Out-of-Pocket Expenditure in Child Immunisation in India: Evidence from a Two-Part Model Analysis

Child immunisation is one of the most cost-effective public health interventions, yet households in India continue to bear out-of-pocket expenditure (OOPE) despite the availability of free vaccines under the Universal Immunisation Programme. This study examines the incidence and magnitude of OOPE for child immunisation across states, religions, social groups, wealth quintiles, and provider types using a two-part model framework. The first part estimates the probability of incurring any OOPE, while the second part analyses the conditional amount spent among households reporting expenditure. Results reveal stark urban–rural disparities, with urban households consistently spending more when costs are incurred. Wealth gradients are pronounced: richer households spend substantially more, particularly in urban areas, while poorer households often report negligible expenditures, potentially reflecting access barriers. Social and religious stratification further shapes expenditure patterns, with minorities and upper-caste households facing distinct burdens. The choice of provider emerges as the strongest determinant: households using private facilities are overwhelmingly more likely to incur OOPE and spend significantly more than those relying on government services. These findings underscore the need to strengthen public provision, reduce indirect costs, and embed equity monitoring into immunisation policy to achieve universal, financially sustainable coverage.