Is health expenditure on immunisation associated with immunisation coverage in sub-Saharan Africa? A multicountry analysis, 2013-2017.

OBJECTIVES: The designing of contextually tailored sustainable plans to finance the procurement of vaccines and the running of appropriate immunisation programmes are necessary to address the high burden of vaccine-preventable diseases and low immunisation coverage in sub-Saharan Africa (SSA). We sought to estimate the minimum fraction of a country's health budget that should be invested in national immunisation programmes to achieve national immunisation coverage of 80% or greater depending on the context, with and without donors' support. DESIGN: Multicountry analysis of secondary data using retrieved publicly available data from the WHO, Global Alliance for Vaccines and Immunization (GAVI) and World Bank databases. SETTING: Data on 24 SSA countries, between 2013 and 2017. METHODS: We model the variations in immunisation coverage across the different SSA countries using a fractional logit model. Three different generalised linear models were fitted to explore how various explanatory variables accounted for the variability in each of the three different vaccines-measles-containing vaccine (MCV)1, diphtheria, pertussis, tetanus (DPT3) and BCG. RESULTS: We observed an association between current health expenditure (as a percentage of gross domestic product) and immunisation coverage for BCG (OR=1.01, 95% CI: 1.01 to 1.04, p=0.008) and DPT3 (OR=1.01, 95% CI: 1.0 to 1.02, p=0.020) vaccines. However, there was no evidence to indicate that health expenditure on immunisation (as a proportion of current health expenditure) could be a strong predictor of immunisation coverage (DPT, OR 0.96 (95% CI 0.78 to 1.19; p=0.702); BCG, OR 0.91 (0.69 to 1.19; p=0.492); MCV, OR 0.91 (0.69 to 1.19; p=0.482)). We demonstrate in selected countries that to achieve the GAVI target of 80% in the countries with low DPT3 coverage, health expenditure would need to be increased by more than 45%. CONCLUSIONS: There is a need to facilitate the development of strategies that support African countries to increase domestic financing for national immunisation programmes towards achieving 2030 targets for immunisation coverage.

Are children on track with their routine immunization schedule in a fragile and protracted conflict state of South Sudan? A community-based cross-sectional study.

OBJECTIVES: The objective of this study was to assess if children aged 0-23 months in a conflict-affected state of South Sudan were on track with their immunization schedule and to identify predisposing factors that affected this study population from being on track with their routine immunization schedule. DESIGN: Community-based cross-sectional study using a semi-structured questionnaire. The binary outcome of interest was defined as being on or off track with routine vaccination schedule. Multivariable logistic regression was used to analyze for the association between the predisposing factors surveyed and being off track with one's routine immunization schedule. SETTING: Rural communities in four counties (Rumbek Center, Rumbek North, Rumbek East and Wulu) of the Western Lakes state in South Sudan during January 10, 2020 to June 10, 2020. PARTICIPANTS: We surveyed 428 children aged 0-23 months and their mothers/caregivers who lived in either of the four counties in the Western Lakes State. Participants were selected using random ballot sampling. RESULTS: More than three-quarters of the children surveyed (75.5%) were off track with their vaccination schedule. Children with an immunization card had 71% reduced odds of being off track with their immunization (AOR = 0.29; 95% CI 0.10-0.83, p-value = 0.021) compared to children without immunization cards. Children who reside near health facilities and do not require transportation to facilities had 87% reduced odds of being off track with their immunization compared to those who lived far and required transport to facilities. Giving an adequate immunization notice before conducting immunization outreach visits to communities was also associated with reduced odds (AOR = 0.27; 95% CI 0.09-0.78. p-value = 0.016) of children being off track with their immunization. CONCLUSION: This study revealed that most children were off track with their vaccination schedule in South Sudan, which is not only influenced by maternal characteristics but mainly by community- and state-level immunization service delivery mechanisms. Policies and interventions to improve child immunization uptake should prioritize these contextual characteristics.

"In cities, it's not far, but it takes long": comparing estimated and replicated travel times to reach life-saving obstetric care in Lagos, Nigeria.

