Understanding the Effect of the GAVI Initiative on Reported Vaccination Coverage Levels

UNIVERSITY OF WASHINGTON

Accountability, transparency and corruption

in global health: the critical role of health

metrics and evaluation

Stephen S Lim

Assistant Professor of Global Health

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Outline

• Context

• Two examples• Tracking immunization coverage

• Conditional cash transfers to women for delivering in a health facility

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Outline

• Context



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Development Assistance (Billions US$) for Health by Institution, 1990, 2007

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Global goals, funders and initiativesGoals• 1978: Alma-Ata: Primary Health Care and Health for All• 1984: Universal childhood immunization by 1990• 2000: Millennium Development Goals• 2003: 3 by 5 – 3 million people on antiretroviral drugs by 2005• 2008: Malaria Elimination

Private philanthropic organizations• 2000: Bill and Melinda Gates Foundation• 2006: Warren Buffet pledged additional US$30 to BMGF

Global Health Initiatives• 2000: Global Alliance for Vaccines and Immunizations (GAVI)• 2002: Global Fund for Aids, Tuberculosis and Malaria (GFATM)• 2003: US President’s Emergency Plan for AIDS Relief (PEPFAR)• 2005: US President’s Malaria Initiative (PMI)• 2007: International Health Partnership (IHP+)

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National health sector reforms and programs

2001: Thailand Universal Coverage

• 30 Baht Scheme

2003/04: Mexico Health Sector Reforms

• System of Social Protection in Health including Seguro Popular

2005: Indian National Rural Health Mission

• Conditional cash transfers for women to give birth in health facilities

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Critical role of health metrics and evaluation

• High-quality measurement of health indicators and evaluation of programs is central to issues of transparency and accountability

• Are resources being used effectively?

• Have initiatives and reforms led to improvements in health system delivery and population health?

• Mounting pressure from funders, civil society, etc to document this

• Economic crisis has led to rising fears that development assistance budgets will be cut

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Outline

• Context



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Tracking childhood immunization coverage

• Substantial resources have been invested in delivering immunization services

• Basic vaccines, e.g. three-dose diptheria, pertussis and tetanus (DTP3) as well as new vaccines, e.g. HiB, rotavirus

• Global initiatives• 1984: Universal Childhood Immunization (UCI) by 1990 initiative, defined as 80%

immunization coverage

• 1999: Global Alliance on Vaccines and Immunizations (GAVI)

• Monitoring the extent of immunization delivery is critical for evaluating how effective these investments and initiatives have been

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• GAVI’s Immunization Services Support (ISS) is the funding that aims to increase coverage of basic vaccines such as three-dose diptheria, tetanus and pertussis (DTP3) vaccination.

• ISS payments are performance-based with funds disbursed in proportion to the number of additional children targeted or reported to receive DTP3.

• Number of additional children receiving DTP3 is based on official reports from countries to WHO and UNICEF.

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Two main questions:

1. What is the trend in the fraction of children receiving three-dose diptheria, tetanus and pertussis vaccination (DTP3 coverage) over the period 1986 to 2006?

2. Do target-oriented initiatives such as universal childhood immunization (UCI) and results-based financing initiatives such as GAVI’s Immunization Services Support (ISS) lead to over-reporting of DTP3 immunization coverage?

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Data sources• Micro-data from standardized multi-country surveys

• DHS, MICS, CDC• Crude coverage: three DTP vaccinations by maternal recall or card documented,

irrespective of vaccine schedule• Estimated for each birth cohort (up to 5 years prior to the survey)• 225 surveys

• Survey reports and WHO/UNICEF database:• 78 multi-country surveys• 142 country-specific surveys with sample size reported• 145 country-specific surveys without sample size reported

• Administrative data estimates based on health service provider registries• Reported routinely to WHO and UNICEF since 1990• Officially reported estimates since 1980

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Quick review of Immunization Services Support (ISS)

• Performance-based payment• Number of additional children reported by countries to have received DTP3

• Reports largely based on administrative data

• Baseline is the year prior to approval of the proposal

• US$20 is paid once per additional child

• Data quality audit (DQA) of administrative data system before reward payments commence (from Year 3)

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Estimating missing survey coverage

Two purposes:

1. Generate plausible estimates over time to allow monitoring of indicators

2. Reduce compositional bias in in causal inference that can stem from missing data

We use validated statistical approaches that are

• Objective

• Replicable

• Characterizes uncertainty

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Global trends in DTP3 coverage

Survey-based global coverage of DTP3 (black) with 95% uncertainty estimates compared to countries’ officially reported (red) and WHO and UNICEF estimates (blue), 1986 to 2006.

