Khushi Baby (KB): Efficacy and Impact Assessment of Novel Mobile Health Solution for Vaccination Record Keeping in Rural Udaipur, Rajasthan, India

Routine immunization (RI) is an important tool to achieve the UN Millennium Development Goal (MDG) 4 of reducing child mortality by ensuring childhood protection from infectious disease. Recent 2013 estimates found that of approximately 6.3 million children died before their fifth birthday, with 51.8% (3.3 million) of these deaths attributed to infectious diseases (Liu et al., 2014). In regards to vaccine preventable diseases (VPDs), pneumonia (935,000 deaths) and diarrhea (578,000 deaths) were responsible for the most deaths. Measles, pertussis, tetanus, and meningitis, four other vaccine preventable diseases, were responsible for 362,000 deaths in children under five years old. (Liu et al., 2014)

Vaccination is one of the most cost-effective interventions for increasing childhood survival. (WHO, 2009). Global estimates find that current immunization programs save over 2.5 million lives a year (WHO, 2009). Despite the lifesaving potential of vaccines, in 2012 approximately 17% of children, or about 23 million infants, did not receive all the scheduled vaccines (CDC, 2013) and if they were immunized, they often received the vaccinations late (Clark & Sanderson, 2009).

In 1985, the Government of India launched the Universal Immunization Programme (UIP) to protect all infants (0-12 months) against six preventable diseases: tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles. The goal of UIP was to ensure 100% coverage of all eligible children with one dose of BCG, three doses of DTP and OPV, and one dose of the measles vaccine. According to the Coverage Evaluation Survey (CES) 2009, a nationwide survey covering all States and Union Territories of India conducted during November 2009 to January 2010 by UNICEF, the national fully immunized coverage (FIC) against the six vaccines included in UIP in the age-group of 12-23 month old children was just 61% (CES, 2009). Coverage with third dose of diphtheria, tetanus and pertussis vaccine (DTP3) is a widely accepted global indicator for RI program performance (Lim SS, et al. 2008). India national estimates found DTP3 coverage was 72% (WHO India 2011), against a global target of 90%. The District Level Health Survey 3 (DLHS 3) findings suggest that the retention rate of childhood immunization was in maximum decline between the second round of DT and polio - 70 % and the third round - 56 % (Shekhar & Yadav, 2013).

The proposed study site, the Udaipur district of Rajasthan, has traditionally had lower immunization estimates than national levels while also performing poorly in other key developmental indicators: infant mortality rate (IMR) is 47 per 1000 live births (SRS Bulletin, 2014, GoI) and maternal mortality rate (MMR) is 244 per 100,000 women of reproductive age (MMR Bulletin, 2013).

To counter the long-standing deficiencies in immunization coverage and other health outcomes, a non-governmental organization (NGO) named Seva Mandir began operations in the area starting in 2004. Seva Mandir, has had a long standing relationship with over 700 villages in Rajasthan, with 105 villages participating in their immunization program. Immunization camps take place at regular, expected intervals throughout the month so caregivers are aware of when the scheduled camps will take place. This study area and its partners have conducted a seminal randomized controlled trial on non-monetary incentives to improve immunization coverage (Banerjee A, et al., 2010).