1 23

Journal of Population Research ISSN 1443-2447 J Pop ResearchDOI 10.1007/s12546-011-9069-y

Socio-economic differentials in childhoodimmunization in India, 1992–2006

Abhishek Kumar & Sanjay K. Mohanty

1 23

Your article is protected by copyright and

all rights are held exclusively by Springer

Science & Business Media B.V.. This e-offprint

is for personal use only and shall not be self-

archived in electronic repositories. If you

wish to self-archive your work, please use the

accepted author’s version for posting to your

own website or your institution’s repository.

You may further deposit the accepted author’s

version on a funder’s repository at a funder’s

request, provided it is not made publicly

available until 12 months after publication.

Socio-economic differentials in childhood immunizationin India, 1992–2006

Abhishek Kumar • Sanjay K. Mohanty

� Springer Science & Business Media B.V. 2011

Abstract This paper examines the socio-economic differentials in coverage of

basic childhood immunization in India and the states of Bihar and Gujarat using

three rounds of National Family Health Survey data. States are selected on the basis

of changes in full immunization coverage during 1992–2006. Bivariate, multivari-

ate, and progression rate is used to understand the differentials and changes in

immunization coverage. Results indicate that there has been a substantial increase in

partial immunization in most of the states, but the increase in full immunization

coverage is relatively slow in many of the states. Along with mother’s education,

standard of living, mass media exposure, and availability of health card is a sig-

nificant predictor in explaining the full immunization coverage irrespective of time.

Keywords Immunization � Progression rate � DPT3 � Measles � India

Introduction

In the last three decades, substantial resources of national government and

international donors have been invested to increase the immunization coverage in

developing countries. As a result, the basic childhood vaccinations have been

integrated in the public health programs of most of the developing countries and

helped to improve child survival (Hardon and Blume 2005; Jolly 2004; Stephen

A. Kumar (&)

International Institute for Population Sciences, Govandi Station Road, Deonar,

Mumbai 400088, India

e-mail: abhi85_iips@rediffmail.com

S. K. Mohanty

Department of Fertility Studies, International Institute for Population Sciences,

Govandi Station Road, Deonar, Mumbai 400088, India

e-mail: sanjayiips@yahoo.co.in

123

J Pop Research

DOI 10.1007/s12546-011-9069-y

Author's personal copy

et al. 2008). The first global initiative to increase childhood immunization was

the Expanded Program on Immunization (EPI) by WHO in 1974. Following this,

the global goal for universal child immunization against the six basic infections

(measles, poliomyelitis, diphtheria, pertussis, tetanus, and tuberculosis) was articu-

lated at the World Health Assembly in 1977. In 1984, UNICEF in partnership with

other stake-holders launched Universal Childhood Immunization (UCI) with the

target of 80% coverage in childhood immunization by 1990 (Keja et al. 1988). The

Global Alliance on Vaccines and Immunizations (GAVI) was launched in 1999 with

aims to accelerate the coverage of basic vaccines and to introduce the new vaccines in

low-income and middle-income countries. In addition, priority was also given to

childhood immunization in the Millennium Development declaration so as to improve

child health (United Nations 2005).

Immunization coverage has been accorded high priority on international and

national agendas as the vaccine-preventable diseases have been a major cause of

child mortality and morbidity (Anand and Barnighausen 2007; Lopez et al. 2006;

United Nations 2005). In the late twentieth century, about 9 million children

throughout the world died each year before reaching their fifth birthday (UNICEF

2007); of these deaths 4% were due to measles and 7% to tetanus (WHO 2002).

Despite the longstanding global, national, and local efforts, improvement in

immunization coverage is stagnating across and within the countries (Brugha et al.

2002; Hardon and Blume 2005; Starling et al. 2002; Westly 2003) with greater

socio-economic divides (Anwar et al. 2004; Carr 2004; Collin et al. 2007; Gwatkin

2000; Gwatkin et al. 2000; Kakwani et al. 1997). Several factors such as household

structure (Bronte-Tinkew and Dejong 2005; Gage et al. 1997), household economic

resources (Bronte-Tinkew and Dejong 2005; Pande and Yazbeck 2003), parental

education (Desai and Alva 1998; Streatfield et al. 1990), socio-cultural context

(Pebley et al. 1996), and accessibility of health services (Gauri and Khaleghian

2002; Gore et al. 1999) were identified as significant determinants of the extent of

childhood vaccinations.

In India, the basic childhood immunization service has been part of essential

health services and accorded top priority in its health delivery system. Following

the Alma Ata Declaration in 1978, the country had adopted the Expanded Program

on Immunization (EPI) and introduced six childhood vaccines—Bacillus Calmette-

Guerin (BCG), DPT, Polio, typhoid, and measles (Basu 1985; Kanitkar 1979).

These services were delivered at all public health centres and sub-centres free of

cost. To further accelerate the implementation of the immunization program, the

Government of India launched the Universal Immunization Program (UIP) in

1985–1986 with the target of universal immunization of all children and pregnant

women by the 1990s against the six vaccine-preventable diseases. All states of the

country were reportedly served by UIP (Sokhey et al. 1993). The UIP became a part

of the Child Survival and Safe Motherhood Program in 1992 and Reproductive and

Child Health (RCH) Program in 1997 (MOHFW 2003). The targets of universal

immunization were revised in the subsequent National Population Policy and the

National Rural Health Mission (MOHFW 2000, 2005).

The coverage of basic childhood immunization in India had never reached the

majority of children. For instance among children of age 12–23 months, 43% had

A. Kumar, S. K. Mohanty

123

Author's personal copy

received all recommended doses of vaccines and 5% were not immunized at all

(IIPS and Macro International 2007). Immunization coverage varies largely across

the states: 23% in Uttar Pradesh compared to 81% in Tamil Nadu. Also, the

differentials in immunization coverage continued to be large by economic and

social status of the household: in 2005–2006, the full immunization of children aged

12–23 months belonging to the lowest wealth quintile was 24.4% compared to

71.0% among the richest quintile (IIPS and Macro International 2007). Studies

indicate that wealth and regional inequalities in India are correlated with the overall

level of immunization in a non-linear fashion (Pande and Yazbeck 2003). Realizing

the need, the National Population Policy and the National Rural Health Mission

reiterated the need to achieve universal immunization by 2012 (MOHFW 2000,

2005).

The aim of this paper is to identify the changes and the underlying factors

associated with childhood immunization in India. The differentials in immunization

coverage have also been examined across selected socio-economic contexts in

the country. The paper has been conceptualized with the following rationale.

First, evidence from large-scale population-based surveys revealed that there is a

large gap between target and achievement of childhood immunization. Second, the

trends in immunization services seem to have stagnated in recent years compared to

other reproductive and child health services: for example, the coverage of full

immunization had increased by 4% points during 1992–1998 and 5% points during

1998–2005. Third, the spatial pattern in immunization coverage is quite puzzling. A

number of states (8 out of 29) had shown a decline in full immunization during

1998–2005. While the demographically backward states such as Bihar, Uttar

Pradesh, and Orissa had shown an increase in coverage of child immunization, it

had declined in the economically progressive states of Gujarat and Maharashtra.

