Strengthening Programs

By Ramanan Laxminarayan and Nirmal Kumar Ganguly

10.1377/hlthaff.2011.0405 HEALTH AFFAIRS 30, NO. 6 (2011): 10961103 2011 Project HOPE The People-to-People Health Foundation, Inc.

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Indias Vaccine Deficit: Why More Than Half Of Indian Children Are Not Fully Immunized, And What CanAnd ShouldBe Done
ABSTRACT Although India is a leading producer and exporter of vaccines, the country is home to one-third of the worlds unimmunized children. Fewer than 44 percent of Indias young children receive the full schedule of immunizations. Indias vaccine deficit has several causes: little investment by the government; a focus on polio eradication at the expense of other immunizations; and low demand as a consequence of a poorly educated population and the presence of anti-vaccine advocates. In this article we describe Indias vaccine deficit and recommend that the government move quickly to increase spending on, and otherwise strengthen, national immunization programs.

Ramanan Laxminarayan (ramanan@cddep.org) is vice president of policy and research at the Public Health Foundation of India; is a visiting scholar and lecturer at Princeton University; and director of the Center for Disease Dynamics, Economics, and Policy, in Washington, D.C., and New Delhi, India. Nirmal Kumar Ganguly is the Distinguished Biotechnology Fellow and Advisor at the Translational Health Science and Technology Institute, and is president of the Jawaharlal Institute of Post Graduate Medical Education and Research, in New Delhi, India.

ndia has experienced impressive improvements in its economic status and population health during the past two decades. However, it lags behind other countries of similar per capita gross domestic product in child survival. The mortality rate for children age five and younger currently stands at sixty-six per thousand live births, compared to thirty-four per thousand live births in the Philippinesa country with roughly the same per capita gross domestic product. Between 1990 and 2001, the probability of dying before age five fell more than twice as rapidly in Bangladesh and Indonesia as it did in India.1 Although child survival rates have improved since 2001,2 India will not achieve its own goal of reducing the number of infant deaths by half before 2012. And at the current rate of decline, it will not meet the goal that was set in the United Nations Millennium Declaration3 of cutting the mortality rate for children under age five by twothirds between 1990 and 2015. There are twenty-seven million new births in India each yearthe largest birth cohort in the world. However, fewer than 44 percent of these children receive the full schedule of immunizations (Exhibit 1).2 This level is only slightly better than it was in 1998, when the proportion was June 2011 30:6

42 percent (Exhibit 2). In contrast, in Bangladesh, on the northeast border of India, 82 percent of children are fully immunized by age two. In adjacent Nepal, 80 percent of children are fully immunized by age one. The 9.6 million unimmunized children in India today account for more than one-third of the 27 million unimmunized children around the world. Indias spending on routine immunizations remains low at US $113 million per year in 201011, down from $137 million in 200910. In 1978 the Indian government launched its Expanded Programme for Immunization. In 1985 the program was relaunched as the Universal Immunization Program, with the goal of extending six basic vaccines to all infants and the tetanus vaccine to pregnant women. The immunization schedule was changed to include measles, and the typhoid vaccine was dropped. In 2006 hepatitis B and Japanese encephalitis vaccines were introduced in selected parts of the country. The National Technical Advisory Group on Immunization, which was established by the Ministry of Health in 2002, is the primary technical advisory group on vaccines to the national government.4 Although the current immunization program targets twenty-seven million infants and preg-

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nant women every year and is one of the largest immunization programs in the world, immunization rates through the national program are uneven across twenty-eight states in India. The proportion of children under age five who are vaccinated exceeds 70 percent in only eleven states; it drops below 53 percent in eight states that are also the most populous.

