The incremental cost of improving immunization coverage in India through the Intensified Mission Indradhanush programme.

Intensified Mission Indradhanush (IMI) was a strategic endeavour launched by the Government of India aiming to achieve 90% full immunization coverage in the country by 2018. The basic strategy of this special drive involved identifying missed children and vaccinating them in temporary outreach sites for 1 week over consecutive 4-month period starting from October 2017. This study estimated the incremental economic and financial cost of conducting IMI in India from a government provider perspective. Five states-Assam, Bihar, Maharashtra, Rajasthan and Uttar Pradesh were purposefully selected because of high concentration of IMI activities. The stratified random sample of 40 districts, 90 sub-districts and 289 sub-centres were included in this study. Cost data were retrospectively collected at all levels from administrative records, financial records and staff interviews involved in IMI. The weighted incremental economic cost per dose (including vaccine costs) was lowest in Uttar Pradesh (US$3.45) and highest in Maharashtra (U$12.23). Incremental economic cost per IMI dose was found to be higher than a recent routine immunization costing study by Chatterjee and colleagues in 2018, suggesting that it requires additional resources to immunize children through an intensified push in hard-to-reach areas. Incremental financial cost of the IMI programme estimated in this study will be helpful for the government for any future planning of such special initiative. The reasons for variation of unit costs of IMI across the study districts are not known, but lower baseline coverage, high population density, migration, geography and terrain and vaccinating small numbers of children per session could account for the range of findings. Further analysis is required to understand the determinants of cost variations of the IMI programme, which may aid in better planning and more efficient use of resources for future intensified efforts.