Though the coverage of immunization varies largely across the states of India, little

is known on the trends, pattern, and the cause of such changes.

Data and methods

Data

Data for the study is taken from three successive rounds of the National Family

Health Survey (NFHS) conducted during 1992–2006. The first round of NFHS was

conducted in 1992–1993, the second round in 1998–1999 and the third in

2005–2006. For convenience, we refer to the periods between 1992–1993 and

1998–1999 as 1992–1998, between 1998–1999 and 2005–2006 as 1998–2005 and

between 1992–1993 and 2005–2006 as 1992–2005. The NFHS is similar to other

Demographic and Health Surveys (DHS) and covers a wide range of topics such as

fertility, mortality, family planning, immunization of children and nutritional status

of children. All three rounds of NFHSs are nationally representative and covered

more than 99% of India’s population. The NFHS-1 covered a sample of 89,777

ever-married women aged 13–49, NFHS-2 covered 90,303 ever-married women

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

aged 15–49 and NFHS-3 covered 124,385 women (unmarried and married) aged

15–49. Along with other states, the NFHS-3 sample covered three newly created

states, Jharkhand, Uttaranchal, and Chhattisgarh, that were created from the

erstwhile states of Bihar, Uttar Pradesh, and Madhya Pradesh respectively. To make

the state-specific estimate comparable we have estimated immunization coverage

separately for Bihar, Uttar Pradesh and Madhya Pradesh for all three periods.

In all DHS surveys, detailed information on vaccination was collected for the live

births to mothers in a reference period. In NFHS-1, information on vaccination was

collected for the last three births in the 4 years preceding the survey; in NFHS-2, it

was the last two births in the 3 years preceding the survey. In NFHS-3, information

was collected for the last five births in the 5 years preceding the survey. To make

the estimate comparable, we have used immunization coverage of children

12–23 months for the last two births (as it is common in all three rounds of the

survey). This cutoff point also reflects the immunization coverage in recent years.

However, we acknowledge that a significant minority of immunized children were

vaccinated between the ages 23 and 48 months.

Immunization status is measured using the information based on health card or

based on mother’s reporting. This is the standard practice for measuring

immunization status using the large-scale population-based survey (Boerma and

Bicego 1994; Langsten and Hill 1998). The immunization coverage is analysed as

‘full immunization’—surviving children who have received one dose of BCG, three

doses of DPT vaccine, three doses of polio vaccine, and one dose of measles

vaccine; ‘partial/any immunization’—surviving children who have received at least

one vaccine; and ‘no immunization’—surviving children who did not receive any

vaccines. We have considered children of age 12–23 months only, according to the

WHO schedule of immunizations.

The study used pertinent socio-economic and demographic variables to explain

the differentials and determinants of immunization coverage. The socio-economic

variables considered in the study are mother’s education, place of residence, religion

of household, caste of household, standard of living index, working status, and

exposure to mass media of mother. The demographic variables are sex of the child,

parity, age of mother. Others variables are antenatal care (ANC) visits and the

availability of health cards.

After defining the dependent variables we have analysed trends and change in

childhood immunization coverage for India and its states during the last 14 years.

Afterwards, we have restricted our analysis to India and states of Bihar and Gujarat

only (the selection criteria of states is briefly described in the results section), in

order to understand the differentials and determinants of immunization coverage.

Methods

Descriptive analysis is used to understand the differentials and changes in

immunization coverage across socio-economic context. The chi-square test is used

to understand the significant association of immunization coverage across selected

socio-economic variables. The progression rate of each vaccine is used to

A. Kumar, S. K. Mohanty

123

Author's personal copy

understand the sequential progression from one vaccine to another. Multivariate

analysis is used to understand the significant determinants of immunization

coverage. As our dependent variable is nominal and consists of three outcomes, no

immunization, partial immunization, and full immunization, we have used the

multinomial logit model. The logit model allows the effects of the independent

variables to differ for each outcome, and handles the non-independence of the

categories of the dependent variable by simultaneous estimation of the models for

all outcomes. Analysis is carried out using Stata 8.0 and maps are prepared using

ArcGis software.

Results

Trends in immunization coverage in India

Figure 1 presents the trends in childhood immunization in India over last 14 years.

While full immunization increased from 35% in 1992–1993 to 44% in 2005–2006,

partial immunization increased from 35 to 51% during the same period. On the other

hand the country has experienced a sharp decline in no immunization from 30% in

1992–1993 to 14% in 1998–1999 and 5% in 2005–2006.

The spatial pattern of immunization coverage in the last 14 years is presented in

Figs. 2, 3, and 4. Full immunization varies across the states over time (Fig. 2).

Among the major states, the coverage of full immunization in 2005–2006 was

highest in Tamil Nadu (81%) followed by Kerala (75%), Himachal Pradesh (74%),

Jammu & Kashmir (67%), Haryana (65%), and West Bengal (64%). It was lowest in

the state of Uttar Pradesh (23%) followed by Rajasthan (27%), Assam (31%), and

Bihar (33%). Among the smaller states, the coverage of full immunization during

2005–2006 was highest in Goa (82%), Sikkim (75%), New Delhi (63%), and

Uttaranchal (60%), while it was lowest in Nagaland (20%), Arunachal Pradesh

(25%), and Meghalaya (32%). Figure 3 presents the coverage in partial immuni-

zation among the states for last 14 years. The coverage of partial immunization

during 2005–2006 was highest in Uttar Pradesh (73%) followed by Rajasthan

Fig. 1 Percentage of children who received full immunization, partial immunization and noimmunization in India, 1992–2005

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

(67%), Bihar (60%), and Assam (53%). Among the smaller states it was higher

in Jharkhand (61%), Nagaland (60%), Arunachal Pradesh, and Meghalaya (50%

for each). The proportion of children not immunized against any infections

in 2005–2006 (Fig. 4) was highest in Assam (15%) followed by Orissa (12%),

Fig. 2 Percentage of children who received all recommended childhood vaccinations in India,1992–2005

A. Kumar, S. K. Mohanty

123

Author's personal copy

Haryana (8%), and Bihar (7%). In the smaller states it was higher in Arunachal

Pradesh (25%), Nagaland (20%), Meghalaya (18%), Mizoram (11%), and New

Delhi (10%). The spatial patterns in immunization coverage remained similar over

the period.

