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Variation in cost and performance of routine immunisation service delivery in India
  1. Susmita Chatterjee1,
  2. Palash Das1,
  3. Aditi Nigam2,
  4. Arindam Nandi2,
  5. Logan Brenzel3,
  6. Arindam Ray4,
  7. Pradeep Haldar5,
  8. Mahesh Kumar Aggarwal5,
  9. Ramanan Laxminarayan2,6
  1. 1Public Health Foundation of India, Gurgaon, India
  2. 2Center for Disease Dynamics, Economics & Policy, Washington, District of Columbia, USA
  3. 3Bill & Melinda Gates Foundation, Washington, District of Columbia, USA
  4. 4Bill & Melinda Gates Foundation, New Delhi, India
  5. 5Immunization Division, Ministry of Health and Family Welfare, Government of India, New Delhi, India
  6. 6Princeton Environmental Institute, Princeton University, Princeton, New Jersey, USA
  1. Correspondence to Dr Susmita Chatterjee; s_chatterjee_123{at}


A comprehensive understanding of the costs of routine vaccine delivery is essential for planning, budgeting and sustaining India’s Universal Immunisation Programme. India currently allocates approximately US$25 per child for vaccines and operational costs. This budget is prepared based on historical expenditure data as information on cost is not available. This study estimated the cost of routine immunisation services based on a stratified, random sample of 255 public health facilities from 24 districts across seven states—Bihar, Gujarat, Kerala, Meghalaya, Punjab, Uttar Pradesh and West Bengal. The economic cost for the fiscal year 2013–2014 was measured by adapting an internationally accepted approach for the Indian context. Programme costs included the value of personnel, vaccines, transport, maintenance, training, cold chain equipment, building and other recurrent costs. The weighted average national level cost per dose delivered was US$2.29 including vaccine costs, and the cost per child vaccinated with the third dose of diphtheria–pertussis–tetanus (DPT) vaccine (a proxy for full immunisation) was US$31.67 (at 2017 prices). There was wide variation in the weighted average state-level cost per dose delivered inclusive of vaccine costs (US$1.38 to US$2.93) and, for the cost per DTP3 vaccinated child (US$20.08 to US$34.81). Lower costs were incurred by facilities and districts that provided the largest number of doses of vaccine. Out of the total cost, the highest amount (57%) was spent on personnel. This costing study, the most comprehensive conducted to date in India, provides evidence, which should help improve planning and budgeting for the national programme. The budget generally considers financial costs, while this study focused on economic costs. For using this study’s results for planning and budgeting, the collected data can be used to extract the relevant financial costs. Variation in cost per dose and doses administered across facilities, districts and states need to be further investigated to understand the drivers of cost and measure the efficiency of service delivery.

  • health economics
  • immunisation

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  • Handling editor Sanni Yaya

  • Contributors SC and RL were involved in conceptualisation; SC, PD, AN, ANa designed the study; SC, PD, AN and ANa conducted the field work; LB, AR, PH, MKA and RL provided detailed inputs throughout the study; SC, PD and AN curated the data; SC, PD and AN analysed the data; SC prepared the draft manuscript; all authors were involved in review and editing of the manuscript. All authors read and approved the final manuscript.

  • Funding This study was funded by Bill & Melinda Gates Foundation and grant number (OPP1054305).

  • Competing interests LB and AR are the employees of the Bill & Melinda Gates Foundation.

  • Patient consent Not required.

  • Ethics approval Institutional Ethics Committee, Public Health Foundation of India.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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