Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality. METHODS AND FINDINGS: Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population. CONCLUSIONS: Declines in healthcare utilization during the COVID-19 pandemic amplified the pandemic's harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

Institutionalizing quality within national health systems: key ingredients for success.

Quality improvement initiatives can be fragmented and short-term, leading to missed opportunities to improve quality in a systemic and sustainable manner. An overarching national policy or strategy on quality, informed by frontline implementation, can provide direction for quality initiatives across all levels of the health system. This can strengthen service delivery along with strong leadership, resources, and infrastructure as essential building blocks for the health system. This article draws on the proceedings of an ISQua conference exploring factors for institutionalizing quality of care within national systems. Active learning, inclusive of peer-to-peer learning and exchange, mentoring and coaching, emerged as a critical success factor to creating a culture of quality. When coupled by reinforcing elements like strong partnerships and coordination across multiple levels, engagement at all health system levels and strong political commitment, this culture can be cascaded to all levels requiring policy, leadership, and the capabilities for delivering quality healthcare.

An equity dashboard to monitor vaccination coverage.

Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementing The2030 agenda for sustainable development. For its new phase of operations, Gavi reassessed its approach to monitoring equity in vaccination coverage. To help inform this effort, we made a systematic analysis of inequalities in vaccination coverage across 45 Gavi-supported countries and compared results from different measurement approaches. Based on our findings, we formulated recommendations for Gavi's equity monitoring approach. The approach involved defining the vulnerable populations, choosing appropriate measures to quantify inequalities, and defining equity benchmarks that reflect the ambitions of the sustainable development agenda. In this article, we explain the rationale for the recommendations and for the development of an improved equity monitoring tool. Gavi's previous approach to measuring equity was the difference in vaccination coverage between a country's richest and poorest wealth quintiles. In addition to the wealth index, we recommend monitoring other dimensions of vulnerability (maternal education, place of residence, child sex and the multidimensional poverty index). For dimensions with multiple subgroups, measures of inequality that consider information on all subgroups should be used. We also recommend that both absolute and relative measures of inequality be tracked over time. Finally, we propose that equity benchmarks target complete elimination of inequalities. To facilitate equity monitoring, we recommend the use of a data display tool - the equity dashboard - to support decision-making in the sustainable development period. We highlight its key advantages using data from Côte d'Ivoire and Haiti.

Le suivi de l'équité est une priorité pour Gavi, l'Alliance du Vaccin et pour ceux qui mettent en œuvre le Programme de développement durable à l'horizon 2030. Dans le cadre de sa nouvelle phase d'opérations, Gavi a repensé son approche relative au suivi de l'équité en matière de couverture vaccinale. Afin de contribuer à cet effort, nous avons réalisé une analyse systématique des inégalités en matière de couverture vaccinale dans 45 pays soutenus par Gavi et comparé les résultats obtenus à partir de différentes méthodes de mesure. Nous nous sommes appuyés sur nos conclusions pour formuler des recommandations concernant l'approche adoptée par Gavi pour suivre l'équité. Cette approche impliquait de définir les populations vulnérables, de choisir des mesures appropriées pour quantifier les inégalités et d'établir des critères en matière d'équité qui reflètent les ambitions du programme de développement durable. Dans le présent article, nous expliquons la raison d'être de nos recommandations et le but de l'élaboration d'un meilleur outil de suivi de l'équité. L'approche précédemment utilisée par Gavi pour mesurer l'équité consistait à calculer la différence en matière de couverture vaccinale entre les quintiles de richesse les plus élevés et les plus bas d'un pays. Nous recommandons de suivre des dimensions de la vulnérabilité (éducation maternelle, lieu de résidence, sexe des enfants et indice de pauvreté multidimensionnelle) autres que l'indice de richesse. Lorsqu'une dimension inclut divers sous-groupes, il convient d'utiliser des mesures de l'inégalité prenant en compte les informations relatives à tous les sous-groupes. Nous conseillons également de suivre les mesures absolues mais aussi relatives d'inégalité au fil du temps. Enfin, nous suggérons que les critères en matière d'équité visent l'élimination complète des inégalités. Afin de faciliter le suivi de l'équité, nous recommandons l'utilisation d'un outil d'affichage de données ­ le tableau de bord de l'équité ­ pour favoriser la prise de décision dans le cadre du programme de développement durable. Nous mettons en avant les principaux avantages de cet outil à l'aide de données provenant de Côte d'Ivoire et d'Haïti.

