Preference and the reasons for utilization of private sector vaccination services of under-five children from high-income neighborhoods

INTRODUCTION

Immunization is the most cost-effective public health measure and significantly reduces childhood morbidity and mortality.^[1,2] Committed to achieving 100% immunization coverage, the Government of India provides vaccines free of cost and delivers them close to the community through the Universal Immunization Program (UIP) and Mission Indradhanush. In India, the public sector offers 90% of vaccination services. However, it was observed that working parents prefer private health facilities for vaccination.^[3] Even though private providers are more responsive to patient demand, there is hardly any data on the quality of the preventive services, especially for vaccines, as they require proper handling, storage, and cold chain maintenance.^[4]

A nationwide analysis in India on the sale of vaccines in the private sector showed that the per-capita income, urbanization, and percentage of births in private health facilities have a statistically significant association with private-sector shares of the UIP vaccines.^[5] Nearly one-fifth of the parents in the study preferred to vaccinate their children at private centers due to the convenience of location and time. They also found that more educated parents take their children to private centers, especially the boy child.^[2,6] The private sector’s contribution to childhood vaccinations ranges from 2.3% for diphtheria-pertussis-tetanus (DPT) to 7.6% for oral polio vaccines (OPVs).^[5]

As per the National Family Health Survey-5 (NFHS-5), the UIP vaccine coverage was comparable in the urban and rural areas; however, vaccination in private healthcare was 11.1% in urban areas and only 1.6% in rural areas.^[7] This is likely to be higher in the highest wealth quintile. A situational analysis of private sector utilization for vaccination services and the reasons for such utilization would guide strengthening the surveillance system, reporting adverse events following immunization, and private– public partnership. Our study aimed to determine the proportion of vaccination (vaccines under UIP and other optional vaccines) from private healthcare providers and to explore the reasons for opting for vaccination in private facilities for children from high-income neighborhoods of Urban Puducherry.

MATERIAL AND METHODS

RESULTS

We enrolled 480 children in our study and their age ranged from 1 year to 5 years. Of them, 55.2% were above 2 years of age. The age ranged from 1 year to 5 years. Majority of them belonged to socioeconomic status of upper middle class (54.2%) as per the Modified Kuppuswamy scale [Table 1].

Mean age of mother was 28.4 (standard deviation [SD] = 4.2) and father was 32.1 (SD = 4.9). Most of the mothers were unemployed, i.e., homemaker (73.1%) yet had completed graduation (49.4%). Most of the fathers were professionals (31.0%) and had completed graduation (56.9%) [Table 2]. Around 52% received antenatal care only from government facility. An 100% vaccination coverage was there for Bacillus Calmette–Guérin (BCG), Hepatitis B, OPV, Pentavalent, Measles-Rubella, Inactivated Polio Vaccine, and DPT vaccines.

We noted that 55% (95% confidence interval [CI] = 50.4– 59.5%) of children received all the vaccines from government sector and 27% (95% CI = 23.2–31.3%) received all the vaccines from private sector. Around 18% utilized both government and private sectors for the immunization services [Figure 1]. Among the vaccines under UIP, only birth dose in private sector and rest in government sector were 2 people. Nearly, 55.6% (95% CI = 51.1–60.1%) of the children received all the vaccines under the UIP from government sector. Around 26% (95% CI: 22.8–30.9%) received all their vaccines under the UIP from private sector only. Nearly, 36% (n = 173) under-five children received optional vaccines. Of the children who received optional vaccines, majority of them (72%) were immunized at the private sector. Among the optional vaccines, 37.4% children vaccinated against varicella, 32.4% against pneumococcal, 24.8% against hepatitis A, and 24.6% against typhoid. Among the vaccine under UIP, proportion utilizing private sector for vaccination varied from 31.7% for Penta 3 to 37.5% for Rota 2 [Supplementary Table 1].

Close

Figure 1:

Utilization pattern of the vaccination facility stratified by the children who received Universal Immunization Program (UIP) only and those who received both UIP and optional vaccines (n = 480). NIP: National immunization program

Export to PPT

Median cost during vaccination from private sector varies from Rs 1000 for BCG to 7000 for pneumococcal conjugate vaccine (PCV) [Supplementary Table 1]. The estimated median direct medical cost for a child of age 2–5 years (in completed years) for complete vaccination at private health delivery system excluding optional vaccines and Vitamin A was 23,650 INR. The median cost of optional vaccines was Rs. 7000 for pneumococcal, Rs. 3000 each for varicella, hepatitis A, and typhoid vaccines.

The reasons for seeking private facility for vaccination are summarized in Table 3 and Figure 2. The most common reason for seeking private facility was accessibility followed by availability, acceptability, and quality of vaccines. “Since, both of us are working, we can’t avail leave or permission for vaccination” said child’s mother. Another parent said “Also, we had to go to private clinic for all illness because of less waiting time including the vaccination.” Hence, the private sector has greater time accessibility. A few parents opted to go private because routine child check-ups by pediatrician were available along with vaccination services. Private sector is socially accessible as it was recommended by their family doctor and their peers. Parents who migrated preferred private sector as in government there are many administrative steps. A parent commented “I got vaccine previously in private place, after going to PHC to get vaccination, they asked me to continue in private.” A parent commented “too many vaccines are there, I am not sure what to put and what to leave, so in private they put all vaccines.” Therefore, parents who were worried or unsure about the vaccine schedule opted to go private because they felt that they would be better informed there. A parent also mentioned that “For first child I was afraid, nervous and confused and got all vaccines from private, for second child we took from Government.”

