The political economy of financing traditional vaccines and vitamin A supplements in six African countries.

Vaccines and vitamin A supplementation (VAS) are financed by donors in several countries, indicating that challenges remain with achieving sustainable government financing of these critical health commodities. This qualitative study aimed to explore political economy variables of actors' interests, roles, power and commitment to ensure government financing of vaccines and VAS. A total of 77 interviews were conducted in Burundi, Comoros, Ethiopia, Madagascar, Malawi and Zimbabwe. Governments and development partners had similar interests. Donor commitment to vaccines and VAS was sometimes dependent on the priorities and political situation of the donor country. Governments' commitment to financing vaccines was demonstrated through policy measures, such as enactment of immunization laws. Explicit government financial commitment to VAS was absent in all six countries. Some development partners were able to influence governments directly via allocation of health funding while others influenced indirectly through coordination, consolidation and networks. Government power was exercised through multiple systemic and individual processes, including hierarchy, bureaucracy in governance and budgetary process, proactiveness of Ministry of Health officials in engaging with Ministry of Finance, and control over resources. Enablers that were likely to increase government commitment to financing vaccines and VAS included emerging reforms, attention to the voice of citizens and improvements in the domestic economy that in turn increased government revenues. Barriers identified were political instability, health sector inefficiencies, overly complicated bureaucracy, frequent changes of health sector leadership and non-health competing needs. Country governments were aware of their role in financing vaccines, but only a few had made tangible efforts to increase government financing. Discussions on government financing of VAS were absent. Development partners continue to influence government health commodity financing decisions. The political economy environment and contextual factors work together to facilitate or impede domestic financing.

Evaluating equity dimensions of infant and child vitamin A supplementation programmes using Demographic and Health Surveys from 49 countries.

OBJECTIVES: Vitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage. METHODS: We used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment. RESULTS: Children who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries. CONCLUSION: VAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries.

Methodologies to measure the coverage of vitamin A supplementation: a systematic review.

Countries are increasingly transitioning from event-based vitamin A supplementation (VAS) distribution to delivery through routine health system contacts, shifting also to administrative, electronic-based monitoring tools, a process that brings certain limitations affecting the quality of administrative VAS coverage. At present, there is no standardised methodology for measuring the coverage of VAS delivered through routine health services. To address this gap, we conducted a systematic review of the literature to identify and recommend methods to measure VAS coverage, with the aim of providing guidance to countries on the collection of consistent data for planning, monitoring and evaluating VAS programmes integrated into routine health systems. We searched the PubMed®, Embase®, Scopus, Google Scholar and World Health Organization (WHO) Global Index Medicus databases for studies published from 1 January 2000 to 1 January 2021, reporting original data on VAS coverage and methodologies used for measurement. We screened 2371 original titles and abstracts, assessed twenty-seven full-text articles and ultimately included eighteen studies. All but two studies used a coverage cluster survey (CCS) design to measure VAS coverage, adapting the WHO Vaccination Coverage Cluster Surveys methodology, by modifying sample size and sampling parameters. Annual two-dose VAS coverage was reported from only four studies. Until electronic-based systems to collect and analyse VAS data are equipped to measure routine two-dose VAS coverage using administrative data, CCSs that comply with the 2018 WHO Vaccination Coverage Cluster Surveys Reference Manual represent the gold-standard method for effective VAS programme monitoring.

Consumption of Vitamin-A-Rich Foods and Vitamin A Supplementation for Children under Two Years Old in 51 Low- and Middle-Income Countries.

Vitamin A supplementation for children 6-59 months old is an important intervention that boosts immune function, especially where children do not consume enough vitamin-A-rich foods. However, the low coverage of vitamin A supplementation is a persistent problem in low- and middle-income countries. We first estimated the percentage of children 6-23 months old receiving the minimum dietary diversity, vitamin-A-rich foods, and vitamin A supplementation, and second, the difference in the percentage receiving vitamin A supplementation between children 6-23 months old and children 24-59 months old using nationally representative cross-sectional household surveys, namely, the Demographic and Health Surveys, conducted from 2010 to 2019 in 51 low- and middle-income countries. Overall, 22% (95% CI: 22, 23) of children received the minimum dietary diversity, 55% (95% CI: 54, 55) received vitamin-A-rich foods, 59% (95% CI: 58, 59) received vitamin A supplementation, and 78% (95% CI: 78, 79) received either vitamin-A-rich foods or supplementation. A wide variation across countries was observed; for example, the percentage of children that received either vitamin-A-rich foods or supplementation ranged from 53% (95% CI: 49, 57) in Guinea to 96% (95% CI: 95, 97) in Burundi. The coverage of vitamin A supplementation should be improved, especially for children 6-23 months old, in most countries, particularly where the consumption of vitamin-A-rich foods is inadequate.