Fig. 3 Percentage of children who received at least one but not all childhood vaccinations in India,1992–2005

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

Changes in immunization coverage in India and states

Table 1 presents the percentage changes in full immunization, partial immunization,

and no immunization in India during 1992–1998, 1998–2005, and 1992–2005. It

is observed that progress in full immunization has stagnated in the country: 11%

Fig. 4 Percentage of children who received no childhood vaccination in India, 1992–2005

A. Kumar, S. K. Mohanty

123

Author's personal copy

increase each during 1992–1998 and 1998–2005; while partial immunization

increased 33% during 1992–1998 and 10% during 1998–2005. On the other hand no

immunization coverage is in consistent decline: 52% decline during 1992–1998 and

63% decline during 1998–2005. Among the major states of India, the percentage of

children without any single vaccination was observed in all the states: more among

the economically and demographically backward states of Jharkhand (93%),

Chhattisgarh (92%), Uttar Pradesh (92%), Rajasthan and Bihar (87% in each), and

Madhya Pradesh (86%). Regional patterns in partial immunization are mixed over

the years. It substantially increased in Rajasthan (121%), Uttar Pradesh (98%),

Bihar (64%), Punjab (62%), and Gujarat (60%), and declined in Kerala (33%), West

Bengal (31%), Himachal Pradesh (19%), and Haryana (8%). Among the smaller

states it increased in Nagaland (185%), Jharkhand (102%), and Arunachal Pradesh

(70%), and declined in New Delhi (25%), Tripura (10%), and Uttaranchal (7%).

Full immunization coverage has increased in most of the states during the last

14 years. Among the major states, Bihar had the maximum increase (204%)

followed by West Bengal (88%), Assam (62%), and Orissa (44%). On the other

hand, the full immunization coverage has declined in the economically progressive

states of Gujarat (9%), Maharashtra (8%), and Punjab (3%) during the same period.

Among the smaller states, full immunization coverage has increased for all states

except Mizoram. Based on changes in full immunization coverage among the major

states we have selected Bihar and Gujarat for further analysis as these two states

present extreme situations: Bihar showed maximum and constant increase in full

immunization over the period while Gujarat showed maximum as well as constant

decline in full immunization coverage. We have focused only on the major states in

order to have a sufficient sample size.

Socio-economic & demographic differentials in full immunization

in India and states

The differentials in full immunization coverage across selected socio-economic and

demographic characteristics are shown in Table 2. In India, full immunization

coverage varied largely with parity, age of mother, place of residence, mother’s

schooling, standard of living, caste, exposure to mass media, antenatal care of

mother, and availability of health card. In 2005–2006 the coverage of full

immunization was higher among lower-parity (55%) than higher-parity women

(31%), younger mothers (44%) than older mothers (29%), urban areas (58%) than

rural areas (39%), higher-educated mother (74%) than less-educated mother (30%)

and children with a high standard of living (62%) than low standard of living (28%).

Similarly, full immunization coverage is higher among children of other castes

(54%) than children belonging to Scheduled Castes/Scheduled Tribes (SC/ST)

(37%). In addition, full immunization coverage is higher among those children

whose mother received 3 or more antenatal checkups than among those whose

mother received less than three: 59% vs. 26%. Immunization coverage is higher

among children with a health card than among those without a health card (76% vs.

24%). Sex and religious differences in full immunization coverage are apparent. The

