Equity in vaccine coverage in Uganda from 2000 to 2016: revealing the multifaceted nature of inequity.

BACKGROUND: This study analyses vaccine coverage and equity among children under five years of age in Uganda based on the 2016 Uganda Demographic and Health Survey (UDHS) dataset. Understanding equity in vaccine access and the determinants is crucial for the redress of emerging as well as persistent inequities. METHODS: Applied to the UDHS for 2000, 2006, 2011, and 2016, the Vaccine Economics Research for Sustainability and Equity (VERSE) Equity Toolkit provides a multivariate assessment of immunization coverage and equity by (1) ranking the sample population with a composite direct unfairness index, (2) generating quantitative measure of efficiency (coverage) and equity, and (3) decomposing inequity into its contributing factors. The direct unfairness ranking variable is the predicted vaccination coverage from a logistic model based upon fair and unfair sources of variation in vaccination coverage. Our fair source of variation is defined as the child's age - children too young to receive routine immunization are not expected to be vaccinated. Unfair sources of variation are the child's region of residence, and whether they live in an urban or rural area, the mother's education level, the household's socioeconomic status, the child's sex, and their insurance coverage status. For each unfair source of variation, we identify a "more privileged" situation. RESULTS: The coverage and equity of the Diphtheria-Pertussis-Tetanus vaccine, 3rd dose (DPT3) and the Measles-Containing Vaccine, 1st dose (MCV1) - two vaccines indicative of the health system's performance - improved significantly since 2000, from 49.7% to 76.8% and 67.8% to 82.7%, respectively, and there are fewer zero-dose children: from 8.4% to 2.2%. Improvements in retaining children in the program so that they complete the immunization schedule are more modest (from 38.1% to 40.8%). Progress in coverage was pro-poor, with concentration indices (wealth only) moving from 0.127 (DPT3) and 0.123 (MCV1) in 2000 to -0.042 and -0.029 in 2016. Gains in overall equity (composite) were more modest, albeit significant for most vaccines except for MCV1: concentration indices of 0.150 (DPT3) and 0.087 (MCV1) in 2000 and 0.054 and 0.055 in 2016. The influence of the region and settings (urban/rural) of residence significantly decreased since 2000. CONCLUSION: The past two decades have seen significant improvements in vaccine coverage and equity, thanks to the efforts to strengthen routine immunization and ongoing supplemental immunization activities such as the Family Health Days. While maintaining the regular provision of vaccines to all regions, efforts should be made to alleviate the impact of low maternal education and literacy on vaccination uptake.

Cost and operational context for national human papillomavirus (HPV) vaccine delivery in six low- and middle-income countries.

INTRODUCTION: There are concerns from immunization program planners about high delivery costs for human papillomavirus (HPV) vaccine. Most prior research evaluated costs of HPV vaccine delivery during demonstration projects or at introduction, showing relatively high costs, which may not reflect the costs beyond the pilot or introduction years. This study sought to understand the operational context and estimate delivery costs for HPV vaccine in six national programs, beyond their introduction years. METHODS: Operational research and microcosting methods were used to retrospectively collect primary data on HPV vaccination program activities in Ethiopia, Guyana, Rwanda, Senegal, Sri Lanka, and Uganda. Data were collected from the national level and a sample of subnational administrative offices and health facilities. Operational data collected were tabulated as percentages and frequencies. Financial costs (monetary outlays) and economic costs (financial plus opportunity costs) were estimated, as was the cost per HPV vaccine dose delivered. Costing was done from the health system perspective and reported in 2019 United States dollars (US$). RESULTS: Across the study countries, between 53 % and 99 % of HPV vaccination sessions were conducted in schools. Differences were observed in intensity and frequency with which program activities were conducted and resources used. Mean annual economic costs at health facilities in each country ranged from $1,207 to $3,190, while at the national level these ranged from $7,657 to $304,278. Mean annual HPV vaccine doses delivered per health facility in each country ranged from 162 to 761. Mean financial costs per dose per study country ranged from $0.27 to $3.32, while the economic cost per dose ranged from $3.09 to $17.20. CONCLUSION: HPV vaccine delivery costs were lower than at introduction in some study countries. There were differences in the activities carried out for HPV vaccine delivery and the number of doses delivered, impacting the cost estimates.

Calculating the Costs of Implementing Integrated Packages of Community Health Services: Methods, Experiences, and Results From 6 sub-Saharan African Countries.

