National legislation and spending on vaccines in Latin America and the Caribbean.

This study examined the dynamics of vaccine spending and vaccine legislation in the Americas Region over the period 1980-2013. Annual vaccine expenditures from thirty-one countries were extracted from the Pan American Health Organization Revolving Fund database. Information on vaccine laws and regulations was provided by the PAHO Family, Gender, and Life Course Unit. Both time series and event history models were estimated. The results show that passing an immunization law led a representative country to increase its vaccine spending, controlling for income, infant mortality, population size, and DPT3 vaccine coverage. Countries with higher vaccine coverage were also more likely to have passed laws. Conversely, higher income countries were less likely to have vaccine laws. Vaccine legislation will likely play a similarly important role in other regions as more countries move towards immunization program ownership.

Country Ownership And Gavi Transition: Comprehensive Approaches To Supporting New Vaccine Introduction.

Since the mid-2000s low- and lower-middle-income countries have been focusing on developing and using evidence for immunization policy making, with an increasing emphasis on cost-effectiveness analysis, program costing, and financial flows-particularly for the introduction of newer, more expensive vaccines. While this is critical to informing decisions, countries still need to increase national immunization investment and explore innovative approaches to augment financing of immunization programs. The need for increased financing is especially strong in countries transitioning from support by Gavi, the Vaccine Alliance. With increased fiscal space to finance health and immunization programs as a result of improved economic performance, low- and lower-middle-income countries can reach the health status enjoyed by wealthier nations within a generation. However, new strategies and approaches related to domestic resources for immunization programs are needed to achieve this goal. Governments will need to increase their investments and modify existing external immunization financing arrangements if country ownership of immunization programs and the full promise of new vaccines are to be realized.

Routes Countries Can Take To Achieve Full Ownership Of Immunization Programs.

A goal of the Global Vaccine Action Plan, led by the World Health Organization, is country ownership by 2020, defined here as the point when a country fully finances its routine immunization program with domestic resources. This article reports the progress made toward country ownership in twenty-two lower- and lower-middle-income countries engaged in the Sabin Vaccine Institute's Sustainable Immunization Financing Program. We focus on new practices developed in the key public institutions concerned with immunization financing, budget and resource tracking, and legislation, using case studies as examples. Our analysis found that many countries are undertaking new funding mechanisms to reach financing goals. However, budget transparency remains a problem, as only eleven of the twenty-two countries have performed sequential analyses of their immunization program budgets. Promisingly, six countries (Cameroon, the Republic of the Congo, Nepal, Nigeria, Senegal, and Uganda) are creating new national immunization funding sources that are backed by legislation. Seven countries already have laws regarding immunization, and new immunization legislative projects are under way in thirteen others.

An analysis of government immunization program expenditures in lower and lower middle income countries 2006-12.

Financing is becoming increasingly important as the cost of immunizing the world's children continues to rise. By 2015, that cost will likely exceed US$60 per infant as new vaccines are introduced into national immunization programs. In 2006, 51 lower and lower middle income countries reported spending a mean US$12 per surviving infant on routine immunization. By 2012, the figure had risen to $20, a 67% increase. This study tests the hypothesis that lower and lower middle income countries will spend more on their routine immunization programs as their economies grow. A panel data regression approach is used. Expenditures reported by governments annually (2006-12) through the World Health Organization/UNICEF Joint Reporting Form are regressed on lagged annual per capita gross national income (GNI), controlling for prevailing mortality levels, immunization program performance, corruption control efforts, geographical region and correct reporting. Results show the expenditures increased with GNI. Expressed as an elasticity, the countries spent approximately $6.32 on immunization for every $100 in GNI increase from 2006 to 2012. Projecting forward and assuming continued annual GNI growth rates of 10.65%, countries could be spending $60 per infant by 2020 if national investment functions increase 4-fold. Given the political will, this result implies countries could fully finance their routine immunization programs without cutting funding for other programs.

Psychosocial processes and sexual initiation among Ghanaian youth.

