Health infrastructure & immunization coverage in rural India

Ashlesha Datar, Arnab Mukherji* & Neeraj Sood

Economics & Statistics Group & *Pardee RAND Graduate School, RAND Corporation
Santa Monica, CA, USA
Received September 1, 2005
Background & objectives: Immunization coverage in India is far from complete with a
disproportionately large number of rural children not being immunized. We carried out this study
to examine the role of health infrastructure and community health workers in expanding
immunization coverage in rural India.
Methods: The sample consisted of 43,416 children aged 2-35 months residing in rural India from
the National Family Health Surveys (NFHS) conducted in 1993 and 1998. We estimated separate
multinomial logit regression models for polio and non polio vaccines that estimated the probability
that a child would receive no cover, some cover or full age-appropriate cover. The key
measure of health infrastructure was a hierarchical variable that assigned each child to categories
(no facility, dispensary or clinic, sub-centre, primary health care centre, and hospital) based on
the best health facility available in the childs village. We also included variables capturing the
availability of various types of community health workers in the village and other health
infrastructure.
Results: While there was under-provision of rural health infrastructure, our results showed that
the availability of health infrastructure had only a modest effect on immunization coverage. Larger
and better-equipped facilities had bigger effects on immunization coverage. The presence of
community health workers in the village was not associated with increased immunization coverage.
Interpretation & conclusion: Our findings suggest that expanding the availability of fixed health
infrastructure is unlikely to achieve the goal of universal coverage. Reforming community outreach
programmes might be better strategy for increasing immunization coverage.
Key words Community health workers - health infrastructure - immunization - India - polio
Roughly 3 million children die each year of
vaccine preventable diseases (VPDs) with a
disproportionate number of these children residing
in developing countries
1
. Vaccines remain one of the
most cost-effective public health initiatives
2
, yet the
cover against VPDs remains far from complete;
recent estimates suggest that approximately 34
million children are not completely immunized with
Indian J Med Res 125, January 2007, pp 31-42
31
almost 98 per cent of them residing in developing
countries
3
. Vaccination coverage in India is also far
from complete despite a longstanding commitment
to universal coverage. A recent evaluation of VPD
coverage in India found that 18 million children did
not receive any coverage in 2001-2002
4
.
In India, immunization has been a central goal
of the health care system from the 1970s, first through
the Expanded Programme on Immunization (EPI) in
1978, and later with the universal immunization
programme (UIP) since 1985. Constitutionally,
health care is on the States list of responsibilities
and is financed by the State. The UIP is an exception;
it is one of the few 100 per cent centrally sponsored
family welfare programmes and provides support for
vaccine storage, training of medical and paramedical
staff, and all infrastructure needs specific to
delivering immunization to infants at the village
level
5
.
Throughout the 1980s, gains in immunization
coverage proved to be rapid for all VPDs; some
VPDs showed gai ns from bel ow 20 per cent
coverage to over 60 per cent coverage by the early
1990s
6
. Pulse polio immunization (PPI) campaign
initiated in 1995, was successful in significantly
increasing first-dose polio immunization coverage,
however, there were limited gains in complete
coverage for polio vaccines
7
. Moreover, coverage
of non-polio vaccines seemed to have remained
unaffected by the PPI campaign. This limited
success in expanding full coverage for VPDs has
renewed the search of ways to expand coverage
effectively. A natural place to start was by studying
the strengths and weakness of the current vaccine
del i very syst em t hrough t he rural heal t h
infrastructure in India.
Indias rural health care system has a strong
dependence on community health infrastructure and
outreach, particularly in remote villages. Community
health infrastructure has been shown to be an
important correlate of health outcomes in other
developing countries
8-11
. In the Indian context, two
studies have examined the role of health
infrastructure on the utilization of maternal health
care using national data
12,13
while others have
examined the relationship between health
infrastructure and child and maternal health at the
State level
14,15
. These studies have mixed findings.
For example, one study used multivariate regressions
to control for individual and household
characteristics and found that distance to a health
facility did not predict health services utilization
13
.
Others have used a similar analytic strategy, but
different data, and the results indicated that presence
of a health facility in the village significantly
increased the likelihood of maternity care
utilization
10,14
. In this study, we examined the role of
rural health infrastructure and community health
workers in expanding immunization coverage in rural
India.
