|BRIEF RESEARCH ARTICLE
|Year : 2020 | Volume
| Issue : 1 | Page : 75-78
Private sector vaccine share in overall immunization coverage in India: Evidence from private sector vaccine utilization data (2012-2015)
Habib Hasan Farooqui1, Sanjay Zodpey2
1 Additional Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, Haryana, India
2 Director, Indian Institute of Public Health-Delhi, Public Health Foundation of India, Gurgaon, Haryana, India
|Date of Submission||08-Dec-2018|
|Date of Decision||01-May-2019|
|Date of Acceptance||06-Feb-2020|
|Date of Web Publication||16-Mar-2020|
Habib Hasan Farooqui
Indian Institute of Public Health-Delhi, Plot No. 47, Institutional Area, Sector 44, Gurgaon - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The objective of this research was to generate the evidence on the private sector's contribution to overall immunization coverage for selected pediatric vaccines in India. Using IMS Health's (now IQVIA) vaccine sales audit data and innovative methodological approach we estimated private-sector vaccine share in the total immunization coverage across selected pediatric vaccines in India. Our estimates suggest that private sector remains an important contributor to immunization services in India not only for Universal Immunization Program vaccines (Bacillus Calmette–Guérin [19.23%], HiB pentavalent [11.09%], hepatitis B [5.75%], oral poliovirus vaccine [5.48%], Diphtheria-Pertussis-Tetanus [2.66%], and measles [2.17%]) but also for newer vaccines (hepatitis A [4.2%], rotavirus [3.4%], typhoid [3.3%], and pneumococcal conjugate vaccine [2.5%]). As the private sector continues to remain an important access point for immunization services in the country, avenues for potential synergy between public and private sectors should be explored to improve the coverage and quality of immunization services.
Keywords: Private sector, Universal Immunization Program, vaccine coverage
|How to cite this article:|
Farooqui HH, Zodpey S. Private sector vaccine share in overall immunization coverage in India: Evidence from private sector vaccine utilization data (2012-2015). Indian J Public Health 2020;64:75-8
|How to cite this URL:|
Farooqui HH, Zodpey S. Private sector vaccine share in overall immunization coverage in India: Evidence from private sector vaccine utilization data (2012-2015). Indian J Public Health [serial online] 2020 [cited 2020 Dec 1];64:75-8. Available from: https://www.ijph.in/text.asp?2020/64/1/75/280779
India has made significant progress in the reduction of childhood morbidity and mortality through the use of safe and effective vaccines delivered through Universal Immunization Program (UIP). India eliminated smallpox in 1975, polio in 2014, and maternal and neonatal tetanus in 2015. Successful eradication of smallpox provided impetus for the launch of Expanded Program on Immunization (EPI) in 1978 with introduction of Bacillus Calmette–Guérin (BCG), oral poliovirus vaccine (OPV), Diphtheria-Pertussis-Tetanus (DPT), and typhoid-paratyphoid vaccines. In 1985, EPI was reorganized as UIP with the introduction of measles vaccines in the program. However, no new antigen was added to the UIP until 2002, although multiple new vaccines were licensed and made available in the private sector. In 2011, the hepatitis B vaccine became the 7th antigen to be introduced in the UIP, after being introduced in the pilot phase during 2002–2003 in the selected districts and metropolitan areas. In 2014, the Prime Minister's office announced the decision to introduce three new antigens (rotavirus, rubella, and polio [injectable]) in the UIP.
India's UIP vaccinates 26 million newborn children each year, with all primary doses of UIP vaccines and approximately 100 million children of 1–5 years age with booster doses of UIP vaccines. While UIP has shown its ability to undertake massive campaigns to improve coverage, the national vaccination coverage remains poor (61%) with considerable variation both within and between the states. As per the latest National Family Health Survey (4), 90.7% of vaccination in India is provided through public health facilities, whereas the private sector contributed to 7.2%. The Ministry of Health and Family Welfare's (MoHFW) multi-year strategic plan on immunization (2013–2017) has recognized the private sector as a key stakeholder in the immunization services and their role in providing access to newer vaccine before their induction in UIP, their role in vaccine-preventable disease surveillance, and adverse events following immunization reporting. However, the coverage estimates and access pattern of vaccines provided in the private sector are largely unknown except for conjugate Haemophilus influenzae and Pneumococcus vaccines., Against this background, this study was carried out to generate the evidence on the contribution of private sector to overall immunization coverage in India during 2012–2015.
We analyzed IMS Health's (now IQVIA) vaccine sales audit data from January 2012 to December 2015 to answer the above-mentioned research objective. IMS collects pharmaceutical sales data from the various stages in the retail pharmaceutical supply chain. In India, the data are collected from a sample of 5600 stockists across the country and projected to reflect the overall sales in the private sector. The data contain pack level information on sales values and volumes of vaccines sold in the Indian retail market. The sales value is reported in the local currency (INR) and the volumes in standard units (SU) (for oral liquids and injectable, one SU is 1 ml). For the present study, vaccine sales volumes were considered proxy for vaccine utilization in the private sector.