Exhibit 1
Rates Of Vaccination And Burden Of Vaccine-Preventable Disease In India, 200408 Vaccination rate (%) (200506) 76 (55.3) 76 (55.3) 76 (55.3) 88.8 58.8 50 a a Deaths in India (200408) 2,000 13,000 86,000 0 81,275 37,000 122,000153,000 371,605 Cases reported by India (2008) 6,081 3,714 44,180 559 48,181 a a a

Disease Diphtheria (DPT1/DPT3) Tetanus (DPT1/DPT3) Pertussis (DPT1/DPT3) Poliomyelitis Measles Hepatitis B Rotavirus Pneumonia

Burden Of Vaccine-Preventable Disease

As shown in Exhibit 1, the burden of childhood infectious diseases is substantial in India. Rotavirus A recent estimate gave a range of 122,000153,000 for rotavirus-related deaths in India annually.5 There were an estimated 457,000884,000 rotavirus-related hospitalizations and two million outpatient visits necessitated by rotavirus infection for children under age five. Polio The great challenge in global eradication of polio has until recently been India, where transmission of the disease has persisted in the states of Uttar Pradesh and Bihar, despite high vaccination rates with multiple doses of vaccine. In addition to routine oral polio vaccine delivered through the immunization program, during 199596 the Pulse Polio Immunization program delivered supplementary doses of oral polio vaccine during what were termed National Immunization Days to cover all children under age three. The target age group was increased during 199697 to all children younger than age five. The National Rural Health Mission is a national program to increase public spending on rural health in states with weak health infrastructure, and the national polio program accounts for 14 percent of their funds compared with the 3 percent spent on routine immunizations.6 There has been a considerable decline in polio cases detected in India recently due to introduction of the so-called monovalent vaccine. This vaccine includes one antigen, or substance capable of producing an antibody or other immune response for type 1 poliovirus, which accounts for more than 95 percent of the cases in India. The monovalent vaccine builds immunity more rapidly than the so-called trivalent vaccine, which also has antigens against the other types of wild poliovirus that are not circulating currently in India. In 2004 there were 559 reported cases of polio, but from September 2010 to March 2011 only three cases were reported. In the first three months of 2011 there was just one case, in Howra district, near the city of Kolkata in West Bengal. However, even with these impressive declines, it is unlikely that the polio program

SOURCES Data for burden of deaths from diphtheria (DPT1/DPT3), poliomyelitis, and hepatitis B are from 2004 estimate of deaths in Southeast Asia: World Health Organization. The global burden of disease: 2004 update. Geneva: WHO; 2008. Data for burden of deaths from tetanus (DPT1/DPT3), pertussis, and measles are from the 2008 World Health Organization (WHO) estimate; see Note 7 in text. Vaccination rates calculated from National Family Health Survey, 200506. aNot available.

can be scaled back anytime soon unless global eradication is achieved. Pneumonia Pneumonia remains the leading killer of children in India; it accounted for 371,605 deaths in children under age five in 2008.7,8 However, assessing the burden of pneumococcal disease through routine surveillance remains a technical challenge in resourcepoor settings. Invasive disease surveillance, which focuses on cases of pneumonia, bacteremia, and meningitis, is useful in mapping the different strains of pneumococci, but the vast majority of infections are noninvasive and only cause middle-ear infections that are not reExhibit 2
Immunization Trends In Nine Indian States And The Country As A Whole, 19982006

SOURCES Note 2 in text. National Family Health Survey, India. Results of the National Family Health Survey 19981999. Mumbai: NFHS; 1999 [cited 2011 Apr 18]. Available from: http://hetv.org/india/ nfhs/index.html.

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ported. Data from randomized control trials of the pneumococcal conjugate vaccine suggest that roughly a third of severe pneumonia cases globally are caused by pneumococci. A global study that assessed the burden of pneumonia caused by a particular strain of bacteria, Streptococcus pneumoniae, estimated that pneumococcal infections were responsible for 142,000 deaths in India in 2000roughly a third of all pneumonia deaths in that countrywhich represents 17 percent of the global deaths from pneumococci;9 72,000 deaths were attributable to Haemophilus influenzae type b (Hib).8 India accounts for a fifth of the 370,000 deaths in children under age five caused by this virus worldwide. Although vaccines for this disease have been used extensively for at least twenty years and have eliminated the disease in both developing and developed countries, they are not distributed in India. Measles According to recent estimates, the 81,275 annual deaths from measles in India account for three-quarters of the global deaths from this disease. It is estimated that two-thirds of the children who die of measles and the other preventable childhood diseases would have survived if they had been immunized.10 Moreover, 94 percent of these deaths in India are concentrated in just ten states: Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Jharkhand, Assam, West Bengal, Andhra Pradesh, Orissa, and Gujarat. The overall rate of vaccination for measles in India among children remains low, at 66 percent. The National Technical Advisory Group on Immunizations advises a catch-up campaign for children ages 912 months in states with a vaccination rate below 80 percent, and a routine second dose in states with higher vaccination rates.

