Child Immunization Campaign with Incentives

Evidence Rating:

Near Top Tier

Highlights

Program:

Monthly, well-publicized immunization camps in poor villages in rural India, combined with small incentives for parents to have their children immunized (e.g., a $1 bag of lentils per immunization).
Evaluation Methods:

A well-conducted randomized controlled trial (RCT).
Key Findings:

Increased the percent of children age 1-3 fully immunized from 6% to 39%, at a cost of about $13 per targeted child; the small incentives were shown to be a key factor causing the increase.
Other:

A study limitation is that villages in the sample were all located in one area of western India. Thus, corroboration of these findings in a second trial, in another setting, would be desirable to show that the effects generalize to other settings where the program might normally be implemented.

The program is a child immunization campaign for children age 0-3 conducted in an impoverished area of rural India with unreliable immunization services (e.g., high staff absenteeism). The program was provided by Seva Mandir, an Indian nonprofit, and included two main components –

Monthly, well-publicized, reliable immunization camps. Monitoring confirmed that 95% of the planned camps took place. Social workers publicized the camps, informing mothers of young children about the camps’ availability and the benefits of immunization.
Small incentives for parents to have their children age 0-3 immunized. These included: (a) a 1 kg bag of raw lentils – worth about $1 – for every immunization their child received; and (b) a set of metal plates used for meals – worth about $2 – for completion of their child’s full immunization course (requiring at least five visits).

The full immunization course provided protection against diphtheria, whooping cough, tetanus, tuberculosis, polio, and measles. The program’s cost was about $13 per targeted child (2017 dollars).¹

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Top Tier

Programs shown in well-conducted RCTs, carried out in typical community settings, to produce sizable, sustained effects on important outcomes. Top Tier evidence includes a requirement for replication – specifically, the demonstration of such effects in two or more RCTs conducted in different implementation sites, or, alternatively, in one large multi-site RCT. Such evidence provides confidence that the program would produce important effects if implemented faithfully in settings and populations similar to those in the original studies.

Near Top Tier

Programs shown to meet almost all elements of the Top Tier standard, and which only need one additional step to qualify. This category primarily includes programs that meet all elements of the Top Tier standard in a single study site, but need a replication RCT to confirm the initial findings and establish that they generalize to other sites. This is best viewed as tentative evidence that the program would produce important effects if implemented faithfully in settings and populations similar to those in the original study.

Suggestive Tier

Programs that have been evaluated in one or more well-conducted RCTs (or studies that closely approximate random assignment) and found to produce sizable positive effects, but whose evidence is limited by only short-term follow-up, effects that fall short of statistical significance, or other factors. Such evidence suggests the program may be an especially strong candidate for further research, but does not yet provide confidence that the program would produce important effects if implemented in new settings.

References

¹ The three largest cost components were the salaries of the nurses and assistants providing the immunizations (29% of total cost), the incentives (28%), and the monitoring to make sure the camps took place as planned (23%). Monitoring was necessitated by the unusually poor health infrastructure in this part of India.

Banerjee, Abhijit, Esther Duflo, Rachel Glennerster, and Dhruva Kothari. “Improving Immunization Coverage in Rural India: Clustered Randomised Controlled Evaluation of Immunization Campaigns With and Without Incentives.” British Medical Journal, June 12, 2010, vol. 340, c2220. The full study is posted here.

Highlights

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Evaluation Methods:

Key Findings:

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References

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