Using IMS Health's vaccine sales audit data and an innovative methodology, we estimated “private-sector vaccine share” which is defined as the percentage of all vaccinated children who received a given vaccine in the private sector to report the contribution of the private sector to overall immunization coverage in India. First, we calculated the number of “children fully vaccinated in the private sector” by dividing selected vaccine (BCG, hepatitis B, OPV, DPT, measles, HiB-pentavalent, pneumococcal conjugate vaccine [PCV], rotavirus, hepatitis A, and typhoid), doses sold in the private sector with the number of doses required to complete the respective vaccine's immunization schedule as per the recommendations of the Indian Academy of Pediatrics Committee on Immunization [Table 1], Column B]. The information on vaccine doses sold for each vaccine was available as SUs in the dataset, which was standardized to vaccine dose per child (in ml) and the number of doses per child required to vaccinate for a given vaccine. We assumed that the wastage factor in the private sector is negligible. It is reasonable to assert low wastage in the private sector since vaccines are primarily supplied as single-dose vials or prefilled syringes, and the payments are primarily made out-of-pocket by the parents. In addition, we assumed that any child receiving a vaccine dose in the private sector has received all subsequent doses and completed the schedule in the private sector.
|Table 1: Private sector vaccine shares in the overall immunization coverage for selected pediatric vaccines (2012-2015)|
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Next, we estimated the percentage of the “birth cohort vaccinated in the private sector” [Table 1], Column C] by applying estimated 4-year birth cohort (January 2012 to December 2015) based on the 2011 Census of Government of India) to the number of children vaccinated in the private sector during that period, whereas the “overall immunization coverage rate” [Table 1], Column D] was derived from WHO-UNICEF Coverage Evaluation Survey 2015. Finally, we calculated the “private sector vaccine share” [Table 1], Column E] for the selected vaccines by taking a ratio of the “children vaccinated in the private sector” to the “children vaccinated in public plus private sectors,” i.e., overall immunization coverage.
Another possible way to quickly arrive at private-sector vaccine share is by dividing vaccine sales estimates from IMS Health (now IQVIA) by the UNICEF coverage estimate for the selected vaccines. However, this approach limits the entire analysis only to those vaccines for which coverage estimates are available in UNICEF-CES, excluding all the newer vaccines, including those recently introduced in the UIP such as rotavirus and PCV. Second, even for the UIP vaccines, estimates on antigen-wise immunization coverage, across the public and private sector, are not available in the evaluation survey reports. Hence, we adopted a different methodological approach as explained above. All statistical analyses were conducted in the Microsoft Excel software.
We observed that the contribution of private sector in overall immunization coverage, defined as “private sector vaccine share” was the highest for BCG (19.23%), followed by HiB pentavalent (11.09%), hepatitis B (5.75%), OPV 3 (5.48%), DPT 3 (2.66%), and measles (2.17%) [Table 1], Column E]. For the newer vaccines (PCV, rotavirus, hepatitis A, and typhoid), which were not part of the UIP in 2015, almost all children (100%) received their vaccination in the private sector. The effective coverage rate at the country level for these vaccines was 4.2% for hepatitis A, 3.4% for rotavirus, 3.3% for typhoid (3.3%), and 2.5% for PCV.
We report new estimates on private sector contribution to overall immunization coverage in India through the use of private-sector vaccine sales audit data and innovative methodology. Our estimates on the private sector's contribution to overall immunization coverage for UIP vaccines stand at 19.2% for BCG, 11.0% for HiB pentavalent, and 5.7% for hepatitis B, highlighting its role in UIP's success.
Earlier, Howard and Roy, using 1995–1996 National Household Survey Data reported that the private sector contributed 17% toward BCG, 13% toward DPT 3, and 13% toward OPV 3 overall vaccination coverage. Another study reported that more than 50% of children accessed immunization services in the private sector, although coverage rates varied by vaccines (hepatitis B [44.7%], HiB [27.8%], and MMR vaccine [27.6%]). While Sharma et al. reported that state-specific per-capita income, urbanization, and percentage births in private sector health facilities have a strong, positive, and statistically significant association with private sector shares of UIP vaccines. Sokhey et al. reported that the coverage of hepatitis B vaccine improved only marginally from 9% to 14% when the vaccine was made available, free of cost, through government and municipal corporation health facilities. We suspect that access to pediatric vaccines is constrained not only by access to immunization services and ability to pay but also by the awareness about diseases and vaccines. While the high coverage of BCG in the private sector can be explained by the high rate of institutional deliveries in the private sector, hepatitis B and HiB are the reflections of increased demand on account of availability of these vaccines in the UIP.
Our estimates also suggest that the private sector is not only providing access to immunization services for UIP vaccines but also enhancing access to newer vaccines. For example, 4.2% of the entire birth cohort received hepatitis A vaccine in the private sector, 3.4% received rotavirus, 3.3% received typhoid vaccine, and 2.5% received PCV in the private sector during the study period. Literature suggests that while the public sector is the key driver for immunization services, private sector is more patient oriented and provides wider coverage of antigens and services. However, Hagan et al. reported poor immunization service quality in the private sector. Some of them include missed opportunities for vaccination, poor cold-chain practices, and poor reporting of vaccine doses and adverse events. We recognize that one of the major strengths of the private sector is timeliness and responsiveness, and it is important to engage the private sector proactively in the immunization services delivery as recommended in the multi-year strategic plan for immunization but not without proper institutional arrangements and accountability mechanisms.
Our study has one limitation. Our calculations on private-sector vaccine coverage assume that every vaccine course initiated in the private sector is completed. However, in the real world, a small proportion of clients often navigates between co-existing public and private sectors for vaccination services.
The launch of Mission Indradhanush has put the routine immunization in the spotlight again. Although majority of pediatric vaccines are available free of cost in public health facilities through UIP, the private sector still remains an important access point for a large proportion of the population for both UIP and newer vaccines, especially in the urban areas. In this regard, MoHFW should explore the potential pathways and avenues of synergy between the public and private sectors to improve access to immunization services. For example, innovative financing mechanisms such as insurance-based reimbursement for immunization services or provision of free of cost vaccines in the private sector can significantly improve the vaccine coverage and quality of services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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