BACKGROUND: Ensuring access to a package of integrated primary health care services is essential for achieving universal health coverage. In many countries, community health programs are necessary for primary health care service provision, but they are generally underfunded, and countries often lack the necessary evidence on costs and resource requirements. We conducted prospective cost analyses of community health programs in 6 countries in sub-Saharan Africa using the Community Health Planning and Costing Tool. METHODS: The Community Health Planning and Costing Tool is a spreadsheet-based tool designed to cost key programmatic elements of community health services packages, including training, equipment, incentives, supervision, and management. In each country, stakeholders defined a package of community health services and corresponding standard treatment guidelines to estimate normative costs, which were applied to program scale-up targets. The data were entered into the tool, and cost models were prepared for different geographical and service utilization scenarios. The results were reviewed and validated with the governments, implementing partners, and expert panels. Additional scale-up scenarios were modeled, taking into account probable constraints to increasing community health service provision and potential funding limitations. RESULTS: The services and scope of community health service packages varied by country, depending on contextual factors and determined health priorities. The package costs also varied significantly depending on the size and contents of the service package, the service delivery approach, the remuneration of the community health workers, and the cost of medicines and supplies. CONCLUSIONS: Community health programs and service packages are different in every country and change over time as they evolve. They should be routinely costed as an integral part of the planning and budgeting process and to ensure that sufficient resources are allocated for their effective and efficient implementation.

Trends of key surveillance performance indicators of acute flaccid paralysis: a descriptive analysis, Uganda, 2015-2020.

BACKGROUND: Polio is disease caused by poliovirus which can in turn cause irreversible paralytic disease, presenting as Acute Flaccid Paralysis (AFP). A sensitive AFP surveillance system, in which all reported AFP cases are evaluated, first to determine if they are true AFP cases or not, is key for tracking polio eradication. True AFP cases are then later categorized as polio AFP or non-polio AFP (NPAFP) cases. Sensitivity is defined by meeting an annual NPAFP rate/100,000 population < 15 years of ≥ 4/100,000, and an annual stool adequacy (SA) rate of ≥ 80%. We describe Uganda's AFP surveillance performance between 2015-2020, based on the WHO-recommended indicators, including; NPAFP and stool adequacy rate. METHODS: We performed a descriptive analysis of national AFP surveillance data, 2015-2020 obtained from ministry of health. We evaluated proportion of reported AFP cases that were true AFP, and changes in NPAFP and stool adequacy (SA) rate over the study period. We evaluated the trends in achieving the targeted NPAFP and SA rates from 2015-2020. We used QGIS to illustrate patterns in NPAFP and SA rates across districts and subregions. RESULTS: Among 3,605 AFP cases reported and investigated countrywide from 2015-2020, 3,475 (96%) were true AFP cases. All the true AFP cases were non-polio related. District reporting was near-complete (97-100% each year). Overall, the mean NPAFP rate declined from 3.1/100,000 in 2015 to 2.1/100,000 in 2020. Less than 40% of districts met the NPAFP target rate in all years. The proportion of districts achieving the NPAFP target rate of ≥ 4/100,000 significantly declined from 35% in 2015 to 20% in 2020. The mean annual SA rate nationally was 88% from 2015-2020. Only 66% of districts achieved the SA target rate of ≥ 80% in the study period. The proportion of districts with SA rate ≥ 80% significantly increased from 68 to 80% between 2015 and 2020. CONCLUSION: Most districts reported AFP cases. However, there was a decline in the NPAFP rate from 2015-2020 and few districts achieved the target rate. The suboptimal AFP surveillance system performance leaves the country at risk of missing ongoing poliovirus transmission. We recommend health worker training on active AFP searches, intensified supportive supervision, increase the number of environmental surveillance sentinel sites to boost AFP surveillance in the country, and periodic review meetings with districts to assess AFP surveillance performance.

Evaluation of Infection Prevention and Control Readiness at Frontline Health Care Facilities in High-Risk Districts Bordering Ebola Virus Disease-Affected Areas in the Democratic Republic of the Congo - Uganda, 2018.

Infection prevention and control (IPC) in health care facilities is essential to protecting patients, visitors, and health care personnel from the spread of infectious diseases, including Ebola virus disease (Ebola). Patients with suspected Ebola are typically referred to specialized Ebola treatment units (ETUs), which have strict isolation and IPC protocols, for testing and treatment (1,2). However, in settings where contact tracing is inadequate, Ebola patients might first seek care at general health care facilities, which often have insufficient IPC capacity (3-6). Before 2014-2016, most Ebola outbreaks occurred in rural or nonurban communities, and the role of health care facilities as amplification points, while recognized, was limited (7,8). In contrast to these earlier outbreaks, the 2014-2016 West Africa Ebola outbreak occurred in densely populated urban areas where access to health care facilities was better, but contact tracing was generally inadequate (8). Patients with unrecognized Ebola who sought care at health care facilities with inadequate IPC initiated multiple chains of transmission, which amplified the epidemic to an extent not seen in previous Ebola outbreaks (3-5,7). Implementation of robust IPC practices in general health care facilities was critical to ending health care-associated transmission (8). In August 2018, when an Ebola outbreak was recognized in the Democratic Republic of the Congo (DRC), neighboring countries began preparing for possible introduction of Ebola, with a focus on IPC. Baseline IPC assessments conducted in frontline health care facilities in high-risk districts in Uganda found IPC gaps in screening, isolation, and notification. Based on findings, additional funds were provided for IPC, a training curriculum was developed, and other corrective actions were taken. Ebola preparedness efforts should include activities to ensure that frontline health care facilities have the IPC capacity to rapidly identify suspected Ebola cases and refer such patients for treatment to protect patients, staff members, and visitors.