How urbanization is driving decline in immunization levels

NEW DELHI: If you thought the decline in immunization levels must be in India’s rural areas, you would be surprised to learn that the decline seen in high performing states seems to have happened largely among the urban poor in peri-urban and newly urbanized areas due to rapid urbanization leaving these areas neither rural nor fully urban.
According to an article in the latest issue of the Indian Journal of Paediatrics by experts collaborating across three leading national institutes, districts with high level of urbanization showed a higher probability of recording a decline in immunization coverage.The experts found that there was a negative relationship between immunization coverage levels and proximity to towns. “As the proportion of villages in the district which were located at a distance of more than 10 km from the nearest town increased, the probability of decline in immunization coverage decreased,” stated the article.
The authors of the article, Rajib Dasgupta of the Centre of Social Medicine and Community Health in JNU, Purnamita Dasgupta of the Institute of Economic Growth of Delhi University and Ankush Agrawal of the Indian Institute of Technology, studied the steep decline in immunization coverage at the district level between the District Level Health Survey of 2002-04 and the 2007-08 round. Since then, there have been no surveys at the district level.
The authors chose nine states known for good governance in terms of performance in several socio-economic factors such as infrastructure availability, law and order, educational achievements and so on, but which had several districts reporting a decline. The states chosen were Punjab, Haryana, Andhra Pradesh, Tamil Nadu, Kerala, Gujarat, Karnataka, Maharashtra and Himachal Pradesh.
“We were puzzled by the very high percentage of districts in high performing states showing a decline. The EAG states (earlier BIMARU states) actually showed an increase in immunization coverage; few districts registering any decline. On closer examination we found that these were districts with many newly classified ‘urban areas’. The decline is likely to be greater in the peripheral and newly urbanising areas rather than the core, fully urbanized areas,” explained Rajib Dasgupta.
The authors found that the probability of decline reduced as the proportion of villages with a primary health centre increased. They also found that with an increase in the proportion of SC/ST population, the probability of decline reduced. They attributed this to special efforts made to reach these groups. Their study revealed that fast-paced urbanization was emerging as a ‘risk factor’; peri-urban areas and small towns with relatively poor health access offered a rational explanation to the phenomenon of decline in immunization coverage.
For example, in Tamil Nadu, all 265 new towns added to the total number of towns in the state between 2001 and 2011 were census towns. Census towns are characterized by three features — more than 5,000 population, a density of at least 400 people per sq km and at least three quarters of its male population engaged in non-agricultural pursuits. Similarly, in Kerala, all 362 new towns added to the total number of towns were census towns and in Karnataka 83 new towns added in the same period were census towns. In India, between 2001 and 2011, the census identified 2,530 census towns compared to just 242 new towns.
“In the context of health service provision in urban India, peri-urban areas are not covered since they fall outside the purview of municipalities, while small towns (with less than 50,000 population) are not covered within the newly -launched National Urban Health Mission. Yet, census data shows that 70% of towns in these nine states are small towns with less than 50,000 population (except in Andhra Pradesh) and are consequently left out of NUHM,” stated the article.
The authors noted that often these peri-urban areas were inhabited by migratory urban poor and characterized by vulnerability due to concentration of population and social diversity, which co-exists with rural traits of isolation and invisibility to policy makers.
No. of districts showing decline (total districts in brackets)
Andhra Pradesh 11 (23)
Gujarat 12 (25)
Haryana 13 (20)
Himachal 5 (12)
Karnataka 11 (27)
Kerala 6 (14)
Maharashtra 23(35)
Punjab 12 (20)
Tamil Nadu 26(30)