This study models primary abstinence and age at first sex in a cross-sectional sample of Ghanaian youth aged 17 to 22 years. The aim is to examine how reproductive knowledge and social cognitive factors jointly affect the choice to initiate sex. Among males, the authors find that reproductive knowledge is negatively associated with abstinence. Its negative association, however, is moderated by the extent of adult support a respondent receives. Among females, reproductive knowledge is positively associated with abstinence. Its positive association is moderated by the extent of household sex communication. Correspondingly, when age at first sex is modeled, knowledge is a negative predictor among females. Its effects are mediated by household sex communication. A third social cognitive variable, perceived permissive peer attitudes about sex, is not associated with knowledge but is a protective factor for sexual initiation for both sexes. Though causal direction cannot be established, the results suggest that cognition affects sexual initiation both directly and through complex social mechanisms. The evidence provides theoretical support for comprehensive adolescent sexual and reproductive health interventions that promote abstinence and other safe sex behaviors through social as well as individual pathways.

Creating sustainable financing and support for immunization programs in fifteen developing countries.

Immunization programs are important tools for reducing child mortality, and they need to be in place for each new generation. However, most national immunization programs in developing countries are financially and organizationally weak, in part because they depend heavily on funding from foreign sources. Through its Sustainable Immunization Financing Program, launched in 2007, the Sabin Vaccine Institute is working with fifteen African and Asian countries to establish stable internal funding for their immunization programs. The Sabin program advocates strengthening immunization programs through budget reforms, decentralization, and legislation. Six of the fifteen countries have increased their national immunization budgets, and nine are preparing legislation to finance immunization sustainably. Lessons from this work with immunization programs may be applicable in other countries as well as to other health programs.

Social integration and health behavioral change in San Luis, Honduras.

This study explores the effects of social integration on behavioral change in the course of an intensive, community-based public health intervention. The intervention trained volunteers and mobilized local organizations to promote 16 key family health practices in rural San Luis, Honduras, during 2004 to 2006. A mixed methods approach is used. Standard household sample surveys were performed in 22 villages before and after the intervention. Eight villages were then resurveyed. A household survey, focus groups, and key informant interviews measured health behaviors and several social structural and psychosocial variables. The villages were then ranked on their mean behavioral and social integration scores. The quantitative and qualitative rankings were in close agreement (Kendall's coefficient of concordance = .707, p < .001). Behaviors changed most markedly in the villages where respondents participated in local organizations, observed that others performed those behaviors, and depended on their neighbors for support. The results show that social integration conditions health behavioral change. Health interventions can be made more effective by analyzing these features a priori.

The health benefits of social mobilization: experiences with community-based Integrated Management of Childhood Illness in Chao, Peru and San Luis, Honduras.

This article reviews the implementation of the community component of the Integrated Management of Childhood Illness (IMCI) strategy in Chao, Peru (2001 to 2004) and San Luis, Honduras (2003 to 2005). An evaluation was conducted in 2005 and included a project documentation review, key-informant interviews, and a household level baseline and follow-up survey of the WHO/UNICEF key family practices in each intervention site. The promotion of the key family practices in Chao and San Luís demonstrated measurable success. In comparison with the initial survey in 2002, the percentage of participant mothers ( N = 78) in Chao in 2004 who knew that they should breastfeed exclusively for at least six months increased from 33% to 94%; the presentation of complete vaccination records for one-year-old children increased by 19%; the recognition of danger signs for pneumonia increased 18% and for diarrhea by 8%; and the percentage of mothers who received four or more prenatal check-ups increased by 25%. A dramatic reduction in malaria cases was also attributed to the intervention in Chao. In San Luis, a quasi-experimental, random household sample ( N = 300) showed that the incidence of diarrheal disease among children under five years old declined by 18% between survey rounds (from 44% in August 2004 to 26% in December 2005). Social mobilization has promoted inter-sector consensus-building around community health issues, especially those related to maternal and child health. The promotion of the participation of representatives from various organizations via the community IMCI social-actor methodology has led to increased civic cooperation. Positive changes in health behaviors have been documented through an increase in preventive health practices, greater demand for primary health care services, and concrete community actions to improve public health.