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

Tab

le1

Per

cen

tag

ech

ang

esin

no

,p

arti

al,

and

full

imm

un

izat

ion

cov

erag

ein

Ind

ia,

19

92–

20

05

Per

cen

tag

ech

ang

esin

imm

un

izat

ion

cov

erag

e

No

imm

un

izat

ion

Par

tial

imm

un

izat

ion

Fu

llim

mu

niz

atio

n

19

92

–1

99

81

99

8–

20

05

19

92–

20

05

19

92

–1

99

81

99

9–

20

05

19

92–

20

05

19

92

–1

99

81

99

8–

20

05

19

92

–2

00

5

Ma

jor

stat

es

Gu

jara

t-

64

.4-

32

.3-

75

.94

3.8

11

.36

0.0

-3

.5-

6.1

-9

.4

Mah

aras

htr

a-

73

.24

1.0

-6

2.2

-1

1.0

51

.93

5.1

13

.4-

19

.2-

8.4

Pu

nja

b-

52

.0-

24

.0-

63

.5-

2.5

65

.76

1.5

15

.5-

15

.7-

2.6

An

dh

raP

rad

esh

-7

3.7

-1

6.7

-7

8.1

16

.21

5.5

34

.11

4.9

-1

1.5

1.7

Jam

mu

-3

7.2

-5

8.9

-7

4.2

88

.4-

16

.75

6.7

-1

5.7

22

.02

.9

Kar

nat

aka

-4

9.9

-9

.8-

54

.91

1.5

4.6

16

.67

.3-

1.7

5.6

Him

ach

alP

rad

esh

-7

4.0

6.4

-7

2.3

-4

5.3

46

.2-

19

.33

0.0

-9

.21

8.1

Utt

arP

rad

esh

-3

0.8

-8

8.5

-9

2.0

36

.14

5.4

97

.90

.82

0.4

21

.3

Har

yan

a-

42

.4-

20

.6-

54

.32

.3-

10

.2-

8.2

12

.78

.62

2.3

Tam

ilN

adu

-8

8.5

-1

00

.0-

10

0.0

-6

3.2

63

.9-

39

.83

5.1

-8

.12

4.2

Raj

asth

an-

53

.7-

72

.6-

87

.31

01

.89

.61

21

.2-

23

.56

4.3

25

.7

Ker

ala

-8

0.3

-1

8.7

-8

4.0

-2

4.6

-1

1.6

-3

3.4

32

.54

.83

8.8

Mad

hy

aP

rad

esh

-5

6.2

-6

7.3

-8

5.7

75

.4-

15

.14

8.8

-2

8.3

99

.64

3.1

Ori

ssa

-6

6.8

24

.3-

58

.73

9.3

-2

6.9

1.7

12

.62

7.8

43

.9

Ass

am-

23

.6-

53

.3-

64

.33

6.3

4.7

42

.6-

16

.89

4.4

61

.8

Wes

tB

eng

al-

39

.1-

56

.3-

73

.4-

1.6

-3

0.3

-3

1.4

27

.64

7.3

88

.1

Bih

ar-

73

.1-

50

.1-

86

.61

04

.4-

19

.66

4.3

2.4

19

7.1

20

4.1

Sm

all

erst

ates

Miz

ora

m-

30

.01

1.1

-2

2.2

5.0

48

.15

5.5

5.0

-2

5.9

-2

2.2

Aru

nac

hal

Pra

des

h-

36

.3-

16

.7-

46

.97

0.0

0.0

70

.0-

15

.02

5.0

6.2

A. Kumar, S. K. Mohanty

123

Author's personal copy

Tab

le1

con

tin

ued

Per

cen

tag

ech

ang

esin

imm

un

izat

ion

cov

erag

e

No

imm

un

izat

ion

Par

tial

imm

un

izat

ion

Fu

llim

mu

niz

atio

n

19

92

–1

99

81

99

8–

20

05

19

92–

20

05

19

92

–1

99

81

99

9–

20

05

19

92–

20

05

19

92

–1

99

81

99

8–

20

05

19

92

–2

00

5

New

Del

hi

-2

4.7

10

6.7

55

.62

6.4

-4

0.9

-2

5.3

-1

3.6

26

.79

.5

Go

a-

10

0.0

-1

00

.0-

10

0.0

10

.0-

9.0

0.0

10

.02

.31

2.5

Utt

aran

chal

-5

6.9

-1

6.0

-6

3.8

50

.0-

38

.0-

7.0

-4

.55

2.3

45

.5

Chhat

tisg

arh

-7

7.2

-6

6.2

-9

2.3

10

0.2

-3

1.0

38

.0-

33

.81

21

.04

6.4

Man

ipu

r-

50

.0-

71

.4-

85

.71

2.5

14

.22

8.5

40

.61

4.3

60

.7

Tri

pu

ra-

47

.6-

27

.4-

62

.0-

5.9

-4

.1-

9.9

12

4.1

18

.81

66

.1

Jhar

kh

and

-5

3.9

-8

4.5

-9

2.8

11

0.1

-3

.71

02

.3-

13

.62

97

.82

43

.6

Nag

alan

d-

56

.8-

37

.1-

72

.91

59

.01

0.0

18

5.0

15

9.1

46

.72

80

.0

Meg

hal

aya

-2

2.6

-5

7.9

-6

7.4

20

.41

0.7

33

.35

4.8

15

0.7

28

8.2

Sik

kim

n.a

.-

10

0.0

n.a

.n

.a.

-3

7.5

n.a

.n

.a.

87

.5n

.a.

Ind

ia-

51

.9-

63

.1-

82

.33

3.4

10

.64

7.7

11

.11

0.6

22

.8

n.a

.In

form

atio

nn

ot

avai

lab

le

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

Tab

le2

Per

centa

ge

of

chil

dre

nw

ho

rece

ived

full

imm

uniz

atio

nb

yse

lect

edso

cio-e

conom

ican

ddem

ogra

phic

char

acte

rist

ics

inIn

dia

,B

ihar

and

Guja

rat,

1992

–2

00

5

Ind

iaB

ihar

Gu

jara

t

19

92

–1

99

31

99

8–

19

99

20

05–

20

06

19

92

–1

99

31

99

8–

19

99

20

05–

20

06

19

92

–1

99

31

99

8–

199

92

00

5–

20

06

Sex

of

chil

d

Mal

e3

6.7

40

.54

5.3

12

.41

2.8

38

.05

1.5

49

.64

8.5

Fem

ale

34

.13

8.2

41

.59

.18

.92

6.7

48

.34

6.9

41

.8

Bir

tho

rder

of

chil

d

14

5.5

51

.05

4.6

13

.31

3.8

44

.45

9.4

55

.45

0.0

24

1.7

45

.94

9.3

14

.61

5.2

38

.25

0.8

46

.14

8.5

3?

26

.42

7.7

31

.18

.38

.02

5.2

41

.64

4.8

38

.3

Ag

eo

fm

oth

er

15

–2

43

7.6

40

.54

4.0

12

.31

1.6

35

.04

8.5

44

.44

4.5

25

–3

43

5.3

40

.04

5.0

10

.21

2.0

33

.75

2.2

53

.94

5.3

35

?2

0.8

25

.12

8.8

6.9

1.5

11

.94

3.5

30

.85

8.3

Pla

ceo

fre

side

nce

Urb

an5

0.8

54

.85

7.6

19

.32

2.0

45

.75

7.0

54

.15

4.7

Ru

ral

30

.93

4.9

38

.69

.61

0.3

31

.14

6.2

44

.94

0.1

Mo

ther

’ssc

ho

olin

g

Les

sth

an5

yea

rs2

6.7

29

.43

0.4

6.8

7.8

25

.43

7.5

38

.83

0.7

5–

10

yea

rs5

9.1

58

.56

0.5

27

.52

3.9

59

.57

3.3

57

.75

8.4

Mo

reth

an1

0y

ears

72

.26

8.6

74

.15

0.0

32

.08

3.3

78

.07

7.8

74

.2

Sta

nd

ard

of

livi

ng

Lo

w2

5.8

29

.02

7.7

6.0

6.4

16

.73

7.7

34

.03

1.3

Med

ium

41

.94

0.9

42

.21

7.0

15

.74

1.4

48

.24

4.9

37

.8

Hig

h6

8.7

58

.56

2.1

38

.12

4.4

62

.56

8.7

70

.15

9.1

A. Kumar, S. K. Mohanty

123

Author's personal copy

Tab

le2

con

tin

ued

Ind

iaB

ihar

Gu

jara

t

19

92

–1

99

31

99

8–

19

99

20

05–

20

06

19

92

–1

99

31

99

8–

19

99

20

05–

20

06

19

92

–1

99

31

99

8–

199

92

00

5–

20

06

Ca

ste

SC

&S

T2

5.8

33

.73

7.1

5.9

9.6

24

.54

0.4

41

.04

6.1

Oth

erB

ackw

ards

Cas

ten.a

.40.7

40.7

n.a

.10.7

35.3

n.a

.44.8

42.3

Oth

ers

38

.24

3.4

53

.91

1.7

14

.63

6.4

52

.15

7.0

48

.5

Rel

igio

n

Hin

du

36

.04

0.0

44

.41

0.3

12

.63

5.9

49

.64

7.9

46

.0

No

n-H

ind

u3

3.2

37

.14

0.6

12

.84

.41

8.5

50

.95

0.0

38

.7

Exp

osu

reto

ma

ssm

edia

No

exp

osu

re2

3.3

24

.22

6.4

7.3

9.3

22

.23

8.2

41

.73

1.4

Ex

po

sure

50

.05

2.3

51

.31

9.9

20

.94

0.5

60

.35

3.1

50

.5

Wo

rkst

atu

so

fm

oth

er

No

tw

ork

ing

36

.14

0.0

46

.31

3.5

12

.33

4.3

55

.35

1.4

50

.8

Wo

rkin

g3

3.9

38

.03

6.5

0.0

6.8

27

.14

0.8

44

.83

5.5

AN

Cch

eck

up

Les

sth

an3

vis

its

18

.52

2.2

26

.17

.39

.32

6.7

25

.42

9.8

24

.3

3an

dm

ore

vis

its

55

.55

9.5

59

.02

5.2

20

.75

7.1

62

.66

0.7

57

.1

Ava

ilab

ilit

yo

fh

ealt

hca

rd

No

hea

lth

card

24

.42

4.2

24

.06

.65

.51

8.2

41

.73

7.1

27

.0

Hea

lth

card

60

.66

9.1

76

.13

1.1

37

.46

0.6

67

.57

1.9

76

.8

n.a

.In

form

atio

nn

ot

avai

lab

le

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

gap in full immunization coverage across the subgroups remained similar over the

periods.