The unfortunate fact is that India spends woefully little on routine immunization.

Expanding Routine Immunization

In recent years there have been some successes in increasing rates of immunization in India. For example, programs that use community health workers have been shown to improve immunization rates overall in India to a greater extent than other interventions, although more evidence is needed to make the connection conclusive.11 The unfortunate fact, however, is that India spends woefully little on routine immunization. Only 2.1 percent of the national governments health budget is allocated to routine immunizationa small amount given the countrys large population and number of births.12 The additional cost per capita each year to reach 90 percent of Indian children with the six basic vaccines already included in the national 1098 Health Affairs June 2011 30:6

immunization programdiphtheria, tetanus, pertussis, tuberculosis, polio, and measles would be less than three rupees, or eight cents, in the poorest states and even less in the other states.3 Or equivalently, the vaccine cost per fully immunized child would be roughly eighty cents. In addition, there is a long list of other challenges to Indias immunization program. These include a shortage of trained personnel to manage the program at both the national and state levels; the need to undertake innovations in vaccines, disease surveillance, vaccine procurement, and effective vaccine management; the absence of good data on disease burden to inform vaccination priorities; the lack of baseline surveillance data for monitoring the effects of vaccination; and the absence of a system of routine reporting and surveillance. Challenges to improving coverage also lie on the demand sidethat is, the degree to which individuals do their part to be vaccinated. Poor education levels, which are consistently correlated with the likelihood that individuals will not complete vaccination schedules, pose a major barrier to expanding vaccination rates in rural areas.13 Adverse events following immunization, even when these are shown to be unrelated to a vaccine, have been widely reported in the Indian news media and have contributed to a culture hostile to vaccination in certain Indian communities.14 Better communication about the benefits of vaccines and the potential but typically harmless side effects, such as sore arms and low-grade fevers, could greatly boost confidence in vaccines and the immunization program. A related issue is the quality of the vaccines administered in India. Low-quality vaccine may explain the poor past performance of the Pulse Polio program, referenced above.15 Furthermore, most of the Universal Immunization Program vaccines procured for routine immunizations in India come from manufacturers that are not prequalified by the World Health Organization. Poor vaccine quality could lead to greater incidence of immunization-related adverse events and lower public trust in immunization programs.

More attention needs to be paid to the effect of vaccination campaigns on routine health system functions.

Incentives could help to improve vaccination rates if their sustainability could be ensured. A recent randomized controlled trial provided evidence of the effect of modest, nonfinancial incentives on vaccination rates in children ages 13. The trial found that villagers provided with lentils and metal plates, in exchange for completing their immunization schedules, had higher rates of vaccination (38.3 percent) than people in villages that used other approaches such as having reliable immunization camps, which are temporary immunization facilities set up to issue mass vaccinations to children (16.6 percent). By contrast, control villages with no interventions registered only a 6.2 percent vaccination rate.16 In addition to finding the best ways to boost vaccination rates, more attention needs to be paid to the effect of vaccination campaigns on routine health system functions. It has long been surmised that having intensive campaigns to immunize for one condition could lead to broader immunization access overall. However, a study of the effect of the polio campaign did not find evidence of synergy between the campaign and nonpolio routine immunization rates.17 In fact, there has been concern that emphasis on the polio program has detracted from routine immunization, rather than increasing it.