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Regional trends

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Does ISS lead to over-reporting?

• Statistical analysis of over-reporting (officially reported coverage minus survey coverage) by years since the GAVI ISS baseline

-0.05

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

-1 0 1 2 3 4 5 6 7 8

Years post-GAVI ISS baseline

Bet

a-co

effi

cien

t

BDDR - PCSE

BDDR - ABBB

Multiple Imputation - PCSE

Multiple Imputation - ABBB

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GAVI Immunization Services Support (ISS)• Number of additional children vaccinated in 51 countries receiving ISS

funding up to the year 2006 :• Based on official reports: 13.9 million• Survey-based: 7.3 (5.5 to 9.2) million

• ISS payments• Based on official reports: US$289 million• Survey-based: US$148 million

• Over-reporting is not uniform• 4 countries that reported increases, number of additional children did not increase• 6 overestimated by > 4x• 10 overestimated by > 2x but ≤ 4x• 23 overestimated by > 1x but ≤ 2x• 8 countries underestimated

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Implications

• At the global level, survey-based immunization coverage has increased continuously and gradually over the last 20 years• Reflects time and investment needed to expand health services

• Improvements more pronounced in some regions (e.g. Central, West sub-Saharan Africa) and countries (e.g. Cameroon) during recent time period

• Targets and payments for performance such as GAVI’s ISS can incentivize improvements but also lead to over-reporting

• Over-reporting likely reflects pressures throughout the reporting system to meet targets

• Monitoring and evaluation systems need to be based on independent, rigorous, empirical measurements that are robust to these effects

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Outline

• Context



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Janani Suraksha Yojana – “Safe motherhood scheme”

• Launched in 2005; 100% centrally funded

• Goal: reduce maternal and neonatal mortality

• Works by incentivizing women to deliver in a health facility

• Implemented through Accredited Social Health Activists (ASHAs)

• ASHAs also receive a cash benefit

• Budget allocation of US$342 million in 2009-10

Accredited Social Health Activist (ASHA)Madhya Pradesh, IndiaPhoto: Department for International Development, UKAID

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National guidelines, Eligibility

In 10 high-focus states • All pregnant women delivering in government

facility or accredited private institutions

Other states & home deliveries• Below the Poverty Line

• >19 years of age

• First two live births

• Targeted to women from scheduled caste or tribe

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National guidelines, Cash payments

Rural Urban

Mothers ASHA Mothers ASHA

High-focus states 1,400 600 1,000 200

Other states 700 600 600 200

Home deliveries 500 500

1 U.S. dollar ~ 45 Indian Rupees

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Questions

• What is the level of implementation of JSY at district and state-levels?

• Is JSY reaching its intended beneficiaries?

• Does receipt of financial assistance under JSY lead to increased antenatal care and in-facility delivery and reduced perinatal, neonatal and maternal mortality?

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Data

• India District-level Household Surveys (DLHS)• DLHS-2: ~1,000 households from 593 districts, 2002 to 2004

• DLHS-3: 1,000 to 1,500 households from 611 districts, late 2007 to early 2009

• Ever-married women aged 15 to 44, for most recent pregnancy• Antenatal care (no. of visits)

• Delivery care (type of provider, location)

• Outcome (live birth, still birth, spontaneous or induced abortion)

• Survival of the child in the case of a live birth

• Receipt of financial assistance under JSY (DLHS-3)

• Individual and household characteristics, e.g. asset-based wealth, caste, education, location of residence and distance to facility

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In-facility birth coverage, 2001 to 2003 Births receiving JSY, 2007/08

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JSY uptake by socioeconomic indicators, national-level

02468

1012141618

Urban Rural, 0-4 Rural, 5-9 Rural, 10-19 Rural, 20+

% JS

Y

Residence, distance from facility (km)

02468

1012141618

no education < primary < secondary ≥ secondary

% JS

Y

Maternal Education

02468

1012141618

sched. caste sched. tribe other caste/tribe

other

% JS

Y

Caste/Tribe

02468

1012141618

1 2 3 to 5 5 or more

% JS

YNumber of Births

02468

1012141618

1 (Poorest) 2 3 4 5 (Richest)

% JS

Y

Wealth Quintile

02468

1012141618

15-19 20-24 25-29 30-24 35-39 40-44

% JS

Y

Maternal Age (years)

