Sustainable financing for Immunization Agenda 2030.

Sustainable financing for immunization refers to the sufficient and predictable allocation and use of resources to support the achievement of immunization goals within the framework of overall health financing. The Immunization Agenda 2030 (IA2030) agenda spells out four important focus areas needed for sustainable financing: (1) ensuring sufficient and predictable resources, (2) making optimal use of resources, (3) aligning partnerships, and (4) supporting sustainable transitions from external assistance. This paper summarizes the evidence and proposes interventions under each area. While immunization is one of the best investments and justifies public financing, the COVID-19 pandemic has led to the worst economic recession since the Great Depression and threatens countries' ability to mobilize funding to ensure continuity and access to essential services, including immunization. Strategies for ensuring adequate resources differ by income group but include raising more revenues, reprioritizing the budget towards health, and ensuring that health resources favor Primary Health Care (PHC) and immunization. In low- and lower-middle income countries, support from Gavi, the Vaccine Alliance, which channels the largest amount of external financing, will remain important, but some lower-middle income countries will need to prepare for transition. Countries benefitting from the Global Polio Eradication Initiative (GPEI) are also experiencing a transition from GPEI financing to domestic and other external financing. This paper outlines ways in which countries can improve the use of domestic and external resources to better incentivize high-quality PHC and immunization services and align immunization programs with health sector reforms. While governments must lead, collective action from development partners, the private sector, and civil society is needed to promote health system financing systems that ensure that the world is better prepared for future outbreaks and pandemics, while reinforcing the IA2030 vision and making progress towards universal health coverage and the Sustainable Development Goals.

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance.

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is: (1) to identify problems associated with the quality of hysterectomy care accessed by members of SEWA, an Indian CBHI scheme; and (2) to discuss mechanisms that might be put in place by SEWA, and CBHI schemes more generally, to optimize quality of health care. Data on the structure and process of hysterectomy care were collected primarily through review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varies tremendously, from potentially dangerous to excellent. Seemingly dangerous aspects of structure include: operating theatres without separate hand-washing facilities or proper lighting; and the absence of qualified nursing staff. Dangerous aspects of process include: performing hysterectomy on demand; removing both ovaries without consulting or notifying the patient; and failing to send the excised organs for histopathology, even when symptoms and signs are suggestive of disease. Women pay substantial amounts of money even for care of poor, and potentially dangerous, quality. In order to improve the quality of hospital care accessed by its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate cases where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocation decisions; (3) select, and contract with, providers who provide a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better-quality care and contract directly with them.

Cost effectiveness and cost utility of preventing trachomatous visual impairment: lessons from 30 years of trachoma control in Burma.

AIMS/BACKGROUND: This paper reports on the findings of a cost and effectiveness study of the trachoma control programme (TCP) in Burma. The TCP began in 1964 employing non-surgical interventions (community education and mass treatment with topical antibiotics) and surgical correction of trichiasis. METHODS: Fixed and variable costs of the TCP are assessed over 30 years (1964-93) and apportioned to either surgical or non-surgical interventions. The change in the prevalence of trachoma blindness during this period is used to calculate cases of visual impairment prevented by the TCP. The years of life saved because of premature mortality averted and from living in a handicapped state are added to yield a single measure of utility called handicap adjusted life years (HALYs). RESULTS: The cost effectiveness of the TCP is $54 per case of visual impairment prevented: $193 and $47 for surgical and non-surgical interventions respectively. The cost utility of the TCP is $4 per HALY averted: $10 and $3 for surgical and non-surgical interventions respectively. Results are highly sensitive to the 1965 prevalence of blindness, the choice of discount rate, and the effectiveness of both interventions. CONCLUSIONS: Thirty years of trachoma control in Burma are associated with a remarkable decline in trachomatous blindness. Both surgical and non-surgical interventions are cost effective means of preventing trachomatous visual impairment. Discussion focuses on methodological limitations and implications for research and policy.

The global burden of trachomatous visual impairment: I. Assessing prevalence.

This paper summarizes primary epidemiologic studies of trachomatous blindness to develop age-/sex-/region-specific estimates of the global prevalence of trachomatous blindness and low vision. These studies are first examined for their validity and then employed to derive a 'minimum' prevalence of trachomatous visual impairment. This method yield a global total for 1990 of approximately 640,000 cases of trachomatous blindness, corresponding to a prevalence of 0.12/1,000 (lower and upper bounds, 0.10 to 0.14/1,000). When those with low vision due to trachoma are included, 1.5 million cases of visual impairment are estimated, corresponding to a prevalence of 0.28/1,000 (lower and upper bounds, 0.15 to 0.75/1,000). A second approach, labeled the 'projected' prevalence of trachomatous visual impairment, selects country-wide studies to derive representative regional prevalence values. A global total of 2,899,000 blind ("projected' prevalence of 0.55/1,000 with lower and upper bounds, 0.37 to 0.83/1,000) is estimated for 1990. With trachomatous low vision included, greater than 6.7 million individuals in 1990 have visual impairment from trachoma ("projected' prevalence of 1.28/1,000 with lower and upper bounds, 0.53 to 4.29/1,000). Analysis of the distribution of the global prevalence by age, gender, visual acuity and region provide direction for trachoma research and programme priorities. Attention is drawn to the limited studies and resulting wide variation in the estimates of trachomatous visual impairment prevalence as indicated by the lower and upper bound estimates. It is recommended that this epidemiologic uncertainty be reflected in global and regional estimates of trachomatous visual impairment prevalence in order to draw attention to how little is known and emphasize the need for further surveys. A second paper incorporates these findings in an assessment of the global burden of trachomatous visual impairment.

The global burden of trachomatous visual impairment: II. Assessing burden.

This paper builds on results of a previous paper on the prevalence of trachomatous visual impairment as the foundation for assessing the global burden of trachomatous blindness and low vision: approximately 2.9 million cases of trachomatous blindness and 3.8 million low visioned corresponding to a global prevalence of trachomatous visual impairment equal to 1.3/1,000 in 1990 was estimated. For each visually impaired person, the years of life lost due to premature mortality and the years lived in a handicapped state are added to yield a single measure of disease burden called handicap adjusted life years (HALYs). Age, gender and visual acuity group specific HALYs are multiplied by the prevalence of trachomatous visual impairment to yield an estimate of the global burden of trachoma visual impairment equal to 80 million HALYs. Analysis of the distribution of the global burden by age, gender, visual acuity and region provide direction for trachoma research and programme priorities. Sensitivity analysis reveals that the burden estimates of trachomatous visual impairment may vary from as low as 15 million to as high as 500 million HALYs. Given this degree of variability, burden comparisons with other blinding and non-blinding conditions for the purposes of identifying health sector priorities may be misleading.