New Antigens
In many developing countries, the immunization schedule goes beyond the basic six vaccines. Newer or underused vaccines can protect against other diseases that pose a danger in India, including hepatitis B, a common cause of liver cancer; Hib; pneumococcus, a major cause of pneumonia; and rotavirus, which causes lifethreatening diarrheal disease. Countries with incomes lower than Indias have already begun to administer these vaccines.18 According to recent estimates, these vaccines could be added to Indias immunization program at an additional

cost of around twenty-one rupees or fifty cents per person nationally each year.3 In 2009 the National Technical Advisory Group on Immunization recommended using a pentavalent vaccinea combination of five vaccines in one injectionconsisting of diphtheria, tetanus, pertussis, hepatitis B, and Hib antigens. Subsequently, the GAVI Alliance authorized $165 million to help introduce a combination vaccine in ten states in India.19 Initially, there were concerns that the cost of the pentavalent vaccine would be covered for only two years, after which India would have to pay for the vaccine out of its own budget.20 The national government plans to roll out the pentavalent vaccine on a trial basis in 2011 in two states, Kerala and Tamil Nadu, which already have high rates of routine immunization.21 The rollout will help generate operational knowledge on the use of these new antigens, but the averted burden might not be indicative of potential in the rest of the country because Tamil Nadu and Kerala may have a lower rate of Hib infection than poorer states with weaker health care infrastructure and less access to antibiotics. A recent study estimated that a rotavirus vaccination program using a 50 percent effective vaccine at the GAVI Alliance price of fifteen cents a dose would prevent 44,000 deaths and $206 million in treatment costs each year.22 The estimated cost-effectiveness of vaccination was $21.41 per disability-adjusted life-year averted, or $662.94 per life saved. Even at a price of $14 per two-course dose, a universal rotavirus vaccination program would be cost-effective at $200 per disability-adjusted life-year averted. Although the rotavirus vaccine has been discussed by the technical advisory group, there has been no proposal to date to introduce this vaccine into Indias immunization program. The Indian government has been reluctant to pay for the newer vaccines, including the pneumococcal conjugate vaccine, demanding that they be supplied for about a quarter of their current price. However, Indias own pharmaceutical and biologics industry should be able to produce newer vaccines at international quality levels and competitive prices, although prices are unlikely to come down to those of vaccines used in routine immunization. Other priorities include implementation of a combination measles-rubella vaccine, targeted use of an inactivated polio vaccine, and possibly a pneumococcal and rotavirus vaccine.

Vaccine Manufacture In India

India is a leading producer and exporter of vaccines, including complex vaccines like the pentaJ u n e 201 1 30:6 Health Affairs 1099

Strengthening Programs
Exhibit 3
Domestic Production And Development Of New Vaccines In India, 200809 Company Hepatitis B Serum Institute of India Ltd., Pune Panacea Biotec, New Delhi Panacea Biotec, New Delhi Bharat Biotech Int. Ltd., Hyderabad HBI, Udhagamandalam, Hyderabad Shanta Biotechnic Pvt. Ltd., Hyderabad Haemophilus influenzae type b Bio-Med Pvt. Ltd., Ghaziabad Panacea Biotec, New Delhi Shanta Biotechnic Pvt. Ltd., Hyderabad Panacea Biotec, New Delhi Shanta Biotechnic Pvt. Ltd., Hyderabad Panacea Biotec, New Delhi Shanta Biotechnic Pvt. Ltd., Hyderabad Pneumococcal conjugate vaccine Serum Institute of India Ltd., Pune; Pancea Biotec, New Delhi Shanta Biotechnic Pvt. Ltd., Hyderabad Japanese encephalitis Shanta Biotechnic Pvt. Ltd., Hyderabad Biological E Ltd., Hyderabad Indian Immunologicals Ltd., Hyderabad Rotavirus Bharat Biotech Int. Ltd., Hyderabad Shanta Biotechnic Pvt. Ltd., Hyderabad Serum Institute of India Ltd., Pune a a a b b b 811 valent a a a a Preclinical development Research and development 2,000 Expected launch in 2012 Research and development Monovalent a a Tetravalent (DPT-Haemophilus influenzae type b ) a Pentavalent (DPT-hepatitis B-Haemophilus influenzae type b) a 40 150 b 4,500 3,000 1,000 b Presentation a Multidose Single dose a a a Installed capacity 1,000 540 120 1,000 200 2,000

