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Contents Introduction

Considering the current state of the coronavirus disease 2019 (COVID-19) pandemic, the importance of universal vaccination is widely recognized. As vaccines are generally administered for infectious and communicable diseases, there is a greater need to improve vaccination uptake worldwide to achieve the level of herd immunity and limit the spread of diseases. Despite these facts, millions of individuals, including children, are reluctant to get vaccinated. Why does such a paradoxical situation exist?

In this paper, we study this puzzle considering India as a case study—which contributes to the largest pool of under-vaccinated children in the world and about one-third of all vaccinepreventable deaths globally. We present evidence 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. We examine the Indian government’s forced sterilization policy implemented in 1976–77 and document that the current vaccination completion rate is low in places where forced sterilization was high. As a consequence, we also present evidence that states more exposed to forced sterilization have higher child mortality today.

As the potential for transmission of infectious diseases will increase as countries globalize, our results have implications for policymakers and practitioners to understand the factors affecting the lower vaccination puzzle to carve out a pragmatic policy and maximize the uptake of current and future vaccines.