We built on this prior research in four important
ways. First, by characterizing the availability of
rural health infrastructure in more detail than prior
studies we were able to discuss the effectiveness of
different levels of health infrastructure in expanding
coverage. Important differences in both the nature
of services provided and the staffing at different
levels of care are likely to have different effects on
immunization coverage (Table I). We constructed
a hierarchical measure of health infrastructure that
captured the highest level of health facility available
in the village, and thus we were able to examine
whether it matters if the best available health facility
in the village is a hospital, or a less equipped,
smaller facility.
Second, we also examined whether the
availability of community health workers (CHWs)
such as village health guides (VHG), Anganwadi
workers (AWW), and trained birth attendants (TBA)
affects immunization coverage.
Third, we classified the set of vaccines under the
UIP into polio and non-polio vaccines to identify the
effect of different mechanisms of immunization
delivery. Since the PPI campaign was initiated
32 INDIAN J MED RES, JANUARY 2007
between the two National Family Health Survey
(NFHS) waves, it is important to examine changes
in coverage for polio and non-polio immunizations
separately.
Finally, in addition to the usual household and
individual covariates we included village level
variables as well as indicator variables for each State
(state fixed effects) in our regression models to
control for variations across areas in unobserved
factors such as policy environment and governance
that are correlated with health infrastructure as well
as immunization coverage. Given that States differ
markedly in terms of development and health related
measures, it was important to adequately control for
these differences.
Material & Methods
Rural health care system: The health care delivery
system in rural India relies on a combination of
primary health care infrastructure and community
outreach. Table I provides details about various levels
of government funded rural health infrastructure, the
intended and actual populations that each level
serves, the medical staff available at each level, and
the shortfall for each level. Community health centres
(CHC) are the largest facility and are the most
endowed in terms of medical staff and equipment,
followed by primary health centres (PHC), and
subsequently, subcentres (SC). CHCs are designed
to serve a much larger population, followed by PHCs,
and then SCs. However, there are substantial
shortfalls at each level of health infrastructure; as of
2005, there were 10 per cent fewer PHCs and SCs
than needed and 50 per cent fewer CHCs than needed
(Table I).
From an immunization delivery perspective, one
key problem in expanding coverage is the demanding,
temperature-controlled environment needed to store
vaccines before they are administered. Most CHCs
and many PHCs, though not all, are currently a part
of the Cold Chain and are technically able to maintain
a stock of vaccines at recommended temperature
zones. While stock-outs at these levels have been
reported, they are rare
15
. Thus, the key area of concern
is how effectively the immunization delivery system
administers vaccines to infants in villages away from
these cold chain facilities.
Table I. State of rural health care system in India
Sub centre Primary health centre Community health centre
(SC) (PHC) (CHC)
Population capacity:
Plain area 5,000 30,000 1,20,000
Hilly/tribal area 3,000 20,000 80,000
Actually serving:
Average population 4,579 27,364 214,000
Average area (sq. km) 22.81 136.31 1,067.10
Specified manpower 2 multi-purpose workers 1 Medical officer + 4 Medical officers (surgeon,
and asset strength (1 male & 1 female 14 Para medical staff; medicine, gynecologist medicine,
(ANM
*
) + 1 lady health 4-6 beds; acts as a gynecologist and paediatrician)
visitor supervising 6 SCs referral unit to 6 SCs + 21 paramedical staff;
30 beds + 1 OT + X-ray facilities +
Labour room and Lab facilities;
serves 4 PHCs
Requirement (Census 2001) 1,58,792 26,022 6,491
Number functioning as of 2005 1,42,655 23,109 3,222
Shortfall (%) 10.16 11.19 50.36
Sources: Ref. 5 : (1) Chapter 3, Section 8, Annual Report 1997-98, Ministry of Health and Family Welfare, http://mohfw.nic.in/
reports/1997-98Er/Contents. pdf (accessed January 31, 2006). (2) Ministry of Health and Family Welfare website.
http://mohfw.nic.in/dofw%20website/about%20us/infrastructure%20frame.htm#a2 (accessed January 31, 2006) and Ref. 15
*ANM, Auxiliary nurse midwife
DATAR et al: RURAL HEALTH INFRASTRUCTURE IN INDIA 33
In villages with just a SC, vaccination delivery
is done with the help of para-medical staff and
community outreach workers. The para-medical staff
consists of the lady health worker (LHV) stationed
at the PHC, and the auxiliary nurse midwife (ANM)
stationed at the SC. The community health and
outreach workers consist of the male health workers
stationed at the SC, Anganwadi workers (AWW)
stationed at an Anganwadi centre that provides day
care for children, village health guides (VHG) who
provide first-aid and act as outreach workers, and
trained birth attendants (TBA) who help with child
birth as well as outreach.
