India's vitamin A supplementation programme is reaching the most vulnerable districts but not all vulnerable children. New evidence from the seven states with the highest burden of mortality among under-5s.

OBJECTIVE: To characterize the coverage of India's national vitamin A supplementation (VAS) programme and document its performance in reaching children in the districts with higher concentration of poor households (2006-2011).

DESIGN: Analysis of VAS programme coverage data collated and collected using standardized bottom-up procedures, data from India's Office of the Registrar General and Census Commissioner, and data from India's District Level Household Survey to compute exposure (poverty) and outcome (full VAS coverage) variables.

SETTING: Seven Indian states with the highest burden of mortality in children (74 % of all deaths among under-5s in the country in 2006).

SUBJECTS: Children 6-59 months old.

RESULTS: Between 2006 and 2011, the mean full VAS coverage (two VAS doses per child per year) in these seven states increased from 44·7 % to 67·3 % while the number of districts with high (≥80 %) full VAS coverage increased from twenty-four (9·4 %) to 131 (51·4 %). The highest increases in full VAS coverage figures were recorded in the districts with the highest concentration of poor households. The estimated number of poor children (i.e. children living in households classified as poor) who did not receive two VAS doses annually decreased from 8·5 million in 2006 to 5·1 million in 2011 (40·3 % decrease); 2·5 million (49·1 %) of these children lived in the districts with the lowest proportion of poor households.

CONCLUSIONS: Despite significant improvements in VAS, a large number of Indian children are not benefitting yet from this life-protecting intervention, particularly among those who are potentially the most vulnerable. Future programme action needs to give priority to sub-district level units - blocks and villages - with higher concentrations of poor households.