India's childhood immunization program reduced deaths while reshaping educational outcomes

Each year, approximately 700,000 children worldwide die from diseases that vaccines could have prevented, nearly all of them in low- and middle-income countries. New research from University of Notre Dame economist Santosh Kumar Gautam finds that India's national childhood immunization program helped address this persistent global health challenge, producing substantial reductions in child deaths.

The study, published in the Journal of Population Economics, also found that the immunization program had mixed long-term effects on educational attainment. While exposure to the program reduced primary school completion, it increased secondary school completion, suggesting that improvements in child survival can influence education through multiple pathways. Findings underscore the importance of coordinating health and education policies so that gains in child survival are matched by investments in schools and learning.

"Vaccines are one of the most cost-effective investments a country can make in improving child health and human capital," said Gautam, professor of development and global health economics at Notre Dame's Keough School of Global Affairs. "I wanted to understand not only how India's immunization program saved lives, but also how it affected educational trajectories and human capital development."

An experiment that reduced infant mortality

India launched its Universal Immunization Programme in 1985 and implemented it district by district, reaching full national coverage by 1990. Because some districts received the program years before others, and because only children under age 1 were eligible for the vaccines, Gautam was able to compare children born just before and just after the program arrived in their district.

Drawing on a national survey of nearly 900,000 children, Gautam found that the program reduced infant mortality by 0.4 percentage points and under-five mortality by 0.5 percentage points - substantial gains at a time when nearly 1 in 10 infants died before their first birthday.

Those mortality gains were concentrated among children in rural areas, from poor households and from historically disadvantaged caste groups. Children from wealthier, urban or higher-caste households saw little change, Gautam said. This may be because many already had access to vaccination before the program arrived.

Mixed educational outcomes

The study also found nuanced effects on educational attainment. While the immunization program reduced primary school completion, it increased secondary school completion among surviving children.

Gautam said the results may reflect who survived because of the program. Some children who benefited from vaccination may not have reached school age otherwise; and, as a group, they tended to have poorer underlying health. That change in the student population may have lowered average primary school completion rates.

Meanwhile, children who would have survived regardless but were healthier because of vaccination were more likely to complete secondary school. Strained school infrastructure may also have reinforced the pattern, Gautam said. A sudden increase in surviving children can crowd classrooms and stretch already limited resources, particularly in the early grades.

Designing health and education policy together

Ultimately, Gautam said, the research shows health and education investments work best when they are planned holistically rather than treated as unrelated priorities.

"This study illustrates how health and education planners can strengthen their coordination and produce better outcomes by working together," Gautam said. "In addition to focusing on saving lives, governments should design policies that follow children into the classroom."

The study also challenges the assumption that large public health campaigns in developing countries are inevitably undermined by weak implementation, Gautam said. Despite documented problems with medical absenteeism and service delivery in India's health system, the program still produced a measurable reduction in child deaths.

The research contributes to Gautam's broader work as an economist who studies how investments in early child and maternal health can reduce poverty and help people thrive. It is particularly relevant for resource-constrained settings, where smarter policy design is critical to improving outcomes amid limited funding.

"Effective immunization policy requires measuring not only who vaccines protect, but also how they shape broader human capital and support the best use of scarce public resources," Gautam said.

A development and global health economics expert at Notre Dame, Gautam is the director of doctoral studies for the Keough School's Ph.D. in Sustainable Development and directs the sustainable development major in the school's Master of Global Affairs program. He is an affiliate of Notre Dame's Eck Institute for Global Health and the Building Inclusive Growth (BIG) Lab (part of the Keough School's Pulte Institute for Global Development) and a faculty fellow at the Keough School's Kellogg Institute.

The study received open access funding from the University of Notre Dame's Hesburgh Libraries.