The key role in immunization delivery is that of
the ANM; she is responsible for not only administering
vaccines, but also for monitoring immunization
coverage
4
. Her primary duty is to conduct monthly
immunization sessions at the SC, and at other villages
in the SCs catchment area that have more than a 1000
individuals. In smaller villages, she is expected to co-
ordinate immunization sessions with the help of the
AWW, once every 3 months. The AWW is responsible
for bringing the children to the Angwanwadi where
the immunization session is held. The ANM is also
responsible for (i) maintaining data on immunization
delivery; (ii) writing monthly reports on the state of
immunization in her catchment area with input from
the LHV and the Medical Officer at the PHC;
(iii) physically carrying vaccines in from the nearest
CHC or PHC on a weekly basis; and (iv) scheduling
each of her immunization sessions at each of the
villages in the SCs catchment area. The male health
worker helps the ANM with some of the logistics,
while the AWW plays an important support role in
the scheduled immunization session, many of which
take place in an Anganwadi centre. Thus, by and large,
parents are expected to bring their children to
immunization sessions run by the ANM, if fixed
facilities are not available, or directly to PHCs or
CHCs
4,5,15
.
Study hypotheses: For our statistical analyses, we
used this knowledge about the health infrastructure
and the ways in which each facility and individual
contributed to the immunization effort to develop our
study hypotheses. We expected to see the presence
of each level of health care infrastructure, such as
the CHC, or the PHC, or the SC, or the availability
of community health workers like the TBA, VHG or
AWW would expand immunization coverage,
particularly when compared to villages without
access to any of these. We also expected that
availability of health facilities that are directly linked
to the cold chain (CHCs & PHCs) to have larger
effects. Among community health workers, we
expected AWWs to have the largest effect on
immunization coverage due to their relatively well-
defined role in immunization delivery.
In addition to the public health infrastructure, the
UIP provides vaccines free of cost to private sector
medical practitioners who can use them on their
patients to further expand immunization coverage
4
.
Therefore, apart from public health facilities, we also
expected the private health facilities such as
dispensaries, clinics, and pharmacies to play a
positive role in expanding coverage. Approximately
7 per cent of mothers in our data reported using a
private facility for their childs vaccination.
Data: We used data from the 1993 and 1998 waves of
the NFHS. The NFHS surveyed a representative
sample of households from 26 major States in India.
Data were collected using structured interviews with
women in the 13-49 yr age group who are, or have
been, married. Interviews were conducted using a
questionnaire designed specially for mothers, and this
was also used to collect data on immunization for
children. In addition, for women residing in rural areas
information was also collected on the availability of
village infrastructure through a village questionnaire.
Our analysis sample consisted of 43,416 children
sampled from rural primary sampling units, including
22,473 children in wave 1 and 20,943 children in wave
2. By matching the mother level data files with the
village level data files we got information on each
childs immunization status, their personal attributes,
their maternal and household attributes, and the village
infrastructure that they have access to.
34 INDIAN J MED RES, JANUARY 2007
Immunization: Mothers were asked about
immunizations received by each of her eligible
children, and when possible, this information was
verified by cross-checking against the childs
vaccination card. Specifically, the survey asked
whether the child had received BCG, DPT (all doses),
polio (all doses) and measles vaccinations. Since we
do not observe the frequency with each dose is
administered, a child was classified as receiving all
doses of the polio vaccine if the survey reported
that the child had received at least one dose (oral or
otherwise) of each of polio1, 2, and 3 vaccines (all
doses is similarly defined for DPT). Our definition
of immunization distinguished across vaccine types
to identify immunization coverage rates for two
categories of VPDs - polio and non-polio. This
categorization was considered useful since the two
waves of NFHS straddled the PPI.
In each of the NFHS waves we categorized a child
as having either no coverage, some coverage or
full age appropriate coverage using Government
of Indias Recommended Immunization Schedule
(Table II). Thus, for example, a child who is 3 months
old, and has BCG, DPT1 and 2, and Polio1 vaccines
would be classified as having fully age-appropriate
coverage under the non-polio vaccine category, but
would only be classified as having some cover for
the polio vaccine. Since many diseases require
multiple doses to provide full coverage across a range
of strains of the disease (e.g., polio) we used this
three-fold classification of immunization status.