SOURCE Central Bureau of Health Intelligence, MoHFW. National Health Profile (NHP) of India2009 [Internet]. New Delhi: The Bureau; 2009 [cited 2011 May 17]. Available from: http://cbhidghs.nic.in/writereaddata/linkimages/11%20Health%20Infrastructure8356493923.pdf. NOTES DPT is diphtheria, pertussis, and tetanus. Installed capacity is expressed as quantity in hundred thousands of doses. aSpecifics of dosage are not available. bNot under production yet.

valent rotavirus vaccine. Although vaccines used in India are primarily provided through the government, a third of the population buys vaccines from the private market. There are thirteen major vaccine manufacturers in India, and the Indian vaccine market is about $260 million in annual sales.23 Roughly 43 percent of the global Universal Immunization Program vaccine supply (more than 70 percent in the case of single vaccine) comes from India. Exhibit 3 shows domestic production capacity for new vaccines.24 Public facilities for vaccine production date back to the days of British rule in India, when vaccines were needed to protect soldiers.23 The Universal Immunization Program had procured vaccines from both the public and the private sectors, but in January 2008, the Drugs Controller General (India), which is the national drug and vaccines regulatory authority similar to the US Food and Drug Administration, withdrew production licenses from all public-sector units for failure to comply with good manufacturing practices. There is an effort under way to restart 1100 Health Affairs J une 201 1 30: 6

vaccine production in the public sector by improving quality and compliance with these standards.

Conclusions
India currently stands poised to make sizable public investments in health and to take on the growing burden of noncommunicable diseases through the National Rural Health Mission. The government has announced that public spending on health will increase from 0.9 percent to 23 percent of gross domestic product. In this environment, reducing the high burden of vaccine-preventable diseases should be an immediate priority. Increasing allocation of resources to the countrys immunization program is an immediate solution and is well worth the cost. The challenge is in increasing allocations for routine immunization while not letting up on the polio eradication program. However, government revenues in India are growing rapidly and should be able to

The ultimate goal must be reducing Indias disturbingly high child mortality rate.

support this expanded commitment. Increasing the current allocation for routine immunization by $221 million per year could greatly improve vaccination rates. This figure is based on an estimated thirteen million children who remain unimmunized and a cost of seventeen dollars per fully immunized child, as well as increasing the technical staff in charge of the national immunization program from the current level of three. The increased spending on routine immunization would represent 3.6 percent of Indias health budget of roughly $6 billion in 2011, and half that proportion if India were to follow through on increasing overall public health spending to even 2 percent of gross domestic product. Moreover, India could improve delivery strategies for these vaccinesfor example, by offering a second opportunity for measles immunization, as recommended by the World Health Organization and UNICEF.25 The second-opportunity measles campaign, which would cost India less than two rupees (about five cents) per person per year, has helped many African countries much poorer than India reduce their measles deaths sharply in the past decade. With regard to vaccine manufacturing, the Indian government should invest in its public facilities to bring them up to the standards of good manufacturing practices, which are followed by international pharmaceutical and biotech firms
The authors are grateful to Sweta Adhikari, Yolisa Nalule, and Sanjukta Sen Gupta for technical and editorial assistance and useful comments. Any errors that remain are the responsibility of the authors.

to ensure that products meet specific requirements for identity, strength, quality, and purity. Given the great national interest in vaccines, achievement of such standards could go a long way toward allaying concerns that vaccination programs primarily drive private-sector profits rather than serving a public good. Adhering to the World Health Organization prequalification standards would enable more domestic manufacturers to find international markets. These standards, coupled with a more efficient procurement system that factors in the timelines of the vaccine manufacturing process, will greatly reduce the risk for vaccine manufacturers. The National Technical Advisory Group on Immunization described earlier should be strengthened in two ways. First, it is important that this body hold regular meetings and widely circulate its recommendations. Indias secretary of health currently chairs the group. Although this provides a connection to the government, maintaining the group as an independent expert body that offers advice to government could be a more valuable function. The time is right to roll out additional vaccines, such as Haemophilus influenzae type b, hepatitis B, and rotavirus, especially in states that have demonstrated high levels of routine immunization. The National Technical Advisory Group on Immunization has already recommended these antigens. It is also time to counter the anti-vaccine advocates who consider any expanded program a ploy by vaccine manufacturers to profit at the expense of the Indian public. Investments in disease surveillance could help evaluate the burden of disease that could be averted by adding new antigens in the immunization schedule. The ultimate goal, of course, must be reducing Indias disturbingly high child mortality rate. Redressing the vaccine deficit, through the steps outlined above, is an essential step along Indias road to development.

