Explaining the socio-economic inequalities in child immunisation coverage in Zimbabwe

Socioeconomic inequalities in health have received significant attention globally because of the well-known association between wealth and health. A lot of studies show that poor people are more prone to sickness than their counterparts. Immunisation has been a key antidote to avert deaths for children under the age of 5. This study represents an initial attempt to assess specific variables that contribute to socioeconomic inequalities in immunisation coverage in Zimbabwe. Data were obtained from the 2015 Zimbabwe Demographic Health Survey, a nationally representative survey. Immunisation coverage was measured using four categories: full immunisation (a child who will have received 10 doses of vaccines), partial immunisation (a child who will have received at least one but not all vaccines), no immunisation (a child who will not have received any immunisation dose from birth) and immunisation intensity (a proportion of doses received to total doses that they should have received). Inequalities in immunisation coverage in Zimbabwe were assessed using concentration curves and indices. A positive (negative) concentration index indicates immunisation coverage concentrated among the rich (poor). The concentration index was decomposed to identify how different variables contribute to the socioeconomic inequality in immunisation coverage in Zimbabwe. Results indicate that immunisation intensity and full immunisation concentration indices were (0.0154) and (0.0250) respectively, indicating that children from lower socio-economic status are less likely to receive all doses of vaccines. No immunisation and partial immunisation concentration indices were (-0.0778) and (-0.0878) indicating that children from higher socioeconomic status are more likely to have their children immunised opposed to their poor counterparts. The main contributors to socioeconomic inequality in immunisation coverage are the mother's education, socioeconomic status and place of residence (rural/urban and province). While immunisation services are free of charge in the public health sector in Zimbabwe, coverage rates are higher among the wealthy, which shows that there may be barriers to utilising these services that may not be the direct cost of vaccination. There have to be measures by the government to reach people in areas that are not easily accessible. Also, more needs to be done to reduce socioeconomic inequalities in Zimbabwe

Economic cost analysis of door-to-door community-based distribution of HIV self-test kits in Malawi, Zambia and Zimbabwe

INTRODUCTION: HIV self-testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder-to-reach populations. This study provides the first empirical evidence of the costs of door-to-door community-based HIVST distribution in Malawi, Zambia and Zimbabwe. METHODS: HIVST kits were distributed door-to-door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on-site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start-up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs. RESULTS: In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site-level fixed costs. Site-level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP. CONCLUSIONS: These early door-to-door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale-up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers' costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door-to-door community-led distribution to reach end-users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs

A costing analysis of B-GAP: index-linked HIV testing for children and adolescents in Zimbabwe

Background By testing children and adolescents of HIV positive caretakers, index-linked HIV testing, a targeted HIV testing strategy, has the ability to identify high risk children and adolescents earlier and more efficiently, compared to blanket testing. We evaluated the incremental cost of integrating index-linked HIV testing via three modalities into HIV services in Zimbabwe. Methods A mixture of bottom-up and top-down costing was employed to estimate the provider cost per test and per HIV diagnosis for 2–18 year olds, through standard of care testing, and the incremental cost of index-linked HIV testing via three modalities: facility-based testing, home-based testing by a healthcare worker, and testing at home by the caregiver using an oral mucosal transudate test. In addition to interviews, direct observation and study process data, facility registries were abstracted to extract outcome data and resource use. Costs were converted to 2019 constant US$. Results The average cost per standard of care test in urban facilities was US$5.91 and US$7.15 at the rural facility. Incremental cost of an index-linked HIV test was driven by the uptake and number of participants tested. The lowest cost approach in the urban setting was home-based testing (US$6.69) and facility-based testing at the rural clinic (US$5.36). Testing by caregivers was almost always the most expensive option (rural US$62.49, urban US$17.49). Conclusions This is the first costing analysis of index-linked HIV testing strategies. Unit costs varied across sites and with uptake. When scaling up, alternative testing solutions that increase efficiency such as index-linked HIV testing of the entire household, as opposed to solely targeting children/adolescents, need to be explored