While some prior studies have used a similar three-
fold classification (no coverage, partial coverage, full
coverage), they restricted their sample to children
12-25 months in a subsample of States in India
7,13
.
Our characterization of immunization coverage
differed from such studies by defining immunization
cover on the basis of its appropriateness at every age
of the infant. This approach had two advantages over
prior studies. First, it allowed us to include all
children in the 2 to 35 months age group in our
analysis. Second, it allowed us to distinguish children
who received age-appropriate coverage from children
who were immunized at an older (or younger) age
and were therefore exposed to the risk of VPDs for a
longer duration of time (or receive vaccinations prior
to being physiologically ready).
Measures of rural health infrastructure and
community health workers: The NFHS collected
village level information in each wave regarding the
presence of rural health infrastructure and community
health workers relevant for immunizations. First, we
constructed a categorical variable that captured the
hierarchy of primary health infrastructure, where a
dispensary or a clinic was the smallest facility,
followed by SC, PHC and the largest facility being a
hospital. Specifically, we assigned each village to
one of five mutually exclusive categories that
captured the highest level of public or private health
facility available in the village (i) no health facility
present, (ii) best facility was a dispensary or a clinic,
(iii) best facility was a SC, (iv) best facility was a
PHC, and (v) best facility was a hospital. While it
was rare for SC, PHC, and hospitals to be co-located,
we found that NFHS data did not report these to be
mutually exclusive (about 2% of all children lived
in villages which had both a hospital and a PHC, and
9 % of all children lived in villages with both a PHC
Table II. Recommended immunization schedule
Age Vaccine BCG DPT Polio Measles Age appropriate coverage
(wk) (months) for all India
Birth 0 X X BCG
6 1.5 X X BCG + DPT1 + Polio1
10 2.5 X X BCG + DPT1-2 + Polio1-2
14 3.5 X X BCG + DPT1-3 + Polio1-3
36 9.0 X BCG + DPT1-3 + Polio1-3 + Measles
Source: Ref. 16
DATAR et al: RURAL HEALTH INFRASTRUCTURE IN INDIA 35
and SC). We were unable to distinguish between
private and public hospitals due to the nature of the
survey questions. As a result, our definition of
hospital included CHCs, government hospitals, NGO
hospitals, and private hospitals.
Second, we constructed indicator variables for
various community health workers present in the
village who did not provide immunizations to
children but played an important role in community
mobilization. These included (i) whether a VHG was
present in the village, (ii) whether a TBA was present
in the village, and (iii) whether an AWW was present
in the village. We also included an indicator for
whether there was a pharmacy or medical shop
present in the village. We expected this variable to
proxy for the availability of private health care in
the village. The survey also asked about visit from a
MHU. We included a separate indicator for whether
a MHU visited the village.
Many households did not have a health facility
in their village, but a facility was available in a
neighboring village. Therefore, we constructed
alternative measures of infrastructure availability that
captured the highest level of facility available within
2 and 5 km from each childs village of residence.
Analysis approach: For each category of
immunizations (polio vaccines and non polio
vaccines), we estimated a multinomial logit
regression model, which estimates the conditional
probability that a child with a specific set of
characteristics (at the child, household and village
levels) was likely to receive no cover, some
cover or full age-appropriate cover. The key
explanatory variables of interest in our models were
the village health infrastructure and health personnel
variables.
Since placement of health facilities and
community health workers was likely to be
influenced by other population and village
characteristics that might also be correlated with a
childs likelihood of being immunized, controlling
for these factors was important in order to assess the
independent impact of health infrastructure on
immunization coverage. The NFHS survey data
allowed us to include a rich set of covariates, at
various levels, that related to a childs likelihood of
being immunized - child-level (age, sex, birth order),
mother-level (age, education, cohabiting, work status,
and if working for a salary), husband-level (age and
occupation), household-level (religion, tribal status,
household size, wealth index
17
). In addition, we also
included a number of village-level variables that were
likely to influence the placement of health facilities
(access to roads, distance to a major town, availability
of post office, schools, and electricity).