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In-facility birth coverage, 2001-2003 In-facility birth coverage, 2007/08

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Evaluating impact of JSY on coverage and outcomes

• Exact matching• Match births receiving JSY to those not receiving JSY in DLHS-3

• Matching covariates: urban/rural residence, BPL card ownership, wealth quintile, caste, education, parity, and maternal age

• Logistic regression on matched data allows more precise control for confounders

• With-vs-without• Logistic regression, comparing births receiving JSY to births that did not receive

JSY in DLHS-3 and all births in DLHS-2

• District-level differences-in-differences• Compare districts by level of JSY uptake, controlling for baseline differences

(DLHS-2)

• 580 district aggregates from DLHS-2 to DLHS-3.

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Outcomes

Intervention coverage

• Antenatal care with at least three visits

• In-facility birth

• Skilled birth attendance (in-facility birth or birth outside of a facility with a skilled attendant)

Mortality

• Perinatal death (stillbirth or death up to and including 7 days after a live birth)

• Neonatal death (death up to and including 1 month after a live birth)

• Maternal mortality* (death of women aged 15 to 49 during pregnancy or up to 6 weeks after birth or termination)

* In district-level analysis only

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Potential confounders

Controlled for:

• maternal age;

• number of live births;

• birth interval;

• single or multiple birth;

• maternal education;

• household wealth based on asset ownership;

• caste/tribe;

• religion; and

• location of residence with respect to distance to the nearest health facility

• Varied using district, state-level fixed and random effects

JSY and intervention coverage, national level

ANC, 3 visits In-facility birth Skilled birth attendance*

∆ Probability (95% CI)

∆ Probability(95% CI)

∆ Probability(95% CI)

District Diff-in-Diff

0.110 (0.047, 0.172)

0.492 (0.432, 0.551)

0.413 (0.352, 0.474)

Matching 0.111 (0.101, 0.122)

0.475 (0.468, 0.482)

0.400 (0.394, 0.406)

With-vs-without

0.109 (0.100, 0.119)

0.438 (0.431, 0.444)

0.356 (0.350, 0.362)

Change in probability of receiving intervention: JSY vs no JSY

Impact on mortality, national level

Perinatal mortal(per 1,000 live

births)

Neonatal mortality(per 1,000 live

births)

Maternal mortality(per 100,000 live

births)

∆ probability(95% CI)



District Diff-in-Diff

-13.2(-30.1, 3.7)

-5.4 (-19.8, 8.9)

105.0(-247.3, 457.2)

Matching -3.6(-5.2, -2.1)

-2.2(-3.7, -0.8)

NA

With-vs-without

-4.1(-5.6, -2.5)

-2.4(-4.1, -0.8)

NA

Change in probability of death: JSY vs no JSY

Variation by State: Intervention coverage

ANC, 3 visits In-facility birth Skilled birth attendance




High-focus states 0.108(0.096, 0.120)

0.629(0.621, 0.637)

0.573(0.566, 0.580)

Northeastern states

0.137(0.102, 0.172)

0.353(0.320, 0.386)

0.307(0.277, 0.337)

Other states 0.036(0.022, 0.049)

0.068(0.054, 0.083)

0.051(0.339, 0.063)

Variation by State: Mortality

Perinatal mortality(per 1,000 live

births)

Neonatal mortality(per 1,000 live

births)



High-focus states -2.7(-5.0, -0.4)

-1.4(-3.5, 0.7)

Northeastern states -2.4(-6.1, 1.3)

-0.1(-4.0, 3.8)

Other states -5.2(-7.4, -3.0)

-4.1(-6.1, -2.1)

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Implications

• Varied uptake of JSY across states; not reaching the very poor

• Increases in ANC coverage and intra-partum care coverage

• Likely reductions in perinatal and stillbirth/neonatal mortality

• But potential quality of care issues in high-focus states indicates

• Alternative monitoring approach needed for maternal mortality

• Continued monitoring and evaluating the program is critical

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Summary

• Substantial resources are being directed towards improving population health

• Need to track in a valid, reliable and comparable way health indicators and evaluate the impact of programs

• Ensure that increased resources for health are being utilized intended purpose and are making a difference to the health of populations

• Increasing relevance during a time of global financial crisis

• Independent and empirically-based monitoring of health indicators and evaluation of programs

Understanding the Effect of the GAVI Initiative on Reported Vaccination Coverage Levels

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