In Bihar, coverage of full immunization varied across all selected socio-

economic and demographic characteristics over the periods. Moreover the

differences across sex, parity, and maternal age have increased in the later

period. In 2005–2006, the full immunization coverage was higher among male

children (38%) than female children (27%), lower-parity women (44%) than

higher-parity women (25%), younger mothers (35%) than older mothers (12%),

and urban areas (46%) than rural areas (31%). Similarly, immunization coverage

starkly varied between uneducated mothers (25%) and educated mothers (83%),

and low standard of living (17%) and high standard (63%). Caste and religious

differences are also considerable in full immunization coverage: immunization

coverage is higher among other castes (36%) than SC/ST (25%), and Hindus

(36%) than non-Hindus (18%). The full immunization varies largely by ANC

visits of mother and health card of child: in 2005–2006, the coverage of full

immunization was 57% for mothers who have received three or more antenatal

checkups compared to 27% of those who have received less than three. Similarly,

full immunization coverage was 60% among children with health card compared

to 18% among children without health cards. Although full immunization

coverage differs across socio-economic and demographic characteristics in Bihar,

full immunization coverage has increased across all selected subgroups over the

periods.

In Gujarat, full immunization coverage varied by background characteristics

and declined cutting across the subgroups over time. Sex differentials in full

immunization coverage have increased in the states in the later period: 49%

among boys compared to 42% among girls in 2005–2006; it was 52% among

boys and 48% among girls in 1992–1993 and 50% among boys and 47% among

girls in 1998–1999. In 2005–2006, full immunization coverage varied largely with

parity (50% among lower-parity vs. 38% among higher-parity women), place of

residence (55% in urban areas vs. 40% in rural areas), education of mother (31%

among less than 5 years of schooling vs. 74% among more than 10 years of

schooling), and standard of living (31% among low SLI vs. 59% among high

SLI). Caste and religious differentials are comparatively lower. Full immunization

coverage substantially varied with mothers’ exposure to mass media (51% among

exposed vs. 31% among non-exposed) and work status of mother (36% working

women vs. 51% among not-working women). Full immunization coverage in

Gujarat also differs by antenatal care of mother and health card of child: it was

57% among mothers who received three or more antenatal care visits compared

to 24% among those who received less than three visits, 77% among children

with health card compared to 27% among children without health card. Though

the coverage of full immunization has declined across the socio-economic groups,

this is not so with respect to the health card. It has substantially increased among

those children who have health cards across the periods: 68% from 1992–1993 to

72% in 1998–1999, and 77% in 2005–2006.

A. Kumar, S. K. Mohanty

123

Author's personal copy

Coverage of specific childhood vaccines in India and states

Table 3 shows the trends in coverage in specific childhood vaccines in India and the

states of Bihar and Gujarat. In 2005–2006, the coverage of Polio1, Polio2 was

universal while BCG, DPT1, and Polio3 covered more than three-fourths of children

in India. Moreover the coverage of these vaccines has substantially increased over

time. For example, coverage of Polio1 increased from 70 to 93%, Polio2 increased

from 61 to 89%, BCG increased from 62 to 78%, and Polio3 increased from 54 to

79% from 1992–1993 to 2005–2006. However, the coverage for DPT3 and measles

vaccine is very slow; fewer than three-fifths of children were immunized against

these infections in 2005–2006.

In Bihar coverage of all three doses of polio vaccine was higher than that of other

vaccines in 2005–2006. More than four-fifths of children aged 12–23 months were

immunized against polio, while about two-fifths of children were immunized with

DPT3 and measles vaccines in 2005–2006. Although the coverage of each vaccine

has substantially increased over the period, the increase is comparatively high for

polio vaccines in the last 13 years: the coverage of Polio1 has increased from 46

to 90%, Polio2 from 42 to 88%, and Polio3 from 33 to 83% from 1992–1993 to

2005–2006. In Gujarat the coverage of BCG, DPT1, Polio1 and Polio2 was higher

than that of other vaccines in 2005–2006. Coverage of these vaccines was more than

four-fifths during the same period. Coverage of BCG, Polio1, Polio2, and measles

has consistently increased over the period in the states, while other vaccines have

shown fluctuating trends.

Rate of progression in successive vaccines in India and states

Table 4 shows the rate of progression of successive vaccines for India and the states

of Bihar and Gujarat for three points of time. In order to obtain the progression rate

we started with the coverage of BCG as it is the initial dose in vaccination schedule.

Subsequently we tried to ascertain how many of those children who were vaccinated

against BCG progressed to DPT1 and thus we calculated the progression rate for

DPT1. Similarly we calculated the progression rate of Polio1: out of those children

who received one dose of BCG and DPT1, how many progressed to Polio1. In that

way we calculated the progression rate for specific vaccines. This is different from

the dropout rate, which provides the difference between DPT1 and DPT3 or Polio1

and Polio3; in contrast, the progression rate applies to each vaccine.

In India the coverage of BCG remained lower than that of other vaccines over

time. Apart from this the progression rate was lowest for DPT3, followed by

measles, Polio3, and DPT1. The pattern remained similar over the time. In Bihar,

the coverage of BCG was very low for all the periods, and the progression rate in

2005–2006 was higher for Polio1, Polio2, and Polio3 followed by DPT1, DPT 2,

and DPT3. But the dropout (complement of progression rate) is highest for measles

followed by DPT3. More than half of the children, who received Polio3 had not

received measles vaccination in Bihar in 2005–2006. In Gujarat, the progression in