We included dummy variables for each State in
our models to control for time invariant unobserved
differences across States that were related to
immunization coverage. We also included a dummy
variable for wave, which controlled for any general
time trend in immunization coverage (e.g., improved
efficiency in providing health care). We estimated
our models using Stata for Windows, Version 8 (Stata
Corp, College Station, Texas, USA). All estimates
were weighted to adjust for the multistage sampling
design. Robust standard errors were estimated to
adjust for clustering at the village level. The variables
in our analysis had extremely low rates of missing
data; on average the variables had a less than 1 per
cent missing rate, with the maximum missing rate
for any one variable being 3 per cent.
Results
Polio and non-polio vaccine coverage: Data on
distribution of age-appropriate immunization
coverage for polio and non-polio vaccines in each
wave in both urban and rural India showed that in
1993, a significant proportion of children in rural
India did not have any vaccination coverage. Between
1993 and 1998 there was a significant decline in the
proportion of children with no coverage for both polio
and non-polio vaccines (Table III). However, the
decline in no-coverage was much more pronounced
for polio vaccines (21 percentage points) compared
36 INDIAN J MED RES, JANUARY 2007
to non-polio vaccines (11 percentage points). The
reduction in no-coverage for polio vaccines translated
into a roughly equal increase in partial and full
coverage. In contrast, the decline in no-coverage for
non-polio vaccines increased full coverage almost
twice as much as partial coverage. Immunization
rates for polio and non polio vaccines in urban areas
were much higher than corresponding rates in rural
areas (Table III).
Availability of rural health infrastructure and
community health workers: Data on the distribution
of rural health infrastructure in each wave of the
NFHS showed three salient trends (Table IV). First
was the limited availability of health infrastructure
in rural India in the early 1990s. For example, in 1993
as many as 43 per cent of children lived in villages
with no health facility and roughly half did not have
a PHC or hospital within a 5 km radius. Second, the
data showed substantial improvements in the
availability of health infrastructure across the two
waves that mimiced the trend of higher immunization
coverage. Third, the data suggested that the
improvement in health infrastructure was
concentrated in areas that already had a health
facility. For example, across all our hierarchical
measures of health infrastructure, the proportion with
no health facility remained relatively stable while
the proportion with PHC or hospital increased across
the two waves. Finally, as expected, the best available
facility in the village improved as we examined
availability within larger distances. Most notably,
there was a significant drop in the percentage of
children who had no dispensary/clinic, SC, PHC or
hospital in their village (only 28% within 2 km, and
just under 9% within 5 km), and an increase in the
percentage of children living in villages where the
best health facility was a hospital (Table IV).
Table III. Age appropriate coverage (%) for polio and non-
polio vaccination, By wave
NFHS I (1993) NFHS II (1998)
Rural sample
Polio age appropriate coverage:
No cover 47.3 26.0
Some cover 13.8 25.7
Full cover 38.9 48.3
Non-polio age appropriate coverage:
No cover 45.3 34.0
Some cover 27.4 31.5
Full cover 27.4 34.5
Urban sample
Polio age appropriate coverage:
No cover 29.2 14.3
Some cover 11.5 22.5
Full cover 59.3 63.2
Non polio age appropriate coverage:
No cover 25.5 14.8
Some cover 28.9 27.6
Full cover 45.6 57.6
NFHS, National Family Health Survey
Estimates are based on weighted NFHS I and II data
Table IV. Availability of rural health infrastructure in the childs
village, By Wave
NFHS I (1993) NFHS II (1998)
(%) (%)
Best health facility in the village:
None 42.9 46.6
Dispensary or clinic 20.7 10.0
Subcentre 20.2 21.9
Primary health centre 5.1 6.5
Hospital 11.2 14.9
Best health facility within 2 km of the village:
None 28.1 29.5
Dispensary or clinic 21.8 9.1
Subcentre 24.3 28.2
Primary health centre 7.3 11.0
Hospital 18.5 22.2
Best health facility within 5 km of the village:
None 8.8 9.7
Dispensary or clinic 18.9 4.8
Subcentre 21.8 26.1
Primary health centre 11.8 18.7
Hospital 38.8 40.7
Other health infrastructure in the village:
Mobile health unit in
the village 16.2 11.3
Pharmacy or medical
shop in the village 26.9 23.9
Community health workers in the village:
Village health guide 45.0 33.2
Trained birth attendant 50.1 57.8
Anganwadi worker 46.2 62.1
Estimates were based on weighted NFHS I and II data
Sample consists of children between the age of 2-35 months
of age whose immunization records were complete for each
category of immunization
NFHS, National Family Health Survey
DATAR et al: RURAL HEALTH INFRASTRUCTURE IN INDIA 37
The availability of other health infrastructure was
also relatively scarce in wave 1. Less than one in
three children lived in villages that had a pharmacy
or medical shop. Visits by a MHU were even less
common. In contrast, the availability of community
health workers in the village was relatively more
common. As many as one in two children lived in
villages that had a TBA, 45 per cent lived in villages
with a VHG, and 46 per cent lived in villages that
had an AWW.