La supervisión de la equidad es una prioridad para la Gavi, la Vaccine Alliance y para los que implementan la Agenda 2030 para el Desarrollo Sostenible. Para su nueva fase de operaciones, la Gavi reevaluó su enfoque para supervisar la equidad en la cobertura de vacunación. Para ayudar a informar este esfuerzo, se realizó un análisis sistemático de desigualdades en la cobertura de vacunación en 45 países apoyados por la Gavi y se compararon los resultados desde distintos enfoques de medición. En base a los resultados, se formularon recomendaciones para el enfoque de supervisión de equidad de la Gavi. El enfoque implicó la definición de las poblaciones vulnerables, la selección de las medidas adecuadas para cuantificar las desigualdades y la definición de las referencias de equidad que reflejan las ambiciones de la agencia de desarrollo sostenible. En este artículo, se explican los motivos de las recomendaciones y el desarrollo de una herramienta mejorada de supervisión de la equidad. El anterior enfoque de la Gavi para la medición de la equidad era la diferencia de la cobertura de vacunación entre los sectores demográficos más ricos y más pobres de un país. Además del índice patrimonial, se recomienda supervisar otras dimensiones de vulnerabilidad (educación de la madre, lugar de residencia, sexo de los niños y el índice de pobreza multidimensional). Para las dimensiones con múltiples subgrupos, deberían utilizarse medidas de desigualdad que tienen en cuenta información acerca de todos los subgrupos. También se recomienda que, con el paso del tiempo, se haga un seguimiento tanto de la medida de desigualdad absoluta como relativa. Por último, se propone que las referencias de equidad tengan como objetivo la eliminación completa de la desigualdad. Para facilitar la supervisión de la equidad, se recomienda utilizar una herramienta de indicación de datos (el tablero de equidad) para apoyar la toma de decisiones durante el periodo de desarrollo sostenible. Se destacan sus ventajas básicas utilizando datos de Côte d'Ivoire y de Haití.

Estimated economic impact of vaccinations in 73 low- and middle-income countries, 2001-2020.

OBJECTIVE: To estimate the economic impact likely to be achieved by efforts to vaccinate against 10 vaccine-preventable diseases between 2001 and 2020 in 73 low- and middle-income countries largely supported by Gavi, the Vaccine Alliance. METHODS: We used health impact models to estimate the economic impact of achieving forecasted coverages for vaccination against Haemophilus influenzae type b, hepatitis B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, rotavirus, rubella, Streptococcus pneumoniae and yellow fever. In comparison with no vaccination, we modelled the costs - expressed in 2010 United States dollars (US$) - of averted treatment, transportation costs, productivity losses of caregivers and productivity losses due to disability and death. We used the value-of-a-life-year method to estimate the broader economic and social value of living longer, in better health, as a result of immunization. FINDINGS: We estimated that, in the 73 countries, vaccinations given between 2001 and 2020 will avert over 20 million deaths and save US$ 350 billion in cost of illness. The deaths and disability prevented by vaccinations given during the two decades will result in estimated lifelong productivity gains totalling US$ 330 billion and US$ 9 billion, respectively. Over the lifetimes of the vaccinated cohorts, the same vaccinations will save an estimated US$ 5 billion in treatment costs. The broader economic and social value of these vaccinations is estimated at US$ 820 billion. CONCLUSION: By preventing significant costs and potentially increasing economic productivity among some of the world's poorest countries, the impact of immunization goes well beyond health.

The effects of user fees on quality and utilization of primary health-care services in Afghanistan: a quasi-experimental health financing pilot study in a post-conflict setting.