2005–2006 was lowest for DPT3 followed by DPT2, measles, and Polio3. Moreover

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

Ta

ble

3P

erce

nta

ge

of

chil

dre

nw

ho

rece

ived

spec

ific

chil

dh

oo

dim

mu

niz

atio

nin

Ind

ia,

Bih

aran

dG

uja

rat,

19

92

–2

00

5

Ind

iaB

ihar

Gu

jara

t

19

92–

19

93

19

98–

19

99

20

05

–2

00

61

99

2–

199

31

99

8–

19

99

20

05–

20

06

19

92–

19

93

19

98–

19

99

20

05

–2

00

6

BC

G6

2.2

71

.67

8.2

34

.43

6.1

64

.67

7.1

84

.78

6.4

DP

T1

66

.37

1.2

75

.94

3.7

38

.56

5.1

77

.88

3.2

81

.5

Po

lio

16

6.9

83

.29

2.9

45

.98

4.2

90

.07

7.8

89

.79

1.9

DP

T2

59

.36

5.0

66

.73

7.7

33

.05

5.6

71

.47

5.5

73

.4

Po

lio

26

1.3

77

.78

8.8

41

.87

4.6

87

.87

1.2

82

.18

3.4

DP

T3

51

.95

5.5

55

.52

9.5

25

.04

6.1

63

.86

4.1

62

.0

Po

lio

35

3.7

60

.07

8.5

32

.64

1.4

82

.86

3.1

62

.66

5.9

Mea

sles

42

.25

0.7

58

.91

4.7

16

.14

0.5

55

.96

3.6

66

.0

A. Kumar, S. K. Mohanty

123

Author's personal copy

Ta

ble

4P

rogre

ssio

nra

teof

two

succ

essi

ve

vac

cinat

ions

inIn

dia

,B

ihar

and

Guja

rat,

1992–2005

Ind

iaB

ihar

Gu

jara

t

19

92–

19

93

19

98–

19

99

20

05

–2

00

61

99

2–

199

31

99

8–

19

99

20

05–

20

06

19

92–

19

93

19

98–

19

99

20

05

–2

00

6

BC

G0

.62

0.7

20

.78

0.3

40

.36

0.6

50

.77

0.8

50

.87

DP

T1

0.9

60

.94

0.9

30

.94

0.9

20

.94

0.9

70

.95

0.9

2

Po

lio

10

.98

0.9

90

.99

0.9

80

.97

0.9

70

.98

0.9

80

.99

DP

T2

0.9

20

.94

0.9

00

.82

0.3

90

.61

0.9

10

.83

0.7

9

Po

lio

20

.99

0.9

80

.99

0.9

90

.96

1.0

00

.97

0.9

70

.97

DP

T3

0.8

90

.87

0.8

50

.71

0.3

30

.52

0.8

80

.77

0.7

3

Po

lio

30

.99

0.9

10

.93

0.9

80

.90

0.9

70

.97

0.8

90

.84

Mea

sles

0.7

60

.82

0.8

80

.41

0.3

20

.45

0.8

10

.81

0.8

2

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

the progression rate has decreased for DPT2 and DPT2, while it stagnated for

measles over the periods.

Factors affecting coverage of immunization in India and states

To understand the significant effect of socio-economic and demographic factors on

immunization coverage, multivariate analysis is used for India and the states of

Bihar and Gujarat. We have used the multinomial logit regression considering the

nature of the dependent variable (immunization coverage), as it has more than two

categories, i.e. no immunization, partial immunization, and full immunization. The

analysis is carried out by using the pooled data from the three periods 1992–1993,

1998–1999, and 2005–2006, to attain an adequate sample size as well as to

understand the effect of time on immunization coverage. We have controlled for

significant covariates in the model such as sex of child, woman’s parity, age and

education of mother, place of residence, standard of living, caste, religion, exposure

to mass media, working status, and possession of health card. Mother’s antenatal

care visit is dropped from the multivariate analysis because of the problem of

multicollinearity. In order to avoid complexity of interpretation, the results obtained

from multinomial logit regression are presented in terms of predicted percentage

using multiple classification application (MCA). We presented results only for full

immunization (Table 5).

In India, immunization coverage significantly varied with parity of women. Full

immunization coverage was 50% among women with one child compared to 34%

among women with 3 or more children. Mother’s educational attainment and

standard of living are significant predictors of full immunization coverage: women

with 10 or more years of schooling were more likely to immunize their children

(60%) than those with less than 5 years of schooling (35%). Similarly, children with

low standard of living are less likely to be immunized (41%) than those with higher

SLI (49%). Exposure to mass media also appeared as a significant determinant of

full immunization coverage: immunization coverage is significantly higher among

those children whose mother was exposed to mass media (47%) compared to those

whose mother had no exposure (33%). Beside the socio-economic and demographic

determinants, possession of a health card appeared as a strong and significant

predictor of full immunization coverage in India: immunization coverage is 62%

among children with a health card and 44% for those without a health card. The

time effect shows a significant but very steady increase in full immunization

coverage: from 38% in 1992–1993 to 40% in 1998–1999 and 41% in 2005–2006.

Full immunization coverage significantly varies with sex of child, place of

residence, caste, religion, and work status of mother, though differences are

minimal.

In Bihar, female children were significantly less likely to be immunized than

male children (11% vs. 16%). Immunization coverage significantly differs across

mother’s educational attainment and standard of living in this state: mothers with 10

and more years of schooling were more likely to immunize their children (40%)

than those with less than 5 years of schooling (12%). Similarly, immunization

coverage is higher among children of high SLI (20%) than those of low SLI (16%).

A. Kumar, S. K. Mohanty

123

Author's personal copy

Table 5 Results of multinomial logit regression (predicted percentages): full immunization coverage in

India and selected states, 1992–2005

Explanatory variables India Bihar Gujarat

Sex of child

Male 42.8 16.1 54.0

Female 40.1*** 11.2*** 49.9

Birth order of child

1 49.7 16.7 55.8

2 45.5** 15.9 49.8

3? 34.1*** 11.7** 50.6

Age of mother

15–24 38.0 12.7 49.0

25–34 46.0*** 16.5 55.2

35? 40.0** 7.3 53.4

Place of residence

Urban 45.0 15.7 52.6

Rural 40.4*** 13.4 51.6

Mother’s schooling

Less than 5 years 35.4 11.7 42.7

5–10 years 51.3*** 22.8*** 60.6***

More than 10 years 59.9*** 39.7*** 70.6***

Standard of living

Low 40.5 15.7 47.9

Medium 34.5*** 9.0** 40.0*

High 48.8*** 20.4*** 60.7***

Caste

SC & ST 37.7 13.3 53.6

Others 42.2*** 15.3 48.4

Religion

Hindu 41.9 18.6 49.2

Non-Hindu 39.3*** 11.2* 48.7

Exposure to mass media

No exposure 33.1 14.3 49.3

Exposure 47.1*** 16.7 48.7

Work status of mother

Not working 40.2 16.1 49.5

Working 42.0*** 11.8** 48.0*

Availability of health card

No health card 43.7 13.4 46.5

Health card 62.3*** 18.9*** 49.3***

Time Dummy

1992–1993 38.4 5.8 51.9

1998–1999 39.9*** 9.2*** 50.4***

2005–2006 40.9*** 29.6*** 42.8***

* p \ 0.1; ** p \ 0.05; *** p \ 0.01

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

The immunization coverage differs significantly by possession of health card:

coverage was 19% among children with a health card and 13% among those without

health card. In Bihar the time effect suggests that full immunization coverage has

significantly and substantially increased over time. In Gujarat, full immunization

coverage is significantly higher among mothers with 10 or more years of schooling,

71% compared to 43% among those with less than 5 years of schooling. Similarly, it

is 61% among children belonging to households with high SLI and 48% among

children of low SLI. The full immunization coverage differs with possession of

health card: 49% among children with and 46% among children without a health

card. In Gujarat the time effect is significantly negative; suggesting that full

immunization coverage has declined over the period.

Discussion

This study focused on trends, changes, and socio-economic differentials in

immunization coverage in India. Immunization coverage is classified into three

categories: no immunization, partial immunization, and full immunization. To

understand the trends and changes, all three categories of immunization are used,

while for differentials and determinants, full immunization coverage is used. To

understand the regional variation, the analysis was carried out for the states of Bihar

and Gujarat. The state of Bihar had recorded significant increase in immunization

and the state of Gujarat had recorded a decline in full immunization coverage over

time.