Regression results: In regression analyses, we
estimated a series of multinomial logit models for
non-polio and polio vaccine coverage. Panels A to C
(Table V) reported estimates of the effect of village
health infrastructure and community health workers
on non polio vaccination coverage for the three
hierarchical measures of health infrastructure. The
estimates in all three panels showed that availability
of a dispensary/clinic, SC, PHC or hospital in the
village reduced no-coverage for non polio vaccines.
The estimates also showed that larger and better-
equipped facilities such as PHCs or hospitals had a
larger effect on non polio vaccine coverage compared
to dispensaries or SCs. For example, children living
in villages where the best available health facility
was a hospital are 4 percentage points less likely to
have no-cover for non-polio vaccines compared to
children that have no health facility in their village.
This decrease translated into an almost equal increase
in some-cover and full-cover. By contrast, children
living in villages where the best available health
facility was a dispensary or clinic are 3 percentage
points less likely to have no-cover for non polio
vaccines and this decreased translates mostly into an
increase in some-cover. The effect of a MHU on
immunization coverage appeared to be weak. One
of the reasons could be that MHUs typically served
very remote populations of whom we saw very little
of in the data. In villages that reported a MHU visit
the mean distances to the nearest SC, PHC, and
hospital were 4, 10 and 11 km, respectively.
Data showed that more restrictive measures of
the lack of health infrastructure had a stronger effect
on vaccination coverage (Table V). For example,
children who resided in villages with no health
facility within 2 km were 4.8 percentage points more
likely to have no vaccination coverage compared to
children where the best facility within 2 km radius
was a hospital. By contrast, children who resided in
villages with no health facility within 5 km were 7.1
percentage points more likely to have no vaccination
coverage compared to children in villages where the
best facility within 5 km was a hospital. Thus, the
results suggested that the likelihood of having some
or full immunization coverage decreased with
increasing distance to rural healthcare infrastructure.
While these gains were important, and statistically
significant, the increase in coverage from health
infrastructure was at best a small fraction of the gap
between current coverage levels and universal
immunization.
The results for other health facilities and
community health workers variables showed that
these factors had little or no influence on
immunization coverage. The availability of MHU
was not associated with changes in non-polio vaccine
coverage. However, the availability of a pharmacy
or medical shop in the village was associated with
an increase in some-cover (2.2 percentage points),
although the effect was smaller than that of hospitals
and PHCs. Among community health workers,
presence of VHGs and TBAs in the village was not
associated with increased immunization coverage.
However, as expected, the presence of an AWW
reduced the likelihood of no-coverage (-1. 8
percentage points).
In contrast to the results for non polio coverage,
the association between the best health facility
available in the village and polio vaccine coverage
was smaller, and not statistically significant (Table VI).