The health benefits of social mobilization: experiences with community-based Integrated Management of Childhood Iliness in Chao, Peru and San Luis, Honduras

This article reviews the implementation of the community component of the Integrated Management of Childhood Illness (IMCI) strategy in Chao, Peru (2001 to 2004) and San Luis, Honduras (2003 to 2005). An evaluation was conducted in 2005 and included a project documentation review, key informant interviews, and a household level baseline and follow up survey of the WHO UNICEF key family practices in each intervention site. The promotion of the key family practices in Chao and San Lu is demonstrated measurable success. In comparison with the initial survey in 2002, the percentage of participant mothers (N equal 78) in Chao in 2004 who knew that they should breastfeed exclusively for at least six months increased from 33 percent to 94 percent; the presentation of complete vaccination records for one year old children increased by 19 percent; the recognition of danger signs for pneumonia increased 18 percent and for diarrhea by 8 percent; and the percentage of mothers who received four or more prenatal check-ups increased by 25 percent. A dramatic reduction in malaria cases was also attributed to the intervention in Chao. In San Luis, a quasi experimental, random household sample (N equal 300) showed that the incidence of diarrheal disease among children under five years old declined by 18 percent between survey rounds (from 44 percent in August 2004 to 26 percent in December 2005). Social mobilization has promoted inter sector consensus building around community health issues, especially those related to maternal and child health. The promotion of the participation of representatives from various organizations via the community IMCI social actor methodology has led to increased civic cooperation. Positive changes in health behaviors have been documented through an increase in preventive health practices, greater demand for primary health care services, and concrete community actions to improve public health. (AU)

The costs of scaling up vaccination in the world's poorest countries.

We examine the relationship between country-level average costs and coverage levels for diptheria-pertussis-tetanus (DTP) vaccines. Coverage data are from the World Health Organization, and cost data are from financial sustainability plans filed with the Global Alliance for Vaccines and Immunization (GAVI) by forty countries from 2000 to 2003. In this data set, average costs are lower for countries that vaccinate more children. At the highest numbers of covered children, there was no trend toward higher average costs. Vaccine programs in this set of poor countries have not yet scaled up to the point at which diminishing marginal returns are observed.

Evaluating program effects on institutional delivery in Peru.

We evaluate the joint effects of two targeted Peruvian health programs on a mother's choice of whether to deliver in a public emergency obstetric care (EmOC) facility. The national maternal and child health insurance, or SMI Program, provided delivery care coverage to Peru's poorest households beginning in 1998. During 1996-2002, Proyecto 2000 sought to improve the quality of EmOC and increase utilization of public EmOC facilities in the districts reporting the highest maternal and neonatal mortality levels. Our data come from the Proyecto 2000 endline evaluation, which sampled 5335 mothers living in the catchment areas of 29 treatment and 29 matched control EmOC facilities. Using propensity scoring and two quality of care indices, we find significantly higher quality of care in Proyecto 2000 treatment facilities. Using variance components logistic models, we find a mother enrolled in the SMI Program was more likely to have delivered her last child in a public EmOC, controlling for household constraints. Residence in a Proyecto 2000 treatment area did not significantly affect the choice. A cross-level interaction term was insignificant, indicating the two program effects were independent.

The role of public health programmes in reducing socioeconomic inequities in childhood immunization coverage.

OBJECTIVES: This paper asks whether intensive outreach services can eliminate socioeconomic differentials in vaccine coverage. METHODS: In 1990, the Matlab Maternal and Child Health/Family Planning Project (MCH-FP) surveyed 4238 respondents in an intervention area that received outreach and 3708 respondents in a comparison area in rural Bangladesh. Interacted multiple regression methods assessed the degree to which various socioeconomic indicators predicted the probability of vaccine receipt in each area. RESULTS: Low parental schooling, small dwelling size and female gender were significantly associated with incomplete vaccination in the comparison area, where only the limited government services existed. Residence in the MCH-FP outreach area greatly reduced, and in some cases eliminated, the effects of these socioeconomic barriers to vaccine receipt. CONCLUSIONS: Public health programmes utilizing outreach can reduce prevailing gender and socioeconomic differentials in vaccine receipt.