The results indicate that there is a huge gap in targets and achievements in

immunization coverage in India. Despite the longstanding government effort to

achieve the goal of universal immunization, little more than two-fifths of children

were immunized with all the recommended vaccines and the coverage of full

immunization stagnated over the period. However, partial immunization has

increased substantially. There is large regional variation in full immunization in

India and a clear north–south differential is observed (Fig. 2). The spatial pattern of

immunization remained similar over time. The economically backward states

recorded significant increases in full immunization coverage, possibly because of

starting from a low level.

The results demonstrate that the coverage of BCG, three doses of DPT, and

measles vaccine is lower than that of polio vaccine, in India and the states; moreover

there is very little improvement over time. In addition, the coverage of BCG

remained very low in India and Bihar over the periods, since BCG is a primary

vaccine, this may be a major obstacle in achieving the goal of universal

immunization. In contrast, the coverage of polio vaccines is relatively high and

even shows consistent increases over time. Results of progression rates demonstrate

that the higher dropout from DPT3 and measles may be possible reasons for slow

progress in full immunization coverage. In Bihar, the lower coverage of specific

vaccines and dropouts in DPT2, DPT3, and measles would have caused a low level

of full childhood immunization. In Gujarat, the decline in full immunization

A. Kumar, S. K. Mohanty

123

Author's personal copy

coverage may be due to the constant decline in progression rate of DPT1, DPT2,

DPT3, and Polio3 vaccines.

The findings demonstrate that full immunization coverage varied largely across

socio-economic context in India and the states over time. Discrimination against

girls appeared in coverage of full immunization, though the gap had narrowed. The

finding accords with previous studies (Hill and Upchurch 1995; Pande and Yazbeck

2003) and reflects persistent discrimination against girl children in Indian society.

Urban children had better immunization coverage than rural children, probably

because of better accessibility and the success of ‘supply side’ factor as evident

from other studies (Ibnouf et al. 2007; Pande and Yazbeck 2003). Full immunization

coverage largely varied by mother’s educational attainment and exposure to mass

media. Immunization coverage is about twice as high among mothers with more

than 10 years of schooling as among those with 5 or less years of schooling. Similar

results are observed for exposure to mass media. These findings are similar to those

of other studies documenting the link between maternal education and child health

(Desai and Alva 1998, Streatfield et al. 1990), as well as between maternal exposure

to mass media and child health (Rahman 2007). Immunization coverage varied

substantially with economic status of households. Economic disparity in immuni-

zation coverage is more pronounced in the state of Gujarat; this is consistent with

the findings of the other studies that corroborated the link between socio-economic

status and immunization coverage and other health care services across the

developing countries (Gwatkin et al. 2000; Kunst and Houweling 2001; Mohanty

and Pathak 2009; Pande and Yazbeck 2003). The lower coverage of full

immunization among children of non-Hindu (Muslim) religion is probably because

of some parents’ mistaken beliefs on the ill-effects of vaccination.

Beside the socio-economic factors, possession of a health card is strongly

associated with full immunization coverage in India and the states. In standard

practice, immunization rates from large-scale Demographic Health Surveys are

derived from the information recorded on health cards where these cards

are available (Boerma and Bicego 1994; Brown et al. 2002) and such estimates are

found to be of good quality (Langsten and Hill 1998). However, in the case of the

absence of health cards, mothers’ reports are associated with errors of overestimation,

of measles vaccine in particular (Hawe et al. 1991; McKinney et al. 1991), and

underestimation of overall immunization in general (Christopher et al. 2003;

Gareaballah and Loevinsohn 1989; Suarez et al. 1997; Valadez and Weld 1991);

our results accord with this underestimation. The coverage of full immunization based

on health cards is consistently increasing over time in India and the states, but progress

is either sluggish or stagnated among children without health cards, even in Gujarat

(see Table 2). Reporting bias may be another plausible reason for slow progress in full

immunization in India and further needs to be explored.

Conclusion

Based on the results, our study draws attentions to two points. First, special effort is

needed to accelerate the coverage of DPT and measles vaccines as coverage of these

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

vaccines is lower than that of polio. Coverage of polio vaccine is high and a marked

increase was observed throughout India in the last 14 years as a result of

government efforts in the Massive Polio Campaign. Thus a similar approach should

be adopted for the remaining vaccines. Second, the health card should be made

compulsory for all newborn babies irrespective of home or institutional delivery to

avoid inaccuracy in reporting of immunization coverage.

Acknowledgments An earlier version of this paper was presented at the 26th IUSSP conference at

Marrakech, Morocco, 26 September–2 October, 2009. We would like to thank the chairperson Anastasia

J. Gage of Tulane University, New Orleans, for her beneficial comments and suggestions to improve the

earlier draft.

References

Anand, S., & Barnighausen, T. (2007). Health worker and vaccination coverage in developing countries:

An econometric analysis. Lancet, 369(9569), 1277–1285.

Anwar, A. T. M. I., Killewo, J., Chowdhury, M. K., & Dasgupta, S. K. (2004). Bangladesh: Inequalities in

utilization of maternal health care services: Evidence from Matlab. Health, Nutrition and Population(HNP) Discussion Paper, Reaching the Poor Program Paper No. 2, Washington, DC: World Bank.

Basu, R. N. (1985). India’s immunization program. World Health Forum, 6, 35–38.

Boerma, J.T., & Bicego, G. T. (1994). The quality of data on child immunization in DHS-I surveys: An

assessment of the quality of health data in DHS-I surveys. DHS Methodological Reports. Calverton,

MD: Macro International and Bombay: Himalaya Publishing House.

Bronte-Tinkew, J., & Dejong, G. F. (2005). Do household structure and household economic resources

predict childhood immunization? Evidence from Jamaica and Trinidad and Tobago. PopulationResearch and Policy Review, 24, 27–57.

Brown, J., Monasch, R., Bicego, G., Burton, A., & Boerma, J. T. (2002) An assessment of the quality of

national child immunization coverage estimates in population-based surveys. MEASURE Evalu-

ation Working Paper WP-02-53. Chapel Hill, NC; University of North Carolina at Chapel Hill.

Brugha, R., Starling, M., & Walt, G. (2002). GAVI, the first steps: Lessons for the Global Fund. Lancet,359, 435–438.

Carr, D. (2004). Health Bulletin Number 1: Improving the health of the world’s poorest people.

Washington, DC: Population Reference Bureau.

Christopher, J. L., Murray, B. S., Gupta, N., Moueeavi, S., Tandon, A., & Thiren, M. (2003). Validity of

reported vaccination coverage in 45 countries. Lancet, 362(9389), 1022–1027.

Collin, S. M., Anwar, I., & Rosmans, C. (2007). A decade of inequality in maternity care: Antenatal care,

professional attendance at delivery, and caesarean section in Bangladesh (1991–2004). InternationalJournal of Equity in Health, 6(9), 1–9.

