Mobile conditional cash transfers to improve routine childhood immunization

Even though routine childhood immunization is a proven public health intervention, the past few years have seen a decline in the number of children getting vaccinated. Drawing on existing evidence that incentives can improve immunization take-up, researchers conducted a randomized evaluation to determine the optimal size and design of incentives for immunization in Pakistan. This evaluation found that small incentives in the form of mobile conditional cash transfers to caregivers increased full childhood immunization coverage. Based on these results, the Government of Sindh province scaled up an immunization incentive support program in seven districts in Sindh that reached over 480,000 children in its first year. 

The Problem

Millions of children are unvaccinated or under-vaccinated, and it is unclear which incentives are most effective and most scalable.
Immunizations are among the most impactful and cost-effective public health interventions, but coverage of childhood immunizations remains low in many low- and middle-income countries, especially in the wake of the Covid-19 pandemic.¹, ² In 2021, 25 million children worldwide were unvaccinated or under-vaccinated.³ Over 60 percent of these children lived in ten countries, including Pakistan.⁴ Full immunization coverage for basic vaccines for children aged 12 to 23 months in Pakistan was 66 percent in 2017-18.⁵

In 1978, the Government of Pakistan launched the Expanded Program on Immunization (EPI) to vaccinate children aged 0 to 23 months against eleven vaccine-preventable diseases over the course of six free vaccination visits.⁶ While this program has led to increased coverage since the early 1990s, diseases like polio and measles still persist. Many families, especially those in rural areas, slums, and other settings at high risk for communicable diseases, live far from vaccination sites and do not have financial resources to travel long distances.⁷ Efforts by the government and its partners to increase take-up have primarily focused on increasing vaccine supply and raising awareness of the importance of vaccines among caregivers. 

Take-up of vaccines early in a child’s life is high in Pakistan—indicating that the majority of households are not opposed to vaccines in principle— but it wanes after the first few visits. At the time of the study, 88 percent of children received the first vaccine in the schedule, compared to 67 percent for the last vaccine.⁸ This decline is typical of the countries where the majority of unvaccinated and under-vaccinated children live. Incentives may be an effective way to address financial barriers and this drop-off and increase immunization rates. 

Prior evidence has suggested that monetary (cash or cash equivalents such as mobile phone airtime) and non-monetary (food or household items) incentives can increase immunization take-up. A randomized evaluation in Udaipur, India, conducted by J-PAL affiliated researchers and coauthors, found that providing caregivers with a small bag of lentils increased full immunization rates more than six-fold relative to the comparison group, but logistical challenges made the program hard to scale. 

Another randomized evaluation tested a combination of SMS reminders and monetary incentives in Kenya and found positive impacts on immunization coverage and timeliness. A later study in Haryana, India tested different combinations of SMS reminders, word of mouth, and mobile credits to improve take-up. The most effective option combined SMS reminders, local immunization ambassadors selected by the community, and incentives that increased across the immunization schedule.

The Research

Small cash transfers delivered through a scalable and low-cost platform increased immunization take-up in Pakistan. 
IRD Global (IRD) is a global health delivery and research organization headquartered in Singapore with country affiliates in nine countries across Africa and Asia, including Pakistan, South Africa, Nigeria, Zimbabwe, the United Arab Emirates, Bangladesh, the Philippines, Vietnam, and Indonesia. In Pakistan, since 2004, IRD has delivered mobile conditional cash transfers (mCCTs) elsewhere in Sindh province, implemented a phone-based electronic immunization registry program with the government, and tested the effectiveness of silicone bracelets as vaccine reminders. To inform these efforts, IRD has conducted rigorous research on incentives. Its 2005 study in Karachi showed food and medicine vouchers were associated with a two-fold increase in timely immunization coverage, relative to a comparison group that did not receive a coupon. Additionally, from 2014 to 2015, IRD piloted lottery-based CCTs as a cost-effective alternative to scaling up a full incentive program, followed by a district-wide implementation of two alternate CCT schemes to increase childhood immunization uptake.

In 2017, the Government of Sindh sought out evidence on the optimal size, design, and structure of incentives to help inform future policy. This knowledge gap prompted IRD researchers Subhash Chandir, Danya Arif Siddiqi, Aamir Javed Khan, and Sara Abdullah to partner with J-PAL affiliated researchers Esther Duflo (Massachusetts Institute of Technology) and Rachel Glennerster (University of Chicago) to conduct a randomized evaluation of small incentives for immunization in Pakistan. 

