The growing demand for spatially detailed data to advance the Sustainable Development Goals agenda of 'leaving no one behind' has resulted in a shift in focus from aggregate national and province-based metrics to small areas and high-resolution grids in the health and development arena. Vaccination coverage is customarily measured through aggregate-level statistics, which mask fine-scale heterogeneities and 'coldspots' of low coverage. This paper develops a methodology for high-resolution mapping of vaccination coverage using areal data in settings where point-referenced survey data are inaccessible. The proposed methodology is a binomial spatial regression model with a logit link and a combination of covariate data and random effects modelling two levels of spatial autocorrelation in the linear predictor. The principal aspect of the model is the melding of the misaligned areal data and the prediction grid points using the regression component and each of the conditional autoregressive and the Gaussian spatial process random effects. The Bayesian model is fitted using the INLA-SPDE approach. We demonstrate the predictive ability of the model using simulated data sets. The results obtained indicate a good predictive performance by the model, with correlations of between 0.66 and 0.98 obtained at the grid level between true and predicted values. The methodology is applied to predicting the coverage of measles and diphtheria-tetanus-pertussis vaccinations at 5 × 5 km in Afghanistan and Pakistan using subnational Demographic and Health Surveys data. The predicted maps are used to highlight vaccination coldspots and assess progress towards coverage targets to facilitate the implementation of more geographically precise interventions. The proposed methodology can be readily applied to wider disaggregation problems in related contexts, including mapping other health and development indicators.

BackgroundNon-communicable diseases (NCD) pose challenges to Cambodia’s health system. Medicines for NCD are on the National Essential Medicines List but no clinical guidelines support their utilization. Two social health protection schemes aimed at the informal sector population exist (Health Equity Funds and Insurance) together with two disease-specific interventions (a Peer Educator Network and Chronic Diseases Clinics) targeted at NCD patients. This study examines performance of these various schemes in relation to NCD.MethodsCross-sectional household survey among 709 individuals self-reporting diabetes and/or hypertension in three geographical locations in rural Cambodia using a structured questionnaire investigating diagnostic and treatment pathways, health seeking behaviour, health expenditures, and financial coping mechanisms.ResultsTwo third of respondents with NCD were female and 55% did not belong to any scheme. The majority (59%) were diagnosed in the private sector and only 56% were on allopathic treatment that was mainly sought in the private sector (49%). Outpatient treatment cost was higher in the private sector and when using multiple providers of care. The majority were indebted, 11% due to health-related expenses. Contrary to social health protection schemes, disease-specific interventions offered better access to allopathic treatment and provided medicines in accordance with NEML.ConclusionThe benefit packages of existing social health protection schemes and services in the public health sector should be adjusted to cater for the needs of people living with NCD in rural Cambodia. Initiatives that offer active disease management strategies and promote patients and community participation appear more successful in increasing treatment adherence and decreasing the risk of financial hardship.

BackgroundUniversal health coverage implies that people obtain the health services they need without experiencing financial hardship. While the factors contributing to catastrophic health expenditure (CHE) among households are well understood, few studies have examined this relationship in the context of environmentally vulnerable regions, such as tropical deltas. This study aims to examine the disparities in the prevalence of CHE and impoverishment due to out-of-pocket (OOP) healthcare payments in the Mekong Delta in comparison with rest of Vietnam. It also intends to investigate the associations between economic and environmental shocks, CHE and the impoverishment from healthcare payments.MethodsUsing data from the Vietnam Household Living Standards Survey 2012, the prevalence of CHE was estimated from the fraction of healthcare costs in relation to household consumption expenditure. The poverty headcount was estimated using the total household consumption expenditure considering both with and without OOP expenditure for healthcare in comparison with the national poverty-line. Simple and multiple logistic regression models were used to examine the associations between geography, health systems, environmental and demographic variables and OOP healthcare expenditure related CHE, and impoverishment respectively.ResultsBoth the level of OOP household healthcare expenditure and the proportion of households suffering from impoverishment as the result of such payments were higher in the Mekong Delta region compared to rest of Vietnam. Although the results from the multiple regression analysis showed that households in the Mekong Delta region were significantly less likely to suffer from CHE, they were significantly more likely to be impoverished due to OOP healthcare expenditure. While health insurance membership did not have a significant effect on either outcomes, households that faced an economic or an environmental shock in past 5 years were considerably more likely to suffer from CHE and impoverishment from OOP healthcare payments.ConclusionsThe findings suggest that the financial protection capacity of health insurance schemes in Vietnam should be improved and expanded to reduce impoverishment as the result of OOP healthcare payments, particularly in the Mekong Delta region. Additional investments in disaster preparedness strategies can further help to reduce the financial burden of households in this environmentally vulnerable region.

BackgroundSub-Saharan Africa continues to account for the highest regional maternal mortality ratio (MMR) in the world, at just under 550 maternal deaths per 100,000 live births in 2015, compared to a global rate of 216 deaths. Spatial inequalities in access to life-saving maternal and newborn health (MNH) services persist within sub-Saharan Africa, however, with varied improvement over the past two decades. While previous research within the East African Community (EAC) region has examined utilisation of MNH care as an emergent property of geographic accessibility, no research has examined how these spatial inequalities have evolved over time at similar spatial scales.MethodsHere, we analysed temporal trends of spatial inequalities in utilisation of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) among four East African countries. Specifically, we used Bayesian spatial statistics to generate district-level estimates of these services for several time points using Demographic and Health Surveys data in Kenya, Tanzania, Rwanda, and Uganda. We examined temporal trends of both absolute and relative indices over time, including the absolute difference between estimates, as well as change in performance ratios of the best-to-worst performing districts per country.ResultsAcross all countries, we found the greatest spatial equality in ANC, while SBA and PNC tended to have greater spatial variability. In particular, Rwanda represented the only country to consistently increase coverage and reduce spatial inequalities across all services. Conversely, Tanzania had noticeable reductions in ANC coverage throughout most of the country, with some areas experiencing as much as a 55% reduction. Encouragingly, however, we found that performance gaps between districts have generally decreased or remained stably low across all countries, suggesting countries are making improvements to reduce spatial inequalities in these services.ConclusionsWe found that while the region is generally making progress in reducing spatial gaps across districts, improvement in PNC coverage has stagnated, and should be monitored closely over the coming decades. This study is the first to report temporal trends in district-level estimates in MNH services across the EAC region, and these findings establish an important baseline of evidence for the Sustainable Development Goal era.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-6241-8) contains supplementary material, which is available to authorized users.