For the more restrictive measures, such as having
a PHC or hospi t al wi t hi n 2 or 5 km of t he
respondents village, the likelihood of full-cover
for polio vaccine increased and was statistically
significant but was also substantively small in
terms of realizing full immunization coverage
38 INDIAN J MED RES, JANUARY 2007
D
A
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A
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:

R
U
R
A
L

H
E
A
L
T
H

I
N
F
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A
S
T
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9
Table V. Marginal effects of rural health infrastructure and community health workers on non-polio vaccine coverage
Panel A: Non-polio vaccine coverage Panel B: Non-polio vaccine coverage Panel C: Non-polio vaccine coverage
response to availability in village response to availability within 2 km response to availability within 5 km
No cover Some cover Full AAC No cover Some cover Full AAC No cover Some cover Full AAC
Best health facility (reference=none):
Dispensary or clinic -3.0* 2.6** 0.4 -3.7** 1.5 2.3* -6.6*** 3.1* 3.5*
Subcentre -3.2** 1.4 1.8 -4.0*** 1.6 2.4** -6.1*** 2.5* 3.6**
Primary health centre -4.7** 3.9** 0.9 -5.8*** 1.8 4.0** -7.0*** 2.7 4.3**
Hospital -4.0** 2.2 1.8 -4.8*** 1.1 3.6*** -7.1*** 2.5* 4.6***
Other health infrastructure in the village

:
Mobile health unit visit 0.2 0.2 -0.4 0.1 0.2 -0.2 -0.1 0.3 -0.2
Pharmacy or medical shop -0.6 2.2** -1.6 -0.7 2.5*** -1.8* -1.0 2.5*** -1.5
Community health workers in the village

:
Village health guide 1.4 -0.7 -0.7 1.4 -0.6 -0.8 1.4 -0.6 -0.8
Trained birth attendant 0.1 -0.9 0.7 0.1 -0.8 0.6 -0.2 -0.6 0.8
Anganwadi worker -1.8* 0.8 1.0 -1.9** 0.9 1.1 -2.0** 0.9 1.1
*Significant at 10%; **significant at 5%; ***significant at 1%. Estimates shown in the Table reflect percentage point changes in No cover; Some cover; and Full
cover in response to changes in availability of health infrastructure and community health workers. All estimates come from weighted multinomial logit models that
include individual, household and village level variables as well as State and wave fixed effects.

Information on distances for the other health infrastructure and

community health worker variables was not collected in wave 2. Therefore, estimates for these variables in panels B and C capture the effect of availability in the
village. AAC, age-appropriate cover
Table VI. Marginal effects of rural health infrastructure and community health workers on polio vaccine coverage
Panel A: Polio vaccine coverage Panel B: Polio vaccine coverage Panel C: Polio vaccine coverage
response to availability in village response to availability within 2 km response to availability within 5 km
No cover Some cover Full AAC No cover Some cover Full AAC No cover Some cover Full AAC
Best health facility (reference=none)
Dispensary or clinic -0.9 1.6* -0.8 -1.5 -0.8 2.2 -2.4 0.6 1.8
Subcentre -0.4 0.5 0.0 -0.9 -1.0 1.8 -0.6 -1.5 2.1
Primary health centre -2.2 1.5 0.7 -3.7* -0.9 4.6** -3.3* -2.4** 5.7***
Hospital -1.3 -0.1 1.5 -2.5* -1.9** 4.3*** -3.4** -1.0 4.4***
Other health infrastructure in the village

Mobile health unit visit 3.2** -1.7** -1.5 3.0* -1.6* -1.4 2.9* -1.5* -1.4
Pharmacy or medical shop -1.3 0.6 0.7 -1.2 0.8 0.4 -1.3 0.7 0.6
Community health workers in the village

Village health guide -0.7 0.2 0.5 -0.7 0.3 0.3 -0.7 0.3 0.4
Trained birth attendant 0.7 -1.7*** 0.9 0.8 -1.5** 0.7 0.5 -1.5** 1.0
Anganwadi worker -1.3 0.6 0.7 -1.4 0.7 0.7 -1.4 0.5 0.8
*Significant at 10%; **significant at 5%; ***significant at 1%. Estimates shown in the table reflect percentage point changes in No cover; Some cover; and Full
cover in response to changes in availability of health infrastructure and community health workers. All estimates come from weighted multinomial logit models that
include individual, household and village level variables as well as State and wave fixed effects.

Information on distances for the other health infrastructure and
community health worker variables was not collected in wave 2. Therefore, estimates for these variables in panels B and C capture the effect of availability in the village
(4.6 percentage points and 5.7 percentage points
increase in full-cover for PHC within 2 and 5 km;
4.3 percentage points and 4.4 percentage points
increase in full-cover for hospital within 2 and 5
km). In contrast to what we found for non-polio
coverage, MHU visits in the village were associated
with a statistically significant decline in no-cover
for polio vaccination (-3.2 percentage points). The
availability of a pharmacy or a medical shop, VHG,
or AWW in the village was not associated with
coverage for polio vaccines. Presence of a TBA in
the village, while not associated with changes in
non polio coverage, reduced the likelihood of some-
cover.
