Tracking progress towards universal childhood immunisation and the impact of global initiatives:
a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage
Stephen S Lim PhD a, David B Stein BA a, Alexandra Charrow BA a, Prof Christopher JL Murray MD a
The Lancet, Volume 372, Issue 9655, Pages 2031 - 2046, 13 December 2008
doi:10.1016/S0140-6736(08)61869-3
Website: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61869-3/abstract [Subscription required]
Background: Substantial resources have been invested in increasing childhood immunisation coverage through global initiatives such as the Universal Childhood Immunisation (UCI) campaign and the Global Alliance on Vaccines and Immunisations (GAVI). There are longstanding concerns that target-oriented and performance-oriented initiatives such as UCI and GAVI's immunisation services support (ISS) might encourage over-reporting. We estimated the coverage of three doses of diphtheria, tetanus, and pertussis vaccine (DTP3) based on surveys using all available data.
Methods: We estimated DTP3 coverage by analysing unit record data from surveys and supplemented this with reported coverage from other surveys and administrative data. We used bidirectional distance-dependent regression to estimate trends in survey-based coverage in 193 countries during 1986—2006. We used standard time-series cross-sectional analysis to investigate any association in the difference between countries' official reports and survey-based coverage as the dependent variable and the presence of GAVI ISS as the independent variable, controlling for country and time effects.
Findings: Crude coverage of DTP3 based on surveys increased from 59% (95% uncertainty interval 51—65) in 1986 to 65% (60—68) in 1990, 70% (65—74) in 2000, and 74% (70—77) in 2006. There were substantial differences between officially reported and survey-based coverage during UCI. GAVI ISS significantly increased the difference between officially reported coverage and survey coverage. Up to 2006, in 51 countries receiving GAVI ISS payments, 7•4 million (5•7 million to 9•2 million) additional children were immunised with DTP3 based on surveys compared with officially reported estimates of 13•9 million. On the basis of the number of additional children immunised from surveys at a rate of US$20 each, GAVI ISS payments are estimated at $150 million (115 million to 184 million) compared with actual disbursements of $290 million.
Interpretation
Survey-based DTP3 immunisation coverage has improved more gradually and not to the level suggested by countries' official reports or WHO and UNICEF estimates. There is an urgent need for independent and contestable monitoring of health indicators in an era of global initiatives that are target-oriented and disburse funds based on performance….”
Prof Christopher J L Murray, Institute for Health Metrics and Evaluation,
Funding Bill & Melinda Gates Foundation.
Comments by:
David M Bishai,
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61853-X/fulltext
“…With close to 600 surveys from 193 countries, this definitive study confirms that the correlation between mothers’ reports and official reports is not good. Sometimes survey data indicate higher, sometimes lower, coverage than official reports. This news is a cause for concern because there might be an upward trend in officially reported rates of vaccine coverage that has occurred in the years since the GAVI Alliance (previously the Global Alliance on Vaccines and Immunizations) began to pay countries proportionally to the number of DTP3-vaccinated children.2 An upward trend would be good news, except that sometimes the upward trend is only in the official reports and not in the survey data. To put it bluntly, the authors are worried that financial incentives to report DTP3 coverage are biasing some of the official reports…”
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