BACKGROUND: After the fall of the Taliban regime, most clinics in Afghanistan were charging fees to patients. The government invested in monitoring and evaluation systems for its newly rebuilt primary care system, but little was known about the effects of user fees. This study was undertaken to provide evidence on user fees' effects on quality and service utilization and to help inform development of health financing policy and strategy. METHODS: A quasi-experimental health financing pilot study was implemented in 2005. Forty-seven facilities were randomized to implement a standardized user fee intervention, offer free services, or serve as controls, continuing current cost-sharing systems. Revenues were co-managed by staff and community leaders for facility improvement. Baseline and follow-up facility assessments, exit interviews, and household surveys, as well as routine data were used to evaluate user fee effects over 2 years. RESULTS: Observed and perceived quality improved at most facilities but did not differ by study group. Utilization increased in all groups, but the increase was 682 to 748 visits per month larger in facilities randomized to free services compared with those randomized to fees or controls (p < 0.01). CONCLUSION: User fees demonstrated few beneficial effects and slowed the rate of increase of service utilization in Afghanistan. In 2008, the government abolished primary care fees, citing results of this study.

What made primary health care resilient against COVID-19? A mixed-methods positive deviance study in Nigeria.

INTRODUCTION: The SARS-CoV-2 (COVID-19) pandemic overwhelmed some primary health care (PHC) systems, while others adapted and recovered. In Nigeria, large, within-state variations existed in the ability to maintain PHC service volumes. Identifying characteristics of high-performing local government areas (LGAs) can improve understanding of subnational health systems resilience. METHODS: Employing a sequential explanatory mixed-methods design, we quantitatively identified 'positive deviant' LGAs based on their speed of recovery of outpatient and antenatal care services to prepandemic levels using service volume data from Nigeria's health management information system and matched them to comparators with similar baseline characteristics and slower recoveries. 70 semistructured interviews were conducted with LGA officials, facility officers and community leaders in sampled LGAs to analyse comparisons based on Kruk's resilience framework. RESULTS: A total of 57 LGAs were identified as positive deviants out of 490 eligible LGAs that experienced a temporary decrease in PHC-level outpatient and antenatal care service volumes. Positive deviants had an average of 8.6% higher outpatient service volume than expected, and comparators had 27.1% lower outpatient volume than expected after the initial disruption to services. Informants in 12 positive deviants described health systems that were more integrated, aware and self-regulating than comparator LGAs. Positive deviants were more likely to employ demand-side adaptations, whereas comparators primarily focused on supply-side adaptations. Barriers included long-standing financing and PHC workforce gaps. CONCLUSION: Sufficient flexible financing, adequate PHC staffing and local leadership enabled health systems to recover service volumes during COVID-19. Resilient PHC requires simultaneous attention to bottom-up and top-down capabilities connected by strong leadership.

Vaccine hesitancy among healthcare workers in low- and middle-income countries during the COVID-19 pandemic: Results from facility surveys across six countries.

BACKGROUND: Vaccine hesitancy remains a critical barrier in mitigating the effects of the ongoing COVID-19 pandemic. The willingness of health care workers (HCWs) to be vaccinated, and, in turn, recommend the COVID-19 vaccine for their patient population is an important strategy. This study aims to understand the uptake of COVID-19 vaccines and the reasoning for vaccine hesitancy among facility-based health care workers (HCWs) in LMICs. METHODS: We conducted nationally representative phone-based rapid-cycle surveys across facilities in six LMICs to better understand COVID-19 vaccine hesitancy. We gathered data on vaccine uptake among facility managers, their perceptions of vaccine uptake and hesitancy among the HCWs operating in their facilities, and their perception of vaccine hesitancy among the patient population served by the facility. RESULTS: 1,148 unique public health facilities participated in the study, with vaccines being almost universally offered to facility-based respondents across five out of six countries. Among facility respondents who have been offered the vaccine, more than 9 in 10 survey respondents had already been vaccinated at the time of data collection. Vaccine uptake among other HCWs at the facility was similarly high. Over 90% of facilities in Bangladesh, Liberia, Malawi, and Nigeria reported that all or most staff had already received the COVID-19 vaccine when the survey was conducted. Concerns about side effects predominantly drive vaccine hesitancy in both HCWs and the patient population. CONCLUSION: Our findings indicate that the opportunity to get vaccinated in participating public facilities is almost universal. We find vaccine hesitancy among facility-based HCWs, as reported by respondents, to be very low. This suggests that a potentially effective effort to increase vaccine uptake equitably would be to channel promotional activities through health facilities and HCWs.However, reasons for hesitancy, even if limited, are far from uniform across countries, highlighting the need for audience-specific messaging.