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NOTES
1 Lopez A. Annex 2a. In: The global burden of disease and risk factors. Washington (DC), New York (NY): World Bank and Oxford University Press; 2006. 2 National Family Health Survey. Child health. Chap. 9 in: Results of the National Family Health Survey 20052006. Mumbai: NFHS; 2006 [cited 2011 May 26]. Available from: http://hetv.org/india/nfhs/nfhs3/ NFHS-3-Chapter-09-Child-Health .pdf 3 Jha P, Laxminarayan R. Choosing health: an entitlement for all Indians. Toronto: Center for Global Health Research, University of Toronto; 2009. 4 John TJ. Indias National Technical Advisory Group on Immunisation. Vaccine. 2010;28(Suppl 1):A8890. 5 Tate JE, Chitambar S, Esposito DH, Sarkar R, Gladstone B, Ramani S, et al. Disease and economic burden of rotavirus diarrhoea in India. Vaccine. 2009;27(Suppl 5):F1824. 6 Deolalikar AB, Jamison DT, Jha P, Laxminarayan R. Financing health improvements in India. Health Aff (Millwood). 2008;27(4):97890. 7 Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010; 375(9730):196987. 8 Watt JP, Wolfson LJ, OBrien KL, Henkle E, Deloria-Knoll M, McCall N, et al. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: global estimates. Lancet. 2009;374(9693): 90311. 9 OBrien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, McCall N, et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet. 2009;374(9693): 893902. 10 Kumar R, Jha P, Bassani D, Dhingra N, Corsi D, Kaur N. Parental recall and the effect of basic immunisation on overall child mortality: a population-based study in Chandigarh, India. Toronto: University of Toronto; 2009. Patel AR, Nowalk MP. Expanding immunization coverage in rural India: a review of evidence for the role of community health workers. Vaccine. 2010;28(3):60413. Ministry of Health and Family Welfare. Routine immunization: releases to state H&FW society routine immunization for the financial year 201011 [Internet]. New Delhi: The Ministry; 2011 [cited 2011 May 17]. Available from: http://mohfw.nic .in/searchdetails.php?lang=1&lid= 376&skey=immunization Elliott C, Farmer K. Immunization status of children under 7 years in the Vikas Nagar area, North India. Child Care Health Dev. 2006;32(4): 41521. Adverse Drug Reaction centers that also deal with adverse events related to immunizations were set up by the Drugs Controller General of India and the Indian Council for Medical Research in the 1980s but were subsequently discontinued. These efforts have been renewed through the National Pharmacovigilance Program of India. Aylward RB, Maher C. Interrupting poliovirus transmissionnew solutions to an old problem. Biologicals. 2006;34(2):1339. Banerjee AV, Duflo E, Glennerster R, Kothari D. Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives. BMJ. 2010; 340:c2220. Bonu S, Rani M, Baker TD. The impact of the national polio immunization campaign on levels and equity in immunization coverage: evidence from rural North India. Soc Sci Med. 2003;57(10):180719. GAVI Alliance. Executive director/ CEO report to the GAVI Alliance and fund board meeting [Internet]. Geneva: GAVI; 2008 [cited 2011 May 6]. Available from: http://www .gavialliance.org/resources/1_CEO_ report_June_2008.pdf GAVI Alliance [Internet]. Geneva: GAVI. Press release, 18 million Indian children to receive life-saving five-in-one vaccine; 2009 Aug 11 [cited 2011 Apr 18]. Available from: http://www.gavialliance.org/ media_centre/press_releases/ 2009_08_11_india_pentavalent.php Vashishta VM. Introduction of Hib containing pentavalent vaccine in national immunization program of India: the concerns and the reality. Indian Pediatr. 2009;46(9):7812. Kounteya S. Gates offers govt $110 mn for 5-in-one shot rollout. Times of India. 2011 Mar 23. Esposito DH, Tate JE, Kang G, Parashar UD. Projected impact and cost-effectiveness of a rotavirus vaccination program in India, 2008. Clin Infect Dis. 2011;52(2):1717. Gogtay NJ, Dhingra MS, Yadav A, Chandwani H. Vaccine policy, regulations, and safety in India. Int J Risk Safety Med. 2009;21:2330. Central Bureau of Health Intelligence, Ministry of Health and Family Welfare. Health infrastructure. Chap. 6 in: National health profile (NHP) of India2009 [Internet]. New Delhi: The Ministry; 2009 [cited 2011 May 26]. Available from: http://cbhidghs.nic.in/writeread data/linkimages/11%20Health% 20Infrastructure8356493923.pdf World Health Organization, World Health Assembly. Reducing global measles mortality [Internet]. Geneva: WHO; 2003 [cited 2011 Apr 18]. [WHA Resolution 56.20]. Available from: https://extranet .who.int/aim_elearning/en/ measles/resources/pdf/WHA_ reducing_measles_mortality.pdf