BACKGROUND: Travel time to comprehensive emergency obstetric care (CEmOC) facilities in low-resource settings is commonly estimated using modelling approaches. Our objective was to derive and compare estimates of travel time to reach CEmOC in an African megacity using models and web-based platforms against actual replication of travel. METHODS: We extracted data from patient files of all 732 pregnant women who presented in emergency in the four publicly owned tertiary CEmOC facilities in Lagos, Nigeria, between August 2018 and August 2019. For a systematically selected subsample of 385, we estimated travel time from their homes to the facility using the cost-friction surface approach, Open Source Routing Machine (OSRM) and Google Maps, and compared them to travel time by two independent drivers replicating women's journeys. We estimated the percentage of women who reached the facilities within 60 and 120 min. RESULTS: The median travel time for 385 women from the cost-friction surface approach, OSRM and Google Maps was 5, 11 and 40 min, respectively. The median actual drive time was 50-52 min. The mean errors were >45 min for the cost-friction surface approach and OSRM, and 14 min for Google Maps. The smallest differences between replicated and estimated travel times were seen for night-time journeys at weekends; largest errors were found for night-time journeys at weekdays and journeys above 120 min. Modelled estimates indicated that all participants were within 60 min of the destination CEmOC facility, yet journey replication showed that only 57% were, and 92% were within 120 min. CONCLUSIONS: Existing modelling methods underestimate actual travel time in low-resource megacities. Significant gaps in geographical access to life-saving health services like CEmOC must be urgently addressed, including in urban areas. Leveraging tools that generate 'closer-to-reality' estimates will be vital for service planning if universal health coverage targets are to be realised by 2030.

Cost of Utilising Maternal Health Services in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: Cost is a major barrier to maternal health service utilisation for many women in low- and middle-income countries (LMICs). However, comparable evidence of the available cost data in these countries is limited. We conducted a systematic review and comparative analysis of costs of utilising maternal health services in these settings. METHODS: We searched peer-reviewed and grey literature databases for articles reporting cost of utilising maternal health services in LMICs published post-2000. All retrieved records were screened and articles meeting the inclusion criteria selected. Quality assessment was performed using the relevant cost-specific criteria of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. To guarantee comparability, disaggregated costs data were inflated to 2019 US dollar equivalents. Total adjusted costs and cost drivers associated with utilising each service were systematically compared. Where heterogeneity in methods or non-disaggregated costs was observed, narrative synthesis was used to summarise findings. RESULTS: Thirty-six studies met our inclusion criteria. Many of the studies costed multiple services. However, the most frequently costed services were utilisation of normal vaginal delivery (22 studies), caesarean delivery (13), and antenatal care (ANC) (10). The least costed services were post-natal care (PNC) and post-abortion care (PAC) (5 each). Studies used varied methods for data collection and analysis and their quality ranged from low to high with most assessed as average or high. Generally, across all included studies, cost of utilisation progressively increased from ANC and PNC to delivery and PAC, and from public to private providers. Medicines and diagnostics were main cost drivers for ANC and PNC while cost drivers were variable for delivery. Women experienced financial burden of utilising maternal health services and also had to pay some unofficial costs to access care, even where formal exemptions existed. CONCLUSION: Consensus regarding approach for costing maternal health services will help to improve their relevance for supporting policy-making towards achieving universal health coverage. If indeed the post-2015 mission of the global community is to "leave no one behind," then we need to ensure that women and their families are not facing unnecessary and unaffordable costs that could potentially tip them into poverty.

e-income countries from a provider's perspective: a systematic review.

INTRODUCTION: Maternal health services are effective in reducing the morbidity and mortality associated with pregnancy and childbirth. We conducted a systematic review on costs of maternal health services in low-income and middle-income countries from the provider's perspective. METHODS: We searched multiple peer-reviewed databases (including African Journal Online, CINAHL Plus, EconLit, Popline, PubMed, Scopus and Web of Science) and grey literature for relevant articles published from year 2000. Articles meeting our inclusion criteria were selected with quality assessment done using relevant cost-focused criteria of the Consolidated Health Economic Evaluation Reporting Standards checklist. For comparability, disaggregated costs data were inflated to 2019 US$ equivalents. Costs and cost drivers were systematically compared. Where heterogeneity was observed, narrative synthesis was used to summarise findings. RESULTS: Twenty-two studies were included, with most studies costing vaginal and/or caesarean delivery (11 studies), antenatal care (ANC) (9) and postabortion care (PAC) (8). Postnatal care (PNC) has been least costed (2). Studies used different methods for data collection and analysis. Quality of peer-reviewed studies was assessed average to high while all grey literature studies were assessed as low quality. Following inflation, estimated provision cost per service varied (ANC (US$7.24-US$31.42); vaginal delivery (US$14.32-US$278.22); caesarean delivery (US$72.11-US$378.940; PAC (US$97.09-US$1299.21); family planning (FP) (US$0.82-US$5.27); PNC (US$5.04)). These ranges could be explained by intercountry variations, variations in provider type (public/private), facility type (primary/secondary) and care complexity (simple/complicated). Personnel cost was mostly reported as the major driver for provision of ANC, skilled birth attendance and FP. Economies of scale in service provision were reported. CONCLUSION: There is a cost savings case for task-shifting and encouraging women to use lower level facilities for uncomplicated services. Going forward, consensus regarding cost component definitions and methodologies for costing maternal health services will significantly help to improve the usefulness of cost analyses in supporting policymaking towards achieving Universal Health Coverage.