Finally, the results for other co-variates in the
models (not presented in the Tables) showed that
there were a number of other important predictors
of childhood immunization. The most prominent
predictors in our models included sex of the child,
maternal literacy and whether the child belonged
to a scheduled caste/tribe (SC/ST) household. For
example, a child born to a mother who was literate,
but not compl et ed mi ddl e school was 8. 6
percentage points less likely to have no-cover for
non polio vaccines compared to an illiterate
mother. Similarly, a child born in an SC/ST
household was 3.0 percentage points more likely
to have no-cover for non polio vaccines when
compared to a child born in a non-SC/ST family;
and a girl child was 4.0 percentage points more
likely to have no-cover for non polio vaccines
when compared to a boy child. Thus, immunization
coverage l evel s vari ed syst emat i cal l y across
distributions of socio-economic and demographic
variables and some sub-groups were more at risk
of not receiving immunization coverage than
others.
Discussion
Our results highlighted two salient facts. First,
the immunization coverage in rural India was far
from universal. Second was that expanding the
availability of fixed health infrastructure would
40 INDIAN J MED RES, JANUARY 2007
result in only modest gains in immunization
coverage and was unlikely to achieve the goal of
universal coverage. Our results also showed that
immunization coverage in urban India although
higher than in rural India was far from universal
despite presumably better access to fixed health
infrastructure.
In principle, community health workers should
play an important role in expanding immunization
coverage to areas that do not have a well-developed
health infrastructure. However, we found that the
effectiveness of community health workers in
expanding immunization coverage was at best
small. It was not immediately obvious from our
study if this poor association was due to weak
mobilization efforts of these community workers,
or due to the ANMs inadequate coverage of the
SC catchment area where these community health
workers operated. Unfortunately, the NFHS does not
provide data on either the location or the time
allocation of the ANM across the many duties she
has. Anecdotal and case-study evidence suggested
that the current job requirements of the ANM may
not be optimally allocating the ANMs time if the
goal is to expand immunization coverage
4,18,19
. At
the same time, providing better training to and
monitoring of the community health workers has
been i dent i fi ed as an i mport ant area for
improvement
18,19
.
The results also showed that the availability of a
higher level facility like a hospital or PHC in the
village, or within 2 or 5 km, tended to have a larger
effect on immunization coverage than lower level
facilities (SCs, dispensaries). This was not surprising
since hospitals and PHCs were not only better staffed
but were also a part of the cold chain and therefore
had a regular supply of vaccines. In addition, they
conducted weekly scheduled immunization sessions
as opposed to the monthly sessions, which were run
at SCs. But the point of concern was that the spread
of Indias rural health network was the thinnest at
the levels of health infrastructure that we found to
be most effective.
DATAR et al: RURAL HEALTH INFRASTRUCTURE IN INDIA 41
Finally, even though the study focused on
evaluating the role of health infrastructure and
communi t y heal t h workers i n expandi ng
immunization coverage, the analysis suggested
other potential avenues for expanding coverage. For
example, maternal literacy was strongly correlated
with immunization coverage and thus policies that
encourage femal e educat i on mi ght l ead t o
significant gains in immunization. Also there were
vulnerable groups like the girl child, or children
born to SC/ST families who were less likely to
receive coverage. Special interventions tailored for
such vulnerable children may also significantly
improve coverage.
In conclusion, systematic expansion of the
availability of fixed infrastructure requires financial
support and a strong political commitment from State
governments. Yet, such a commitment is unlikely to
attain universal coverage. Critical improvements in
delivery of care are more important as a key failure
has been the low effectiveness of community outreach
activities in remote villages. There is evidence that
the ANM has huge responsibilities with few resources.
Significant improvement in the functionality of the
existing rural infrastructure may be possible by
rationalizing the role of the ANMs and providing them
with adequate (financial and manpower) resources to
realistically meet the goals. Other interventions such
as female literacy and those targeted towards the needs
of vulnerable populations would help expand the
coverage of immunization in India.
Acknowledgment
Authors acknowledge the financial support from the RAND
Corporation, a non-partisan and not for profit think tank based
in Santa Monica, California, USA. Authors thank Dr P. Biswal
(Assistant Commissioner, Universal Immunization Programme,
Government of India), Dr Naresh Goel (Monitoring and
Surveillance Officer, WHO-NPSP India), Dr R.S. Bakshi (Chief
Medical Officer, Ranbaxy Community Healthcare Society), and
Dr Vandana Joshi (Regional Director, CARE India) for
discussion about the rural health system in India. Neeraj Sood
and Ashlesha Datar are economists at the RAND Corporation
and Arnab Mukherji is a doctoral fellow at the Pardee RAND
Graduate School.
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42 INDIAN J MED RES, JANUARY 2007