What the states show

THE latest edition of The Economist revealed unpublished data from a 2013-14 survey that was based on over 200,000 interviews, conducted in India by the UN agency for children, Unicef, and the Indian government. The Rapid Survey on Children (RSOC), a high-quality study, shows full immunisation rates for children by state (among other things) and makes clear that wealth is not correlated directly with better health outcomes. Most notably, the relatively prosperous state of Gujarat, which was above the national average for immunisation in 2002, has since fallen well below the national average. The report was due to be published in October last year. The data are embarrassing for the man who ruled Gujarat from 2001 to 2014, Narendra Modi, who is now the prime minister. Might this have something to do with the delay?

The survey shows that in national terms there has been stagnation in recent years so far as immunisation is concerned. Full immunisation means that children receive protection against measles, tuberculosis, polio, diphtheria and several other prevalent diseases. Across India the RSOC data found an overall immunisation rate of 65.2%, with 71.9% of children in urban areas covered but only 62.2% of rural ones. Boys and girls are immunised roughly equally (64.9% for males, 65.5% for females) suggesting no discrimination there. On the other hand, results for low-caste Indians who are categorised as “scheduled caste” (61.6%) and for Indians categorised as “scheduled tribes” (55.5%), suggest that society's more neglected members are still being left behind. Similarly, among those categorised as lowest-income only 50.5% were immunised, whereas the wealthiest group managed 80.7% coverage.

Such disparities are not entirely surprising. What is troubling, however, is that gains in overall immunisation coverage have stalled. A partial survey in 2009 showed 14m children were reached by vaccination campaigns. Nearly five years later the RSOC suggests only a tiny increase, to 15m children being covered. Considering India's overall population gained about 80m people in the same period, that is a poor outcome. India has a goal to get 90% of children immunised against preventable diseases by 2020, and to eradicate tuberculosis and measles by the same year. If its overall coverage has stalled at roughly 65% for the past half-decade, reaching that higher target looks all the more daunting. It is up to individual states, with help from the central government and international agencies, to improve their ability to get to hard-to-reach groups of people, such as poor migrant workers—for example those who labour at out-of-the-way brick kilns or those who relocate between planting and harvesting seasons.

Immunisation data within states are also revealing. For various reasons Gujarat's record deserves scrutiny. Mr Modi as prime minister has boasted about his state being a model for the rest of India to follow, which on matters of health and education looks troubling. In addition the state is among the wealthiest in India, with incomes of $2,065 per person in 2013; you would expect sufficient resources to be available to provide its residents with the most basic health care, such as immunisation. It also appears there is no specific cultural or historical reason for Gujarat to be backward, since it was well ahead of national averages at the turn of the 21st century. Its performance today is presumably the result of policies and government choices, and not any particularly problematic social, religious or cultural constraint peculiar to the state or its region.

The overall immunisation rate for Gujarat is 56.2%, according to RSOC, far below the national average and even behind states such as Bihar, Chhattisgarh and Jharkhand that are typically described as more backward. And it is rural Gujaratis who fare particularly badly, with just 53.6% covered. Even among urban residents the rate is low, at 59.9%. No result is given for scheduled castes in Gujarat, but among the scheduled tribes an estimate is provided of 44.3%. (By contrast a next-door state, Maharashtra, manages to immunise 66.2% of its tribal population.) In the Other Backward Classes (OBC) category, Gujarat’s coverage is 59.7%.

Compare the results from Kerala, which is another relatively prosperous state but one where governments have long laid much more emphasis on health, education and social concerns than in Gujarat. Kerala's overall immunisation rate is far higher, at 83%, approaching first-world standards. Its rural-urban split is negligible, with 82.1% in villages getting necessary jabs and 83.9% coverage in towns. For Kerala there is no estimate for scheduled tribes, but for its scheduled castes 77.1% coverage is reported. For OBCs the rate is 85.2%, vastly higher than for the same category in Gujarat.

What is especially striking is the evidence that vaccinations in Gujarat could be higher today if only there were resources and political will to make it happen. A recent campaign to tackle measles has shown success in India. National coverage for the first dose of measles vaccination has reached 78.8% of Indian children. Gujarat, to its credit, did even better, with 80.5% of its child population getting the first dose of measles vaccine. (Kerala did better yet, reaching 93.4% of its children with the measles jab.)

One puzzle, therefore, is how Gujarat manages to reach four-in-five of its children for the measles jab, but barely more than half of its children for the full immunisation course. Part of the answer is that full immunisation is more complicated to do and involves getting jabs at different times. Another part of the answer could be that the health institutions, clinics and nurses who provide regular check-ups and care are less efficient and capable in Gujarat than in many other states. Short campaigns to roll out one-off vaccinations are one thing, but sustained investment in health is required to achieve long-term improvements in full immunisation. In Gujarat this apparently has not happened. That, in turn, raises questions about the leadership and attention Mr Modi is likely to offer on health issues as prime minister. The results from Gujarat are not encouraging.