Date of Award

Fall 2023

Document Type

Open Access Dissertation


Health Services and Policy Management

First Advisor

Jan Ostermann


Despite the availability of effective vaccines, 1.5 million children under the age of 5 years die every year because of vaccine preventable diseases. Improvements in vaccine delivery infrastructure have resulted in relatively high coverage of vaccines, but many children are not receiving their vaccines on a timely basis. Timely administration of routine vaccines recommended by the Expanded Programme on Immunization (EPI) ensures maximum efficacy. It is vital to explore rates of vaccination timeliness and the correlates of timely vaccination among children to design targeted interventions for improving both coverage and timeliness. We conducted a secondary data analysis of the Demographic and Health Surveys from three South Asian Countries: Bangladesh, India and Pakistan. The study estimated the proportion of children receiving timely vaccination for different EPI vaccines and survival models to characterize correlates of timely vaccination among children below age 2 years. Almost one third of the children did not have vaccination documentation in Bangladesh and Pakistan. India had a higher documentation rate of 87%. For nearly all vaccine doses, the proportion of children receiving the vaccination in a timely manner was higher in Bangladesh than in India and Pakistan. In Pakistan, only 53% of children received the first dose of the Pentavalent vaccine within 28 days of the recommended age, compared to 72% in Bangladesh and 55% in India. Similar patterns were observed for all vaccine doses except for Bacille Calmette-Guerin (BCG). In all three countries, for multidose vaccines, the proportion of children receiving timely vaccination decreased for subsequent doses. Household wealth, media exposure, antenatal care, and facility-based delivery were consistently associated with greater vaccination timeliness across all three countries and all vaccine doses. The study also found some country-specific associations that may provide insights for targeted interventions to improve vaccination timeliness. These factors include rural versus urban residence in Bangladesh, maternal age, education, and family size in India, and maternal education and birth order in Pakistan. The study highlights the need for national immunization programs to provide vaccination documentation to all mothers and to include vaccination timeliness as a performance metric in addition to vaccination coverage in order to optimize vaccine efficacy and provide maximum protection against vaccine-preventable infections for children.


© 2024, Tanzir Ahmed Shuvo