Resilience of front-line facilities during COVID-19: evidence from cross-sectional rapid surveys in eight low- and middle-income countries.

Responsive primary health-care facilities are the foundation of resilient health systems, yet little is known about facility-level processes that contribute to the continuity of essential services during a crisis. This paper describes the aspects of primary health-care facility resilience to coronavirus disease 2019 (COVID-19) in eight countries. Rapid-cycle phone surveys were conducted with health facility managers in Bangladesh, Burkina Faso, Chad, Guatemala, Guinea, Liberia, Malawi and Nigeria between August 2020 and December 2021. Responses were mapped to a validated health facility resilience framework and coded as binary variables for whether a facility demonstrated capacity in eight areas: removing barriers to accessing services, infection control, workforce, surge capacity, financing, critical infrastructure, risk communications, and medical supplies and equipment. These self-reported capacities were summarized nationally and validated with the ministries of health. The analysis of service volume data determined the outcome: maintenance of essential health services. Of primary health-care facilities, 1,453 were surveyed. Facilities maintained between 84% and 97% of the expected outpatient services, except for Bangladesh, where 69% of the expected outpatient consultations were conducted between March 2020 and December 2021. For Burkina Faso, Chad, Guatemala, Guinea and Nigeria, critical infrastructure was the largest constraint in resilience capabilities (47%, 14%, 51%, 9% and 29% of facilities demonstrated capacity, respectively). Medical supplies and equipment were the largest constraints for Liberia and Malawi (15% and 48% of facilities demonstrating capacity, respectively). In Bangladesh, the largest constraint was workforce and staffing, where 44% of facilities experienced moderate to severe challenges with human resources during the pandemic. The largest constraints in facility resilience during COVID-19 were related to health systems building blocks. These challenges likely existed before the pandemic, suggesting the need for strategic investments and reforms in core capacities of comprehensive primary health-care systems to improve resilience to future shocks.

Vaccination Utilization and Subnational Inequities during the COVID-19 Pandemic: An Interrupted Time-Series Analysis of Administrative Data across 12 Low- and Middle-Income Countries.

BACKGROUND: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3. METHODS: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries. RESULTS: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI -1.2%, -9.8%) in Guinea and ~19% (95% CI -16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (-4%, 95% CI -1%, -7%), Ghana (-3%, 95% CI -1%, -5%), Haiti (-7%, 95% CI -1%, -12%), and Kenya (-3%, 95% CI -1%, -4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022. CONCLUSIONS: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.

New technology - demonstration of a vector velocity technique.

With conventional Doppler ultrasound it is not possible to estimate direction and velocity of blood flow, when the angle of insonation exceeds 60-70°. Transverse oscillation is an angle independent vector velocity technique which is now implemented on a conventional ultrasound scanner. In this paper a few of the possibilities with transverse oscillation are demonstrated.

Infant and under-five mortality in Afghanistan: current estimates and limitations.

OBJECTIVE: To examine historical estimates of infant and under-five mortality in Afghanistan, provide estimates for rural areas from current population-based data, and discuss the methodological challenges that undermine data quality and hinder retrospective estimations of mortality. METHODS: Indirect methods of estimation were used to calculate infant and under-five mortality from a household survey conducted in 2006. Sex-specific differences in underreporting of births and deaths were examined and sensitivity analyses were conducted to assess the effect of underreporting on infant and under-five mortality. FINDINGS: For 2004, rural unadjusted infant and under-five mortality rates were estimated to be 129 and 191 deaths per 1000 live births, respectively, with some evidence indicating underreporting of female deaths. If adjustment for underreporting is made (i.e. by assuming 50% of the unreported girls are dead), mortality estimates go up to 140 and 209, respectively. CONCLUSION: Commonly used estimates of infant and under-five mortality in Afghanistan are outdated; they do not reflect changes that have occurred in the past 15 years or recent intensive investments in health services development, such as the implementation of the Basic Package of Health Services. The sociocultural aspects of mortality and their effect on the reporting of births and deaths in Afghanistan need to be investigated further.

