Access to Routine Immunization: A Comparative Analysis of Supply-Side Disparities between Northern and Southern Nigeria.

BACKGROUND: The available data on routine immunization in Nigeria show a disparity in coverage between Northern and Southern Nigeria, with the former performing worse. The effect of socio-cultural differences on health-seeking behaviour has been identified in the literature as the main cause of the disparity. Our study analyses the role of supply-side determinants, particularly access to services, in causing these disparities. METHODS: Using routine government data, we compared supply-side determinants of access in two Northern states with two Southern states. The states were identified using criteria-based purposive selection such that the comparisons were made between a low-coverage state in the South and a low-coverage state in the North as well as between a high-coverage state in the South and a high-coverage state in the North. RESULTS: Human resources and commodities at routine immunization service delivery points were generally insufficient for service delivery in both geographical regions. While disparities were evident between individual states irrespective of regional location, compared to the South, residents in Northern Nigeria were more likely to have vaccination service delivery points located within a 5 km radius of their settlements. CONCLUSION: Our findings suggest that regional supply-side disparities are not apparent, reinforcing the earlier reported socio-cultural explanations for disparities in routine immunization service uptake between Northern and Southern Nigeria. Nonetheless, improving routine immunisation coverage services require that there are available human resources and that health facilities are equitably distributed

Challenges to sustainable immunization systems in Gavi transitioning countries.

The Global Vaccine Action Plan 2011-2020 (GVAP) aims to extend the full benefit of vaccination against vaccine-preventable diseases to all individuals. More than halfway through the Decade of Vaccines, countries classified as Middle-Income by the World Bank struggle to achieve several GVAP targets. Countries transitioning from Gavi, the Vaccine Alliance, represent a key sub-group of Middle Income Countries. Through a review of available literature on the subject, this study documents the lack of comparative analyses on immunization system performance in countries transitioning from Gavi support. Despite increased emphasis on the importance of programmatic sustainability beyond financing through the Gavi 2016-2020 Strategy and availability of data, existing literature has predominantly documented challenges related to domestic financing of immunization. This study complements a review of current literature with an analysis of country assessments conducted by immunization partners since 2011, in an effort to document programmatic challenges related to decision-making for immunization policy, delivery of services, and access to affordable and timely supply in Gavi transitioning countries. In light of the findings, we suggest continued systematic compilation of country performance data beyond financing to inform policy-making, in particular for: (i) development of a more nuanced theory of change towards sustainable immunization programmes and (ii) measurement of progress and key areas for attention and investment

Cost-effectiveness of eye care services in Zambia.

OBJECTIVE: To estimate the cost-effectiveness of cataract surgery and refractive error/presbyopia correction in Zambia. METHODS: Primary data on costs and health related quality of life were collected in a prospective cohort study of 170 cataract and 113 refractive error/presbyopia patients recruited from three health facilities. Six months later, follow-up data were available from 77 and 41 patients who had received cataract surgery and spectacles, respectively. Costs were determined from patient interviews and micro-costing at the three health facilities. Utility values were gathered by administering the EQ-5D quality of life instrument immediately before and six months after cataract surgery or acquiring spectacles. A probabilistic state-transition model was used to generate cost-effectiveness estimates with uncertainty ranges. RESULTS: Utility values significantly improved across the patient sample after cataract surgery and acquiring spectacles. Incremental costs per Quality Adjusted Life Years gained were US$259 for cataract surgery and US$ 375 for refractive error correction. The probabilities of the incremental cost-effectiveness ratios being below the Zambian gross national income per capita were 95% for both cataract surgery and refractive error correction. CONCLUSION: In spite of proven cost-effectiveness, severe health system constraints are likely to hamper scaling up of the interventions

Building resource constraints and feasibility considerations in mathematical models for infectious disease: A systematic literature review

Priority setting for infectious disease control is increasingly concerned with physical input constraints and other real-world restrictions on implementation and on the decision process. These health system constraints determine the 'feasibility' of interventions and hence impact. However, considering them within mathematical models places additional demands on model structure and relies on data availability. This review aims to provide an overview of published methods for considering constraints in mathematical models of infectious disease. We systematically searched the literature to identify studies employing dynamic transmission models to assess interventions in any infectious disease and geographical area that included non-financial constraints to implementation. Information was extracted on the types of constraints considered and how these were identified and characterised, as well as on the model structures and techniques for incorporating the constraints. A total of 36 studies were retained for analysis. While most dynamic transmission models identified were deterministic compartmental models, stochastic models and agent-based simulations were also successfully used for assessing the effects of non-financial constraints on priority setting. Studies aimed to assess reductions in intervention coverage (and programme costs) as a result of constraints preventing successful roll-out and scale-up, and/or to calculate costs and resources needed to relax these constraints and achieve desired coverage levels. We identified three approaches for incorporating constraints within the analyses: (i) estimation within the disease transmission model; (ii) linking disease transmission and health system models; (iii) optimising under constraints (other than the budget). The review highlighted the viability of expanding model-based priority setting to consider health system constraints. We show strengths and limitations in current approaches to identify and quantify locally-relevant constraints, ranging from simple assumptions to structured elicitation and operational models. Overall, there is a clear need for transparency in the way feasibility is defined as a decision criteria for its systematic operationalisation within models