Desai, S., & Alva, S. (1998). Maternal education and child health: Is there a strong causal relationship?

Demography, 35(1), 71–81.

Gage, A. J., Sommerfelt, A. E., & Piani, A. L. (1997). Household structure and childhood immunization

in Niger and Nigeria. Demography, 34(2), 295–309.

Gareaballah, E. T., & Loevinsohn, B. P. (1989). The accuracy of mother’s reports about their children’s

vaccination status. Bulletin of World Health Organization, 67, 669–674.

Gauri, V., & Khaleghian, P. (2002). Immunization in developing countries: Its political and organizational

determinants. World Development, 30(12), 2109–2132.

Gore, P., Madhavan, S., Curry, D., Mcclung, G., Castiglia, M., Rosenbluth, S. A., et al. (1999). Predictors

of childhood immunization completion in a rural population. Social Science and Medicine, 48,

1011–1027.

Gwatkin, D. (2000). Health inequalities and the health of the poor: What do we know? What can we do?

Bulletin of the World Health Organization, 78(1), 3–17.

Gwatkin, D., Rutstein, S., Johnson, K., Pande, R., & Wagstaff, A. (2000). Socio-economic differences inhealth, nutrition and population: An overview. Washington, DC: The World Bank.

A. Kumar, S. K. Mohanty

123

Author's personal copy

Hardon, A., & Blume, S. (2005). Shifts in global immunization goals (1984–2004): Unfinished agenda

and mixed results. Social Science and Medicine, 60, 345–356.

Hawe, P., Wilson, A., Fahey, P., Field, P., Cunningham, A. L., Baker, M., et al. (1991). The validity of

parental report of vaccination as a measure of a child immunizations status. Medical Journal ofAustralia, 155, 681–686.

Hill, K., & Upchurch, D. (1995). Gender differences in child health: Evidence from the demographic and

health surveys. Population and Development Review, 21(1), 127–151.

Ibnouf, A. H., Van Den Borne, H. W., & Maarse, J. A. M. (2007). Factors influencing immunisation

coverage among children under five years of age in Khartoum State, Sudan. South African FamilyPractice, 49(8), 14.

International Institute for Population Sciences (IIPS) & Macro International. (2007). National FamilyHealth Survey (NFHS-3), 2005–06: India: Volume I. Mumbai.

Jolly, R. (2004). Global development goals: The United Nations experience. Journal of HumanDevelopment, 5, 69–95.

Kakwani, N., Wagstaff, A., & Van Doorslaer, E. (1997). Socioeconomic inequalities in health:

Measurement, computation and statistical inference. Journal of Econometrics, 77(1), 87–104.

Kanitkar, T. (1979). Development of maternal and child health services in India. In K. Srinivasan,

P. Saxena, & T. Kanitkar (Eds.), Demographic and socio-economic aspects of the child in India.

Bombay: Himalaya Publishing House.

Keja, K., Chan, C., Hayden, G., & Henderson, R. H. (1988). Expanded programme on immunization.

World Health Statistical Quarterly, 41, 59–63.

Kunst, A. E., & Houweling, T. (2001). A global picture of poor-rich differences in the utilization of

delivery care. Studies in Health Services Organisation and Policy, 17, 297–315.

Langsten, R., & Hill, K. (1998). The accuracy of mother’s reports of child vaccination: Evidences from

rural Egypt. Social Science and Medicine, 46(9), 1205–1212.

Lopez, A. D., Mathers, C. D., Ezzati, M., Jamson, D. T., & Murry, C. J. L. (2006). Global burden ofdiseases and risk factors. New York: Oxford University Press and the World Bank.

McKinney, P. A., Alexander, F. E., Nicholson, C., Cartwright, R. A., & Carrette, J. (1991). Mother’s

reports of childhood vaccinations and infections and their concordance with general practitioner

records. Journal of Public Health Medicine, 13, 13–22.

Ministry of Health and Family Welfare (MOHFW). (2000) National Population Policy–2000, New Delhi

: Department of Family Welfare, Government of India.

Ministry of Health and Family Welfare (MOHFW). (2003) Annual Report (2002–03), New Delhi:

Ministry of Health and Family Welfare, Government of India.

Ministry of Health and Family Welfare (MOHFW). (2005) National Rural Health Mission (2005–2012)Mission Document, Department of Family Welfare, Government of India. New Delhi: India.

Mohanty, S. K., & Pathak, P. K. (2009). Rich-poor gap in utilization of reproductive and child health care

services in India, 1992–2005. Journal of Biosocial Sciences, 41(3), 381–398.

Pande, P. R., & Yazbeck, S. A. (2003). What’s in a country average? Wealth, gender, and regional

inequalities in immunization in India. Social Science and Medicine, 57, 2075–2088.

Pebley, A. R., Goldman, N., & Rodriguez, G. (1996). Prenatal and delivery care and childhood

immunization in Guatemala: Do family and community matter? Demography, 33, 231–247.

Rahman, M. S. (2007). Socioeconomic disparities in health, nutrition, and population in Bangladesh: Do

education and exposure to media reduce it? Pakistan Journal of Nutrition, 6(3), 286–293.

Sokhey, J., Mathur, Y., & Biellik, R. (1993). Country overview: A report of the international evaluation

of the immunization program in India. Indian Pediatrics, 30(2), 153–174.

Starling, M., Brugha, R., Walt, G., Heaton, A., & Keith, R. (2002). New products into old systems. Theglobal alliance for vaccines and immunizations (GAVI) from a country perspective. London: Save

the Children Fund.

Stephen, S. L., David, B. S., Alexandra, C. C., & Murry, J. L. (2008). Tracking progress towards universal

childhood immunization and the impact of global initiatives: A systematic analysis of three-dose

diphtheria, tetanus, and pertussis immunization coverage. Lancet, 372, 2031–2046.

Streatfield, K., Singarimbun, M., & Diamond, I. (1990). Maternal education and child immunization.

Demography, 27(3), 447–455.

Suarez, L., Simpson, D. M., & Smith, D. R. (1997). Errors and correlates in parental recall of child

immunization: Effects on vaccination coverage estimates. Pediatrics, 1–5.

UNICEF. (2007). The state of the world’s children 2007. New York.

Socio-economic differentials in childhood immunization in India, 1992–2006

123

Author's personal copy

United Nations (UN). (2005). Indicators for monitoring the Millennium Development Goals: Definitions,rationale, concepts and sources. New York.

Valadez, J. J., & Weld, L. H. (1991). Maternal recall error of child vaccination status in a developing

nation. American Journal of Public Health, 82, 120–122.

Westly, S. B. (2003). Child survival and healthcare in developing countries. Asia-Pacific Population and

Policy, East-West Centre, Population and Health Studies, 67. Accessed on (www.eastwestcenter.org).

World Health Organization (WHO). (2002). Department of immunization. Vaccines and biologicalestimates for under-five death. Geneva.

A. Kumar, S. K. Mohanty

123

Author's personal copy