs and both mortality and morbidity have costs that are not always private costs. That is, there are negative effects on GDP, now, and more importantly, in the future.
‘Assessment of the benefits of vaccines has traditionally focused on a specific range of health-related impacts: cost-effectiveness and cost-benefit analyses of the numbers of averted illnesses; hospitalization and deaths; disability-adjusted life years (DALYs) gained; and medical costs avoided are the most common assessment methods. Cost-effectiveness analysis looks at the cost of a health intervention per life saved (or per DALY gained, etc.); cost-benefit analysis takes into account the value of each life saved or the extra years of healthy life gained, and compares the total value of those benefits to the cost of the intervention. Neither cost-effectiveness nor cost-benefit analysis has so far taken full account of the broader economic impacts of immunization.
‘These impacts stem from the fact that immunization protects individuals not only against getting an illness per se, but also against the long-term effects of that illness on their physical, emotional, and cognitive development. The importance of these effects is borne out by recent work demonstrating the link from improved health to economic growth. This research has made clear the importance of health interventions for achieving growth and suggests that cost-effectiveness analyses, as currently conducted, are likely to underestimate the benefits of vaccination. A more thorough investigation of the impacts of vaccination, then, should look not just at direct medical cost savings and averted illness, but also at the effects on cognitive development, educational attainment, labour productivity, income, savings, investment, and fertility.’12
This is a point that can’t be disputed. However, there is a parallel between what has happened in education and what should happen in health, remembering that India has shown sharp improvements in gross enrolment ratios in primary school education. Government sources often tend to argue that this improvement in education has occurred because of the Sarva Shiksha Abhiyan (SSA) and the Mid-Day Meal Scheme (MDMS). There may be a bit of truth in that. However, supply-side changes have also occurred because there is greater choice in the form of alternatives to government schools, even among the poor. Even among the poor, there is increasing resort to non-government schools. More than supply-side changes that have led to the availability of such schools, there has thus been a shift in demand. A value is perceived in education and this explains the sharp increase in enrolment. In the absence of this shift in demand, supply-side changes alone would not have worked.
What does it take to bring about these demand shifts for immunization in particular and health in general? Involving communities and PRIs is part of the answer. But that is not the entire story. Private expenditure on health has increased, even among the poor. However, this increase has been on curative health care, rarely on preventive health care. Some surveys show that 85% of such private health care expenditure is on curative concerns (doctors, other dispensers, medicines, tests). The demand for something like immunization is non-existent, though there is a positive correlation between educational levels of the mother and vaccination coverage.
In the NRHM, there is a list of 235 laggard districts and focus on states does not always bring out these intra-state differences. The immunization problem is primarily in these backward districts which are invariably rural, and inadequate coverage is concentrated in segments that are backward because of gender, ethnicity, religion or caste. For instance, mothers are often not aware about the need for immunization. Even if immunization is desired, the place or the time for the vaccination is not known. Even if the time and place are known, these many be inconvenient. The ANM may not be present, or the vaccine may not be available. And in some cases, there are also fears of side-effects.
To compound the demand problem, there is a supply-side issue too. The Census 2011 figures are not yet available. However, Census 2001 showed that out of around 600,000 villages, around 235,000 have populations that are smaller than 500. This does not make the delivery of any public good or service there viable. Even a PHC is unlikely to be located there, or an ANM. And there are also problems connected with cold storage facilities for storing and transporting vaccines. In other words, there are problems of connectivity, especially road connectivity, and that is the weakest link.
There are now 137,311 sub-centres, 22,875 PHCs and 3,054 CHCs.13So the numbers have increased. However, there are several states where the PHC is far away. In states like JammuKashmir, Andaman & Nicobar Islands and Mizoram, the PHC can be more than 10 km away. Even in states like Madhya Pradesh, Jharkhand and Rajasthan, the PHC can be 8-9 km away. This is simply too far. In the absence of integrating immunization with other public services that are perceived to be more essential, or in the absence of ANMs visiting these villages, low levels of immunization will continue in large chunks of rural India.
The mere existence of a PHC, or access to it, doesn’t solve the problem. For instance, contrary to perception, Bihar is well connected through PHCs. However, 71% of PHCs in Bihar have no supply of electricity. Though the figures aren’t as high as 71%, several PHCs in Arunachal Pradesh, Chhattisgarh and Uttar Pradesh also function without electricity. Without these connectivity and infrastructure problems being solved, immunization numbers will not increase significantly. That is a pity, because the gains from immunization are considerable.
Footnotes:
1.World Development Report 1993, Investing in Health, World Bank and OxfordUniversity Press, 1993.
2. See, David E. Bloom, David Canning and Mark Weston, ‘The Value of Vaccination’,World Economics6(3), July-September 2005. Cost-benefit analyses of vaccination under-estimate benefits and over-estimate costs.
3. IVB_2010_eng.pdf
4. UNICEF.pdf
5. Millennium Development Goals – India Country Report 2009, Central Statistical Organization, Ministry of Statistics and Programme Implementation.
6. Ibid.
7. Ibid.
8. See, Mid-Term Appraisal of the Eleventh Five Year Plan, Planning Commission, 2010.
9. Ibid.
10. Since these are surveys, probably not too much weight should be attached to the apparent slippage in some of the better performing states.
11. Annual Report to the People on Health, Ministry of Health and Family Welfare, September 2010.
12. David E. Bloom et al., op cit.
13. 1997-2002. Data are from the Rural Health Survey.