IntroductionThe essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies prove effective at driving coverage is not well-established. To address this gap, we identified critical success factors associated with advancing key policies and programs that may have led to the substantial changes in routine childhood immunization coverage in Zambia between 2000 and 2018.MethodsWe conducted mixed-methods research based on an evidence-based conceptual framework of core vaccine system requirements. Additional facilitators and barriers were explored at the national and subnational levels in Zambia. We conducted a thematic analysis grounded in implementation science frameworks to determine the critical success factors for improved vaccine coverage.ResultsThe following success factors emerged: 1) the Inter-agency Coordinating Committee was strengthened for long-term engagement which, complemented by the Zambia Immunization Technical Advisory Group, is valued by the government and integrated into national-level decision-making; 2) the Ministry of Health improved the coordination of data collection and review for informed decision-making across all levels; 3) Regional multi-actor committees identified development priorities, strategies, and funding, and iteratively adjusted policies to account for facilitators, barriers, and lessons learned; 4) Vaccine messaging was disseminated through multiple channels, including the media and community leaders, increasing trust in the government by community members; 5) The Zambia Ministry of Health and Churches Health Association of Zambia formalized a long-term organizational relationship to leverage the strengths of faith-based organizations; and 6) Neighborhood Health Committees spearheaded community-driven strategies via community action planning and ultimately strengthened the link between communities and health facilities.ConclusionBroader health systems strengthening and strong partnerships between various levels of the government, communities, and external organizations were critical factors that accelerated vaccine coverage in Zambia. These partnerships were leveraged to strengthen the overall health system and healthcare governance.HighlightsThis paper describes how policies and programs contributed to improved vaccine coverage in ZambiaCommunication, coordination, and collaboration between implementing levels were imperativeAdjacent successes in health systems strengthening and governance were leveragedPolicies in Zambia include flexibility in implementation for tailored approaches in each district
IntroductionRoutine immunisation is a cost-effective way to save lives and protect people from disease. Some low-income countries (LIC) achieved remarkable success in childhood immunisation. Yet, previous studies comparing the relationship between economic growth and health spending with vaccination coverage have been limited. We investigated these relationships among LIC to understand what financial changes lead to childhood immunisation changes.MethodsWe identified which financial indicators were significant predictors of vaccination coverage in LIC by fitting regression models for several vaccines, controlling for population density, land area and female years of education. We then identified LIC with high vaccination coverage (LIC+) and compared their economic and health spending trends with other LIC (LIC−) and lower-middle income countries. We used cross-country multi-year regressions with mixed-effects to test financial indicators’ rate of change. We conducted statistical tests to verify if financial trends of LIC+ were significantly different from LIC−.ResultsDuring 2014–2018, gross domestic product per capita (p=0.67–0.95, range given by tests with different vaccines), total/private health spending per capita (p=0.57–0.97, p=0.32–0.57) and aggregated development assistance for health (DAH) per capita (p=0.38–0.86) were not significant predictors of vaccination coverage in LIC. Government health spending per capita (p=0.022–0.073) and total/government spending per birth on routine immunisation vaccines (p=0.0007–0.029, p=0.016–0.052) were significant positive predictors of vaccination coverage. From 2000 to 2016, LIC+ increased government health spending per capita by US$0.30 per year, while LIC− decreased by US$0.16 (significant difference, p<0.0001). From 2006 to 2017, LIC+ increased government spending per birth on routine immunisation vaccines by US$0.22 per year, while LIC− increased by US$0.10 (p<0.0093).ConclusionVaccination coverage success of some LIC was not explained by economic development, total health spending nor aggregated DAH. Vaccination coverage success of LIC+ was associated with increasing government health spending particularly in routine immunisation vaccines.