Water and hygiene interventions to reduce diarrhoea in rural Afghanistan: a randomized controlled study.

A randomized controlled trial of four interventions was conducted using tubewells (n=2,486), liquid sodium hypochlorite ('Clorin') distributed with an improved water vessel (n=2,305), hygiene promotion (n=1,877), and a combination of the three (n=2,040) to create an evidence-base for water policy in Afghanistan. A fifth group served as a control (n=2,377). Interventions were randomized across 32 villages in Wardak province. Outcomes were measured through two household surveys separated by one year and twice-weekly household surveillance conducted over 16 months. The households receiving all three interventions showed reduction in diarrhoea compared with the control group, through both longitudinal surveillance data (IRR [95% CI]=0.61 [0.47-0.81]) and cross-sectional survey data (AOR [95% CI]=0.53 [0.30-0.93]). This reduction was significant when all household members were included, but did not reach significance when only children under five were considered. These results suggest multi-barrier methods are necessary where there are many opportunities for water contamination. Surveillance data suggested a greater impact of interventions on reducing diarrhoeal diseases than data from the surveys. Higher economic status as measured through household assets was associated with lower rates of diarrhoea and greater intervention uptake, excepting Clorin. Use of soap was also associated with lower prevalence of diarrhoea.

Trends in the quality of health care for children aged less than 5 years in Afghanistan, 2004-2006.

OBJECTIVE: To study trends in the quality of the health care provided to children aged less than 5 years in Afghanistan between 2004 and 2006. In particular, to determine the effect on such quality of a basic package of health services (BPHS), including Integrated Management of Childhood Illness (IMCI), introduced in 2003. METHODS: In each year of the study, 500-600 health facilities providing the BPHS were selected by stratified random sampling in 29 provinces of Afghanistan. We observed consultations for children aged less than 5 years, interviewed their caretakers, interviewed health-care providers and measured adherence to case management standards for assessment and counselling in a random sample. FINDINGS: The quality of the assessment and counselling provided to sick children aged less than 5 years improved significantly between 2004 and 2006. A 43.4% increase in the assessment index and a 28.7% increase in the counselling index (P < 0.001) were noted. Assessment quality improved significantly every year and was statistically associated with certain characteristics of the provider (being a doctor, having a higher knowledge score, being trained in IMCI, being part of a "contracting-in" mechanism and providing a longer consultation time) and the child (being younger and having a female caretaker). Counselling quality was also significantly associated with these characteristics, except for provider cadre and child age. The presence of clinical guidelines and the frequency of supervision were significantly associated with improved quality scores in 2006 (P < 0.05 and < 0.01, respectively). CONCLUSION: Quality of care improved over the study period, but performance remained suboptimal in some areas. Continued investments in Afghanistan's health system capacity are needed.

Are monitoring and evaluation systems adequate to report the programmatic coverage of HIV services among key populations in countries?

There was no global guidance or agreement regarding when a country has an adequate system to report on the service packages among human immunodeficiency virus (HIV) key populations. This article describes an approach to categorizing the system in a country for reporting the service package among HIV key populations. The approach consists of four dimensions, namely the epidemiological significance, comprehensiveness of the service packages, geographic coverage of services, and adequacy of the monitoring system. The proposed categorization approach utilizes available information and can inform the improvement of the service delivery and monitoring systems among HIV key populations.

Determinants of skilled birth attendant utilization in Afghanistan: a cross-sectional study.

OBJECTIVES: We sought to identify characteristics associated with use of skilled birth attendants where health services exist in Afghanistan. METHODS: We conducted a cross-sectional study in all 33 provinces in 2004, yielding data from 617 health facilities and 9917 women who lived near the facilities and had given birth in the past 2 years. RESULTS: Only 13% of respondents had used skilled birth attendants. Women from the wealthiest quintile (vs the poorest quintile) had higher odds of use (odds ratio [OR] = 6.3; 95% confidence interval [CI] = 4.4, 8.9). Literacy was strongly associated with use (OR = 2.5; 95% CI = 2.0, 3.2), as was living less than 60 minutes from the facility (OR = 1.5; 95% CI = 1.1, 2.0) and residing near a facility with a female midwife or doctor (OR = 1.4; 95% CI = 1.1, 1.8). Women living near facilities that charged user fees (OR = 0.8; 95% CI = 0.6, 1.0) and that had male community health workers (OR = 0.6; 95% CI = 0.5, 0.9) had lower odds of use. CONCLUSIONS: In Afghanistan, the rate of use of safe delivery care must be improved. The financial barriers of poor and uneducated women should be reduced and culturally acceptable alternatives must be considered.

