BACKGROUND & OBJECTIVE: 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 child's 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.
BACKGROUND & OBJECTIVE: 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 child's 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.