Policy opportunities and limitations of evidence-based planning for immunization: lessons learnt from a field trial in Bangladesh.

Despite success in scaling up immunization, the national immunization programme in Bangladesh remains challenged by persisting inequities in health access related to geographic location and social factors, including income and education status. In order to tackle these inequities in access, the national immunization programme has conducted a field trial of the evidence-based planning model in Bangladesh between 2011 and 2013, in 11 low-performing districts and 3 city corporations. The main elements of this intervention included bottleneck analysis in local areas, action planning and budgeting to correct the bottlenecks, and establishment of a monitoring system to track progress. Coverage improved in 8 out of 14 districts post intervention. The main success factors associated with the intervention included more analytic approaches to situation assessment and taking action on health inequities at the local level, as well as more considered use of local data to track immunization drop-outs. The main factors associated with coverage declines in trial areas (6 districts) included poor financial resourcing and supervisory support, and gaps and turnover in human resources. In order to sustain and improve coverage, it will be necessary in future to link pro-equity approaches to subdistrict planning to higher-level health-system-strengthening strategy and planning systems. This will ensure that local area planners have the required resources, comprehensive operational plans and political support to sustain implementation of corrective actions to address identified system bottlenecks and inequities in health access at the local level.

Measuring universal health coverage: a three-dimensional composite approach from Bhutan.

Background: In the early 1960s, the Kingdom of Bhutan began to develop its modern health-care system and by the 1990s had developed an extensive network of health-care facilities. These developments, in tandem with wider social and economic progress encapsulated in the Gross National Happiness concept, have resulted in major gains in child survival and life expectancy in the past 50 years. In order to sustain these gains, the country has identified a constitutional and healthpolicy mandate for universal access to health. Methods: Based on analysis of the literature, and qualitative and quantitative health data, this case study aims to provide an assessment of universal health coverage in Bhutan, and to identify the major challenges to measuring, monitoring and sustaining universal coverage. Results: The study reveals that the wide network of primary and secondary care, reinforced by constitutional and policy mandates, ensures high population coverage, as well as wide availability and accessibility of care, with significant levels of financial protection. This achievement has been attributable to sustained state investment in the sector over past decades. Despite this achievement, recent surveys have demonstrated gaps in utilization of health services and confirmed associations between socioeconomic variables and health access and outcomes, which raise important questions relating to both supply- and demand-side barriers in accessing health care. Conclusion: In order to sustain and improve the quality of universal health coverage, improved measurements of service availability at subnational levels and of the determinants of pockets of low service utilization are required. More rigorous monitoring of financial protection is also needed, particularly in relation to rates of public investment and the impact of out-of-pocket costs while accessing care. These approaches should assist improvements in quality and equity in universal health coverage, in the context of ongoing epidemiological, demographic and social transition.

Evaluation of immunization knowledge, practices, and service-delivery in the private sector in Cambodia.

A study of private-sector immunization services was undertaken to assess scope of practice and quality of care and to identify opportunities for the development of models of collaboration between the public and the private health sector. A questionnaire survey was conducted with health providers at 127 private facilities; clinical practices were directly observed; and a policy forum was held for government representatives, private healthcare providers, and international partners. In terms of prevalence of private-sector provision of immunization services, 93% of the private inpatient clinics surveyed provided immunization services. The private sector demonstrated a lack of quality of care and management in terms of health workers' knowledge of immunization schedules, waste and vaccine management practices, and exchange of health information with the public sector. Policy and operational guidelines are required for private-sector immunization practices that address critical subject areas, such as setting of standards, capacity-building, public-sector monitoring, and exchange of health information between the public and the private sector. Such public/private collaborations will keep pace with the trends towards the development of private-sector provision of health services in developing countries.