Monitoring equity in vaccination coverage: A systematic analysis of demographic and health surveys from 45 Gavi-supported countries.

OBJECTIVES: (1) To conduct a systematic analysis of inequalities in childhood vaccination coverage in Gavi-supported countries; (2) to comparatively assess alternative measurement approaches and how they may affect cross-country comparisons of the level of inequalities. METHODS: Using the most recent Demographic and Health Surveys (2005-2014) in 45 Gavi-supported countries, we measured inequalities in vaccination coverage across seven dimensions of social stratification and of vulnerability to poor health outcomes. We quantified inequalities using pairwise comparisons (risk differences and ratios) and whole spectrum measures (slope and relative indices of inequality). To contrast measurement approaches, we pooled the estimates using random-effects meta-analyses, ranked countries by the magnitude of inequality and compared agreement in country ranks. RESULTS: At the aggregate level, maternal education, multidimensional poverty, and wealth index poverty were the dimensions associated with the largest inequalities. In 36 out of 45 countries, inequalities were substantial, with a difference in coverage of 10 percentage points or more between the top and bottom of at least one of these social dimensions. Important inequalities by child sex, child malnutrition and urban/rural residence were also found in a smaller set of countries. The magnitude of inequality and ranking of countries differed across dimension and depending on the measure used. Pairwise comparisons could not be estimated in certain countries. The slope and relative indices of inequality were estimated in all countries and produced more stable country rankings, and should thus facilitate more reliable international comparisons. CONCLUSIONS: Inequalities in vaccination coverage persist in a large majority of Gavi-supported countries. Inequalities should be monitored across multiple dimensions of vulnerability. Using whole spectrum measures to quantify inequality across multiple ordered social groups has important advantages. We illustrate these findings using an equity dashboard designed to support decision-making in the Sustainable Development Goals period.

Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries.

BACKGROUND: Important inequalities in childhood vaccination coverage persist between countries and population groups. Understanding why some countries achieve higher and more equitable levels of coverage is crucial to redress these inequalities. In this study, we explored the country-level determinants of (1) coverage of the third dose of diphtheria-tetanus-pertussis- (DTP3) containing vaccine and (2) within-country inequalities in DTP3 coverage in 45 countries supported by Gavi, the Vaccine Alliance. METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted between 2005 and 2014. We measured national DTP3 coverage and the slope index of inequality in DTP3 coverage with respect to household wealth, maternal education, and multidimensional poverty. We collated data on country health systems, health financing, governance and geographic and sociocultural contexts from published sources. We used meta-regressions to assess the relationship between these country-level factors and variations in DTP3 coverage and inequalities. To validate our findings, we repeated these analyses for coverage with measles-containing vaccine (MCV). RESULTS: We found considerable heterogeneity in DTP3 coverage and in the magnitude of inequalities across countries. Results for MCV were consistent with those from DTP3. Political stability, gender equality and smaller land surface were important predictors of higher and more equitable levels of DTP3 coverage. Inequalities in DTP3 coverage were also lower in countries receiving more external resources for health, with lower rates of out-of-pocket spending and with higher national coverage. Greater government spending on heath and lower linguistic fractionalization were also consistent with better vaccination outcomes. CONCLUSION: Improving vaccination coverage and reducing inequalities requires that policies and programs address critical social determinants of health including geographic and social exclusion, gender inequality and the availability of financial protection for health. Further research should investigate the mechanisms contributing to these associations.

State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys.

BACKGROUND: Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries. METHODS: We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as difference and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries-ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Significance was determined using 95% CIs. FINDINGS: National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a difference of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the difference between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in five high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda. INTERPRETATION: Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations. FUNDING: None.