Health impact and cost-effectiveness of expanding routine immunization coverage in India through Intensified Mission Indradhanush

Background: Many children do not receive a full schedule of childhood vaccines, yet there is limited evidence on the cost-effectiveness of strategies for improving vaccination coverage. We evaluated the cost-effectiveness of periodic intensification of routine immunization (PIRI), a widely applied strategy for increasing vaccination coverage. Methods: Intensified Mission Indradhanush (IMI) was a large-scale PIRI intervention implemented in India in 2017-2018. In 40 sampled districts, we measured the incremental economic cost of IMI using primary data, and used a quasi-experimental impact evaluation to estimate incremental vaccination doses delivered. We estimated deaths and disability-adjusted life years (DALYs) averted using the Lives Saved Tool and reported cost-effectiveness from government provider and societal perspectives. Findings: In sampled districts, IMI had an estimated incremental cost of 2021US$15.7 (95$7.14 per dose ($3.20 to dominated),$95.24 per zero-dose child reached ($45.48 to dominated),$375.98 ($168.54 to dominated) per DALY averted,$413.96 ($185.56 to dominated) per life-year saved, and$11,133 ($4,990 to dominated) per under-five death averted. At a cost-effectiveness threshold of 1x per-capita GDP per DALY averted, IMI was estimated to be cost-effective with 89% probability. Interpretation: This evidence suggests IMI was both impactful and cost-effective for improving vaccination coverage. As vaccination programs expand coverage, unit costs may increase due to the higher costs of reaching currently unvaccinated children. Funding: Bill & Melinda Gates Foundation