The health sector cost of different policy responses to COVID-19 in low- and middle- income countries

Much attention has focussed in recent months on the impact that COVID-19 has on health sector capacity, including critical care bed capacity and resources such as personal protective equipment. However, much less attention has focussed on the overall cost to health sectors, including the full human resource costs and the health system costs to address the pandemic. Here we present estimates of the total costs of COVID-19 response in low- and middle-income countries for different scenarios of COVID-19 mitigation over a one year period. We find costs vary substantially by setting, but in some settings even mitigation scenarios place a substantial fiscal impact on the health system. We conclude that the choices facing many low- and middle- income countries, without further rapid emergency financial support, are stark, between fully funding an effective COVID-19 reponse or other core essential health services.</jats:p

Informing Balanced Investment in Services and Health Systems: A Case Study of Priority Setting for Tuberculosis Interventions in South Africa.

OBJECTIVES: Health systems face nonfinancial constraints that can influence the opportunity cost of interventions. Empirical methods to explore their impact, however, are underdeveloped. We develop a conceptual framework for defining health system constraints and empirical estimation methods that rely on routine data. We then present an empirical approach for incorporating nonfinancial constraints in cost-effectiveness models of health benefit packages for the health sector. METHODS: We illustrate the application of this approach through a case study of defining a package of services for tuberculosis case-finding in South Africa. An economic model combining transmission model outputs with unit costs was developed to examine the cost-effectiveness of alternative screening and diagnostic algorithms. Constraints were operationalized as restrictions on achievable coverage based on: (1) financial resources; (2) human resources; and (3) policy constraints around diagnostics purchasing. Cost-effectiveness of the interventions was assessed under one "unconstrained" and several "constrained" scenarios. For the unconstrained scenario, incremental cost-effectiveness ratios were estimated with and without the costs of "relaxing" constraints. RESULTS: We find substantial differences in incremental cost-effectiveness ratios across scenarios, leading to variations in the decision rules for prioritizing interventions. In constrained scenarios, the limiting factor for most interventions was not financial, but rather the availability of human resources. CONCLUSIONS: We find that optimal prioritization among different tuberculosis control strategies in South Africa is influenced by whether and how constraints are taken into consideration. We thus demonstrate both the importance and feasibility of considering nonfinancial constraints in health sector resource allocation models

Adolescent Girls Empowerment Programme: Research and evaluation mid-term technical report

The Adolescent Girls Empowerment Programme (AGEP) was a social, health, and economic asset-building program targeting vulnerable adolescent girls aged 10–19. The Population Council, in partnership with the Young Women’s Christian Association of Zambia, successfully implemented the AGEP program from late 2013 to early 2016. The results presented in this midterm report have implications for recommendations on future programming for adolescent girls in Zambia and elsewhere and should be coupled with burgeoning evidence from AGEP and the literature to adapt programming for vulnerable adolescent girls in order to improve impact. While the underlying root causes of girls’ vulnerabilities are interrelated, it is possible that a more direct focus on a particular outcome, driven by a more targeted intervention, would have led to greater impact in the shorter term. For older adolescents, it may imply a direct focus on livelihoods and entrepreneurship, whereas younger adolescents may need more focus on educational support. Also, providing direct resources through incentivized activities may be a constructive approach to increasing engagement with the program

Adolescent Girls Empowerment Programme: Research and evaluation mid-term technical report—Executive Summary

The Adolescent Girls Empowerment Programme (AGEP) was an ambitious project directed toward changing girls’ lives in a significant and meaningful way across areas of education, sexual and reproductive health, marriage and fertility, and experience of violence. This Executive Summary of the project’s findings shows that, overall, the AGEP cohort data, and lessons they have generated from the AGEP are rich, nuanced, and important for informing the next generation of programs for adolescents in Zambia and elsewhere. Even though the study is still under way, and the full longer-term effects of AGEP remain to be seen, the information presented in this report can be used to guide programs and policymakers on program areas of promise, gaps that need to be filled, and a range of questions about how to best serve this population that still need to be answered