The research team tested the impact of small mCCTs⁹ that varied by amount, payment schedule, certainty of payment, and payment method, as well as SMS reminders about immunization coverage and timeliness. For each of the six immunization visits completed, caregivers with a registered cell phone number received a small cash incentive delivered directly to their phone.

The evaluation took place in the province of Sindh, where full immunization coverage falls below the national average. Nearly 12,000 caregiver-child pairs were randomized into seven different groups. The five mCCT groups received SMS reminders about vaccine due dates as well as incentives that varied by payment amount (either PKR240 (US$2.40) per visit or PKR80 (US$0.80) per visit), payment schedule (flat versus increasing payments at each visit), and payment method (airtime or mobile money).¹⁰ Within each mCCT group, caregiver-child pairs were randomly assigned to guaranteed payments or lottery payments. A sixth group received only SMS reminders. The full random assignment is depicted in the figure below. 

Results showed that small mCCTs increased full immunization coverage at 12 months and up-to-date coverage at 18 months.¹¹ The researchers also found that the higher payment amount, the payment’s certainty, and the format of airtime payments increased full coverage, and whether the payments remained flat or increased over the course of the schedule did not have an impact. Although the higher payments had a slightly larger impact on full coverage than lower payments, researchers suggested that  smaller payments that reach more people may be a better option when implementing the program at scale, given the reality of limited budgets. 

For more information, see the full evaluation summary. 

From Research to Action

Based on the evidence and the long-standing partnership with IRD the Government of Sindh Health Department scaled up an incentive-based intervention to improve immunization coverage and timeliness. 
Evidence from the evaluation informed the decision to launch and scale up the Choti Khushi Incentive Support Program, a collaboration between IRD and the Government of Sindh Health Department, in January 2022. The design of the incentive was shaped by the evaluation findings: the program utilizes guaranteed incentives of PKR200 (US$1.26) per vaccine, delivered as mobile airtime payments, to improve immunization coverage, timeliness, and equity. IRD chose a flat payment schedule because the evaluation showed that a rising payment plan had no additional impact. 

Evidence from the evaluation also helped bring in funding from GiveWell, which since 2020 has included incentives for immunization as a top cause, to implement the mCCT program. The funding also provides assistance to maintain the Sindh Electronic Immunization Registry (SEIR), which the government was already operating at scale, over a four-year period from 2022 to 2025. 

As of the end of 2022, the program was operating in all seven high-risk districts¹² in Sindh province. Incentives are offered for all routine vaccines administered through the program. Caregivers who bring their children in for the government-provided vaccination receive incentives over the course of six visits. 

The program relies on the provincial government’s SEIR to track and monitor children’s immunization status and provision of incentives. In addition to the incentives tested in the evaluation, the program also uses SMS reminders, community engagement campaigns, and mass media directed at caregivers of unvaccinated or under-vaccinated children in order to raise awareness. IRD is supporting the government by training vaccinators and supervisors, rolling out the community engagement strategy, implementing the immunization registry and the mCCTs, and monitoring the program, among other activities. 

Although significant flooding in 2022 temporarily halted immunization provision, over the course of the year, a total of 487,599 children were enrolled in the Choti Khushi Program and 960,709 incentivized vaccines were administered to children across enrollment and follow-up visits. Following eligibility checks, caregivers successfully received an incentive in nearly 900,000 of these cases. During the flooding, vaccinators traveled to camps for internally displaced persons, bus stops, and other fixed sites to try to sustain vaccination rates. The scaled-up program, which is currently being evaluated, aims to reach approximately two million children over the next two years, adjusting as needed based on lessons learned from the first year. 

Parents play a vital role in making decisions about immunization of children and the Choti Khushi-Immunization Incentive Support program is a catalyst for nudging caregivers towards timely and complete immunization Our research over the last 15 years has shown that even small amount conditional cash transfers can effectively overcome barriers to vaccination like transport costs. These small yet critical cash transfers provide a form of social incentive to caregivers and promote behavioral change favoring immunizations. The Choti Khushi program is a vital step towards achieving the Immunization Agenda 2030, ensuring that no child in Sindh is left behind.

— Dr. Subhash Chandir, Program Director of the IRD Maternal and Child Health Program

References

Chandir, Subhash, Danya Arif Siddiqi, Sara Abdullah, Esther Duflo, Aamir Javed Khan, and Rachel Glennerster. "Small mobile conditional cash transfers (mCCTs) of different amounts, schedules and design to improve routine childhood immunization coverage and timeliness of children aged 0-23 months in Pakistan: An open label multi-arm randomized controlled trial." Eclinicalmedicine 50 (2022): 101500.