In a drastic step to ensure that all children below five years of age are fully vaccinated, the Kerala government introduced a draft health policy in February 2018, which made vaccination compulsory for school admissions. In this post, Kaushik Bharati assesses the feasibility of the policy for other Indian states, based on a comparison of parameters such as health index, vaccination coverage, and literacy rates.
In February this year, the Kerala government, in a drastic step to ensure that all children below the age of five years are fully vaccinated, introduced a draft health policy that has made vaccination compulsory for school admissions. As per this policy, students seeking admission to grade 1 must produce a vaccination card. However, the major caveat in this policy is that if any children miss out on vaccination, they will be deprived of school admissions, which is a direct violation of the Right of Children to Free and Compulsory Education Act, 2009 (RTE), under Article 21 A of the Indian Constitution.
This policy comes after Kerala government’s vaccination drive last year was delayed by the anti-vaccination campaign launched on social media sites including Facebook and WhatsApp, which spread misinformation about vaccination. This controversial health policy is currently being debated by key stakeholders such as parents, health activists, policy experts, and medical professionals.
Kerala has a robust health system and very high literacy rates – the highest in India – which positively impact health awareness in the state. Consequently, due to a better understanding of health issues, including vaccination, amongst the general public, it may be feasible to implement this new health policy in Kerala. What about the other states? Would this vaccine policy be feasible and replicable in other states too? In this context, it should be remembered that in most states the health infrastructure is weaker and the literacy levels are generally lower than of Kerala. In this post, I analyse this issue based on a comparison of NITI Aayog’s health index, vaccination coverage, and literacy rates for several Indian states. Importantly, the analysis seeks to explore whether literacy rates could influence vaccine uptake, while keeping the health index as a constant parameter.
NITI Aayog’s health index
The health index is a part of a report titled ‘Healthy States, Progressive India’. It ranks states and union territories based on year-to-year changes in their overall performance in terms of health outcomes. This index comprises several health indicators like infant mortality rates, under-five mortality rates, vaccination rates, and institutional deliveries throughout the states. This health index has identified five top-performing states and five bottom-performing states. The top performing ones include Kerala, Punjab, Tamil Nadu, Gujarat, and Himachal Pradesh, with Kerala topping the list. The five bottom performers include Madhya Pradesh, Odisha, Bihar, Rajasthan, and Uttar Pradesh, with Uttar Pradesh at the bottom (Figures 1 and 2 respectively).
Figure 1. Health index of top five Indian states (2015-2016)
Figure 2. Health index of bottom five Indian states (2015-2016)
The basic panel of childhood vaccines used in the Universal Immunisation Programme (UIP) in India include BCG (Bacillus Calmette–Guérin - TB vaccine), OPV (Oral Polio Vaccine), DPT (Diphtheria-Pertussis-Tetanus vaccine), and Measles vaccine. The aim of childhood vaccination is to reduce the infant mortality rate and under-five mortality rate. The vaccination coverage for the top five states and bottom five states are presented below (Figures 3 and 4 respectively). The data has been extracted from the 4th National Family Health Survey (NFHS-4).
Figure 3. Fully vaccinated children of top five Indian states (2015-2016)
Data source: NFHS-4 (2015-2016).
Figure 4. Fully vaccinated children of bottom five Indian states (2015-2016)
Data source: NFHS-4 (2015-2016).
The literacy rates of adults aged 15-49 years for the five top and five bottom states are presented below (Figures 5 and 6 respectively).
Figure 5. Literacy rate of adults of top five Indian states (2015-2016)
Data source: NFHS-4 (2015-2016).
Figure 6. Literacy rate of adults of bottom five Indian states (2015-2016)
Data source: NFHS-4 (2015-2016)
What do these data tell us?
Tables 1 and 2 summarise the data from the above figures for the top and bottom states, respectively. The tables compare the states with reference to the three parameters, namely, health index, vaccination coverage, and literacy rates.
Table 1. Summary of data of the five top-performing states (2015-2016)
|Kerala||Punjab||Tamil Nadu||Gujarat||Himachal Pradesh|
|Vaccination coverage (%)||82.1||89.1||86.7||74.48||87.43|
|Literacy rates (%)||98.3||84.5||84.25||81.25||92.2|
Five top-performing states
- The vaccination coverage for all the states is higher than the respective health index.
- The reason for the lower health index compared to vaccination coverage could be lesser awareness about the other health indicators that constitute the health index.
- The increase in vaccination coverage could be influenced by the high literacy rates in all the states (all above 80%).
- The high literacy rates could make people more receptive to the information disseminated during vaccination campaigns. Awareness about vaccines could be more due to sustained advocacy efforts; this is especially true for the OPV campaign in recent years.
- In spite of the highest literacy rate and health index in Kerala, the vaccination coverage is lower than that of Punjab, Tamil Nadu, and Himachal Pradesh. This could reflect the stiff opposition faced by health workers from the anti-vaccination lobby in the state, leading to lower vaccination coverage.
Table 2. Summary of data of the five bottom-performing states (2015-2016)
|Madhya Pradesh||Odisha||Bihar||Rajasthan||Uttar Pradesh|
|Vaccination coverage (%)||77.1||88.5||81.05||75.98||73.3|
|Literacy rates (%)||70.6||75.85||63.7||70.95||71.7|
Five bottom-performing states
- The vaccination coverage for all the states is remarkably high, despite the low health index.
- Importantly, the vaccination coverage rates in these five bottom-performing states are not much lower than that of the five top-performing states.
- The high vaccination coverage could be due to more awareness about the advantages of vaccination amongst the general public.
- Except for Bihar, the literacy rates in all the five bottom-performing states are higher than 70%. This could translate into greater awareness about vaccination as opposed to the other health interventions covered in the health index.
It is evident that literacy rate has a major influence on the success of a vaccination campaign. Advocacy can only be effective if the targeted population is receptive and capable of assimilating the information. This can be achieved by adult education, particularly amongst women, who can then take the initiative to vaccinate their children. Thus, by improving the adult literacy rate, the vaccination coverage could be appreciably increased.
The above analysis indicates that implementation of the Kerala vaccination policy could be feasible in the majority of the states, except in states like Bihar, where the literacy rate is very low. Having said this and as indicated at the outset, the Kerala vaccination policy itself could be severely flawed because vaccination cards may not be sufficient to solve the problem, and many children may be deprived from school admissions if they are not vaccinated. This is indeed a likely scenario and something to ponder over, since 100% vaccination coverage has so far not been achieved anywhere in the country.