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ABOUT THE AUTHORS: RAMANAN LAXMINARAYAN NIRMAL KUMAR GANGULY

to support better decision making in health policy. Laxminarayans research deals with the integration of epidemiological models of infectious diseases and drug resistance into the economic analysis of public health problems. He has served on a number of advisory committees at the World Health Organization, the US Centers for Disease Control and Prevention, and the Institute of Medicine. In 200304 he served on the National Academy of Sciences/ Institute of Medicine Committee on the Economics of Antimalarial Drugs. He subsequently helped create the Affordable Medicines Facility for Malaria, a novel financing mechanism for antimalarials. Laxminarayan earned his master of public health degree and his doctorate in economics from the University of Washington in Seattle.

&

Ramanan Laxminarayan is vice president of policy and research at the Public Health Foundation of India.

Ramanan Laxminarayan and Nirmal Kumar Ganguly provide Health Affairs readers with a disturbing review of vaccine coverage in Indiaa country with a third of the worlds unvaccinated children. Having such low coverage is inconsistent with a country that wants to put a man on the moon in ten years, says Laxminarayan. Expanding immunization rates as a key intervention to avert needless deaths of young children should be an urgent priority. Laxminarayan is vice president of policy and research at the Public Health Foundation of India, a public-private partnership designed to strengthen training, research, and policy development in public health. He is also a visiting scholar and lecturer at Princeton University. He is director of the Center for Disease Dynamics, Economics, and Policy, with headquarters in Washington and New Delhi. The center was founded with the objective of using research

Nirmal Kumar Ganguly is president of the Jawaharlal Institute of Post Graduate Medical Education and Research.

at the Translational Health Science and Technology Institute in New Delhi and president of the Jawaharlal Institute of Post Graduate Medical Education and Research. He is a fellow of the Imperial College Faculty of Medicine in London, the Royal College of Pathologists in London, the International Academy of Cardiovascular Sciences in Canada, the Third World Academy of Sciences in Italy, the International Medical Sciences Academy in New Delhi, the National Academy of Medical Sciences in New Delhi, the Indian National Science Academy in New Delhi, the National Academy of Science in Allahabad, and the Indian Academy of Sciences in Bangalore. In January 2008 Ganguly was honored with the prestigious Padma Bhushan award by the president of India for his work in medicine. Ganguly earned his bachelor of medicine, bachelor of surgery degree from the University of Calcutta; his doctor of medicine degree from the Post Graduate Institute of Medical Education and Research, Chandigarh; and honorary doctor of science degrees from Bundelkhand University, Jhansi; Chhatrapati Shahu Ji Maharaj University, Kanpur; and the University of Calcutta, Kolkata.

Ganguly is the Distinguished Biotechnology Fellow and Advisor

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