Predictors of ‘Out-of-Pocket Expenditure’ on Routine Immunization of Under-Five Children: A Regression Analysis

Introduction: ‘Out-of-pocket expenditure’ (OOPE) is the expenditures at the point of receiving health care directly by households which affects the economic stability of the household. When the expenditure on immunization of under-five children results in OOPE, it affects the motivation of parents for vaccination inversely. Aim: This study was planned to evaluate the out-of-pocket expenditure and to assess predictors of OOPE on routine immunization practices. Settings and design: This was a cross-sectional community-based study conducted from May to August 2019 at one of the immunization sites at primary health centers under a tertiary care institute of southern Rajasthan. Material and methods: At the selected health facility, randomly 75% of beneficiaries of routine immunization were enrolled for the study. Data were collected using a pre-designed, pre-tested semi-structured questionnaire about direct and indirect expenses during the process of immunization incurred by the parents of the vaccinee by interview technique. Results: In the study, 72.36% were infants, and 56.10% had first birth order. Mother accompanied nearly half of the vaccinee (49.6%) to the vaccination centre and the most used mode of transportation was the personal vehicle (63%). Mean loss of wages among parents/caretakers was 0.58 (±0.66) USD (median = 0.69; interquartile range (IQR) = 0.69; 95% confidence interval (CI) = 0.42-0.73) while average cost of transportation worn was 0.16 (±0.20) USD (median = 0.07; IQR = 0.21; 95% CI = 0.12-0.19) and mean duration of travelling to reach health facility was 11.87 (±7.53) minutes (median = 10; IQR = 10; 95% CI = 10.53-13.20). Vaccination at the centre was free of cost (zero USD) and no cost was incurred for drugs or registration. Average OPPE was 0.74 (±0.97) USD (median = 0.35; IQR = 0.62; 95% CI = 0.56-0.91) and regression analysis predicted significant contributors as age of vaccinee (p = 0.00; OR = 0.11; 95% CI = 0.04-0.34), religion (p = 0.04; OR = 0.34; 95% CI = 0.12-0.97) area of residence (p = 0.00; OR = 6.77; 95% CI = 2.37-19.32), birth order of vaccinee (p = 0.02; OR = 0.3; 95% CI = 0.11-0.85), longer waiting time (p = 0.03; OR = 0.16; 95% CI = 0.03-0.85), travelling time (p = 0.00; OR = 3.47; 95% CI = 1.49-8.09) and long distances (p = 0.00; OR = 10.40; 95% CI = 2.56-42.03) travelled to reach vaccination centre. Conclusion: The hidden cost of vaccination in the form of loss of wages and time, travel cost due to stretched distance traveled by family members to accompany vaccinee to immunization facility is experienced as OOPE by the families and could be one of the impediments in vaccination coverage. Amendments in the existing policies are required to reduce this invisible cost of vaccination.