Health impact and cost-effectiveness of expanding routine immunization coverage in India through Intensified Mission Indradhanush: a quasi-experimental study and economic evaluation

BackgroundMany children do not receive a full schedule of childhood vaccines, yet there is limited evidence on the cost-effectiveness of strategies for improving vaccination coverage. We evaluated the cost-effectiveness of periodic intensification of routine immunization (PIRI), a widely applied strategy for increasing vaccination coverage. MethodsIntensified Mission Indradhanush (IMI) was a large-scale PIRI intervention implemented in India in 2017-2018. In 40 sampled districts, we measured the incremental economic cost of IMI using primary data, and used a quasi-experimental impact evaluation to estimate incremental vaccination doses delivered. We estimated deaths and disability-adjusted life years (DALYs) averted using the Lives Saved Tool and reported cost-effectiveness from government provider and societal perspectives. FindingsIn sampled districts, IMI had an estimated incremental cost of 2021US$15.7 (95% uncertainty interval: 11.9 to 20.1) million from a provider perspective and increased vaccine delivery by an estimated 2.2 (-0.5 to 4.8) million doses, averting an estimated 1,413 (-350 to 3,129) deaths. The incremental cost was $7.14 per dose ($3.20 to dominated), $95.24 per zero-dose child reached ($45.48 to dominated), $375.98 ($168.54 to dominated) per DALY averted, $413.96 ($185.56 to dominated) per life-year saved, and $11,133 ($4,990 to dominated) per under-five death averted. At a cost-effectiveness threshold of 1x per-capita GDP per DALY averted, IMI was estimated to be cost-effective with 89% probability. InterpretationThis evidence suggests IMI was both impactful and cost-effective for improving vaccination coverage. As vaccination programs expand coverage, unit costs may increase due to the higher costs of reaching currently unvaccinated children. FundingBill & Melinda Gates Foundation