Improving Immunization Coverage in Rural India: A Clustered Randomized Controlled Evaluation of Immunization Campaigns with and without Incentives

(278 words) Context: Immunization rates in developing countries are low. The efficacy of incentive-based interventions designed to increase immunization rates has not been established. Objective: We conducted a randomized, controlled study of immunization camps in rural India to assess the efficacy of modest, non-financial incentives on immunization rates of children aged 1-3, and compare it with the effect of improving the reliability of the supply of services. Design: 134 villages were randomized to one of 3 groups: a once-monthly reliable immunization camp (intervention A; 30 villages); a once-monthly reliable immunization camp with small incentives (lentils and metal plates for completed immunization; intervention B; 30 villages), or control (no intervention, 74 villages). Surveys were undertaken in randomly selected households at baseline and approximately 18 months after the interventions started (at endline). The primary end point was the proportion of village children aged 1-3 at endline who were partially or fully immunized. Participants: 1640 children aged 1-3 at endline. Findings: Among children aged 1-3 in the endline survey, rates of full immunization were 38.3% for intervention B villages, compared to 16.6% for intervention A villages, and 6.2% for control villages. The relative risk of complete immunization for intervention B versus control was 6.19 (p<0.0005) and for intervention B versus intervention A was 2.30 (p< 0.0005). Children in areas neighboring intervention B villages were also more 3 likely to be fully immunized than were those from areas neighboring intervention A villages (RR 2, p<0.07). Interpretation: Improving reliability of services improves immunization rates, and small, non-financial incentives have large positive impacts on the uptake of immunization services in resource-poor areas.