Close

Figure 2:

Treemap diagram of hierarchy chart of the reasons for preferring private sector for vaccination from the parent’s perspective (n = 217).

Export to PPT

The other common reason to avail private sector was availability of optional vaccines and parents wanted to get all vaccines (including UIP vaccines) at one place. A parent remarked “My child has poor health, so after getting vaccinated I can directly get free consultation from doctor.” Furthermore, a parent remarked “Child was born with assisted fertilisation, so thought why take a chance. So went to private.” Parents’ opinions on acceptability included that the medical staff in the private sector are gentle (social acceptability) and the facility is clean and less crowded (experiential acceptability). Some parents had the opinion that vaccines in private sector were pure and had fewer side effects.

DISCUSSION

Immunization is a multisectorial activity with public as well as private service delivery. This study was conducted in a high-income neighborhood, where majority of them belonged to upper middle class. The vaccination coverage was 100% for UIP vaccines. Around 45% children received at least one vaccination from private sector. All vaccines were received from private sector by 27% children. The reasons quoted by parents to avail services from private sector were accessibility followed by availability, acceptability, and quality of vaccines. The better time accessibility of the vaccination services in the private facility including services in the evenings and shorter waiting time made parents prefer private facility, especially employed parents.

The utilization of private sector for vaccination noticed in this study (45%) was higher than that reported from a secondary data analysis done in 2016 where the private sector’s contribution to childhood vaccinations ranged from 2.3% for DPT to 7.6% for OPV.^[5] Furthermore, data from NFHS-5 show that the proportion of children receiving vaccination from private sector is 11% in urban area.^[10] These indicate that the major role is played by the private sector in childhood vaccination. Furthermore, parents choose private healthcare facilities for vaccination if the out-of-pocket expenditure is affordable, so as to avoid the perceived high time cost in government facility due to lengthy waiting time and inflexible service delivery schedules.^[11] Working parents preferred clinics that were available in the evenings.^[6] Offering a flexible schedule for service delivery could be difficult and not immediately achievable. Hence, there is a need for private public partnership. However, there is a limited documentation of the private sectors’ contribution to immunization activity leading to lack of recognition.^[12] Similarly, there is a lack of studies exclusively on the quality of immunization services provided in the private sectors which would be useful for the monitoring activities and regulating the private sectors in immunization of children.^[13] In addition, a study from Gujarat, India, reported crucial gaps in the knowledge of immunization practices among healthcare providers in private sector. Hence, the partnership should focus on robust monitoring on the supply chain and logistics which is essential to maintain the potency and quality of the vaccine.^[14] Strategic engagement of private sector starting from planning to supervision and monitoring is needed.^[15] Focus on monitoring of infrastructure to deliver best practices in avoiding missed opportunities for vaccination, cold chain maintenance to provide a quality-assured immunization service with reporting on adverse effects following immunization is needed.^[12,16] Adoption of U-WIN for registration of beneficiaries details availing vaccination should include also services from the private facility which will support the continuous real-time monitoring of service provision.

In government sector, the vaccines and drugs are provided free of cost. However, there is hidden cost in the form of loss of wages and travel cost.^[17] Parents also feel that in private clinic, they receive additional free-of-cost benefits during vaccination such as complete information about optional vaccines, support to alleviate concerns on child health, and also checkup for their illnesses. Parents perceive that these services are not available in the public sector in spite of its availability under the UIP. Hence, it is imperative for healthcare worker to counsel the antenatal mother about the vaccination services and the array of additional services provided including counseling/health education services, regular monitoring of growth and development, and care for illness. In addition, parents need to be educated on the myths on poor quality of vaccine from public sector.

A qualitative study done in Vietnam found that word of mouth, relationship with the doctor, the staff ’s behavior, and attitude and service reputation/brand were reasons for choosing private over public health facility services. Comparably, our study also identified the following reasons for choosing private services, especially social accessibility (word of mouth comments by peers and family doctor), social acceptability (attitude of the healthcare provider), and perceived quality of vaccine (impact of service reputation/brand).^[18] A study done among adults in the same study setting also identified that availability of services and quality of care are the reasons for seeking private care facility.^[19] Analysis of national level data also noted that particularly for boy children, better-educated parents take the vaccination from private sector.^[6]

The current study provided a comprehensive understanding of health-seeking behavior with respect to vaccination among children born in high-income neighborhood by ascertaining the proportion of people availing vaccination services from private facility (quantitative outcome) and the reasons for the same. This information will help in strengthening the quality of delivery of vaccination services. One of the limitations of this study is that this was focused on high-income urban neighborhood and has limited generalizability to the rural areas or district or state level. The cost calculated for the out-of-pocket expenditure for the purchase of vaccine was from the interview and this cannot be validated as there was no monitoring on high prices variation. In areas where the immunization coverage is 100%, the next focus should be to improve the delivery of services by enhancing accessibility, availability, acceptability, and perceived quality of services at Government health facility. In addition, an effective private– public cooperation is required.

CONCLUSION

A considerable number of parents from high-income neighborhood availed vaccination services from private health facility. The common reasons for the preference of private sector were flexible timing for service delivery, availability of optional vaccines, shorter waiting period, recommendation by peers/family doctor, no administrative formalities, complete care at one spot, access to complete information on various vaccines, and perceived good quality of vaccine at private sector.