Understanding Vaccine Hesitancy: Empirical Evidence from India

TL;DR

This paper investigates how India's historical forced sterilization policy has long-lasting negative effects on current vaccination rates and child mortality, revealing the enduring impact of past government policies on health behaviors.

Contribution

It provides empirical evidence linking historical sterilization campaigns to current low vaccination rates and higher child mortality in India using robust estimation methods.

Findings

Higher sterilization exposure correlates with lower vaccination completion.

Places with more sterilization have 60% higher child mortality.

Past policies have persistent adverse effects on health-seeking behavior.

Abstract

Why do vaccination rates remain low even in countries where long-established immunization programs exist and vaccines are provided for free? We study this paradox in the context of India, which contributes to the world's largest pool of under-vaccinated children and about one-third of all vaccine-preventable deaths globally. Combining historical records with survey datasets, we examine the Indian government's forced sterilization policy, a short-term aggressive family planning program implemented between 1976 and 1977. Using multiple estimation methods, including an instrumental variable (IV) and a geographic regression discontinuity design (RDD) approach, we document that the current vaccination completion rate is low in places where forced sterilization was high. We also explore the heterogeneous effects, mechanisms, and reasons for the mechanism. Finally, we examine the enduring consequence and present evidence that places more exposed to forced sterilization have an average 60 percent higher child mortality rate today. Together, these findings suggest that government policies implemented in the past can have persistent adverse impacts on demand for health-seeking behavior, even if the burden is exceedingly high.