Background Childhood vaccination, family planning, healthcare access, and women's empowerment are goals targeted by the Sustainable Development Goals (SDG). Barriers to healthcare access impede vaccination, and tackling goals holistically could create larger gains than siloed efforts. We studied Nepal, Senegal, and Zambia to test the association between childhood vaccinations and other SDG indicators to identify clustered deprivations. We quantified how children with few - or no - vaccines and their mothers were vulnerable in other SDG areas. Methods We analyzed Demographic and Health Surveys (DHS) from Nepal, Senegal, and Zambia. Through ordinal logistic regressions, controlling for household/mother's characteristics, we identified strong predictors of the number of vaccine doses one-year-old children received. Through bootstrapping and optimal propensity scores matching, we compared children with no or few childhood doses (0-2 doses in early 2000s, or 0-4 in late 2010s) to children who received eight doses (DTP1-3, MVC1, Pol1-3, and BCG vaccines). Findings Mothers of children who received eight doses were 14-30% more likely than mothers of children with few or no doses to have accessed a health facility in the last year (95% CIs were 16-44% in Nepal 2001, -5% to 33% Nepal 2016, 3-26% Senegal 2005, 1-31% Senegal 2019, 9-38% Zambia 2001-02, 7-36% Zambia 2018), knew on average 0.7-1.5 more contraceptive methods (0.9-2.0 Nepal 2005, 0.1-1.5 Nepal 2016, 0.6-1.7 Senegal 2005, 0.2-1.7 Senegal 2019, 0.1-1.4 Zambia 2001-02, 0.5-1.4 Zambia 2018), and had 10-22% higher literacy rates (12-32% Nepal 2001, -7% to 36% Nepal 2016, 10-26% Senegal 2005, -3 to 22% Senegal 2019, -4% to 28% Zambia 2001-02, 5-36% Zambia 2018). Interpretation Children with few or no vaccine doses and their mothers were behind in access to family planning, healthcare, and education compared to fully vaccinated children and their mothers. Such differences can further impede immunizations; therefore, integrated education and health services are needed to improve vaccination outcomes.
SummaryBackgroundRoutine childhood immunization is a cost-effective way to save lives and protect people from disease. Some low-income countries (LIC) have achieved remarkable success in childhood immunization, despite lower levels of gross national income or health spending compared to other countries. We investigated the impact of financing and health spending on vaccination coverage across LIC and lower-middle income countries (LMIC).MethodsAmong LIC, we identified countries with high-performing vaccination coverage (LIC+) and compared their economic and health spending trends with other LIC (LIC-) and LMIC. We used cross-country multi-year linear regressions with mixed-effects to test financial indicators over time. We conducted three different statistical tests to verify if financial trends of LIC+ were significantly different from LIC- and LMIC; p-values were calculated with an asymptotic χ2 test, a Kenward-Roger approximation for F tests, and a parametric bootstrap method.FindingsDuring 2014–18, LIC+ had a mean vaccination coverage between 91–96% in routine vaccines, outperforming LIC- (67–80%) and LMIC (83–89%). During 2000–18, gross national income and development assistance for health (DAH) per capita were not significantly different between LIC+ and LIC- (p > 0·13, p > 0·65) while LIC+ had a significant lower total health spending per capita than LIC- (p < 0·0001). Government health spending per capita per year increased by US$0·42 for LIC+ and decreased by US$0·24 for LIC- (p < 0·0001). LIC+ had a significantly lower private health spending per capita than LIC- (p < 0·012).InterpretationLIC+ had a difference in vaccination coverage compared to LIC- and LMIC that could not be explained by economic development, total health spending, nor aggregated DAH. The vaccination coverage success of LIC+ was associated with higher government health spending and lower private health spending, with the support of DAH on vaccines.
The multiple knapsack problem with grouped items aims to maximize rewards by assigning groups of items among multiple knapsacks, considering knapsack capacities. Either all items in a group are assigned or none at all. We propose algorithms which guarantee that rewards are not less than the optimal solution, with a bound on exceeded knapsack capacities. To obtain capacityfeasible solutions, we propose a binary-search heuristic combined with these algorithms. We test the performance of the algorithms and heuristics in an extensive set of experiments on randomly generated instances and show they are efficient and effective, i.e., they run reasonably fast and generate good quality solutions.
Introduction: Senegal has demonstrated catalytic improvements in national coverage rates for early childhood vaccination, despite lower development assistance for childhood vaccines in Senegal compared to other low and lower-middle income countries. Understanding factors associated with historical changes in childhood vaccine coverage in Senegal, as well as heterogeneities across its 14 regions, can highlight effective practices that might be adapted to improve vaccine coverage elsewhere. Methods: Childhood vaccination coverage rates, demographic information, and health system characteristics were identified from Senegal's Demographic and Health Surveys (DHS) and Senegal national reports. Multivariate logistic and linear regression analyses were performed to determine statistical associations of demographic and health system characteristics with respect to childhood vaccination coverage rates. Results: Factors associated with childhood vaccination coverage include urban residence, female literacy, skilled prenatal care, and self-reported ease of access to care when sick, considering travel distance to a healthcare facility and concerns over traveling alone. Higher coverage with less variability over time was reported in urban regions near the capital and the coast, with increased coverage in recent years in more rural and landlocked regions. Conclusion: Childhood vaccination was more likely among children whose mothers had higher literacy, received skilled prenatal care, and had perceived ease of access to care when sick. Overall, vaccination coverage is high in Senegal and disparities in coverage between regions have decreased significantly in recent years.
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