https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)60325-0.pdf

Achieving child survival goals: potential contribution of community health workers

Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health

This book was commissioned by the Department of Ethics, Equity, Trade and Human Rights as part of the work undertaken by the Priority Public Health Conditions Knowledge Network of the Commission on Social Determinants of Health, in collaboration with 16 of the major public health programmes of WHO: alcohol-related disorders, cardiovascular diseases, child health, diabetes, food safety, HIV/AIDS, maternal health, malaria, mental health, neglected tropical diseases, nutrition, oral health, sexual and reproductive health, tobacco and health, tuberculosis, and violence and injuries. In addition to this, through collaboration with the Special Programme of Research, Development and Research Training in Human Reproduction, the Special Programme for Research and Training in Tropical Diseases, and the Alliance for Health Policy and Systems Research, 13 case studies were commissioned to examine the implementation challenges in addressing social determinants of health in low-and middle-income settings. The Priority Public Health Conditions Knowledge Network has analysed the impact of social determinants on specific health conditions, identified possible entry-points, and explored possible interventions to improve health equity by addressing social determinants of health.

Equity, social determinants and public health programmes.

Objective To assess the efficacy of modest non-financial incentivesonimmunisationratesinchildrenaged1-3and to compare it with the effect of only improving the reliability of the supply of services. Design Clustered randomised controlled study. Setting Rural Rajasthan, India. Participants 1640 children aged 1-3 at end point. Interventions 134 villages were randomised to one of threegroups:aoncemonthlyreliableimmunisationcamp

https://www.bmj.com/content/bmj/340/bmj.c2220.full.pdf

Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives.

It is often argued that cost-sharing—charging a subsidized, positive price—for a health product is necessary to avoid wasting resources on those who will not use or do not need the product. We explore this argument through a field experiment in Kenya, in which we randomized the price at which prenatal clinics could sell long lasting anti-malarial insecticide-treated nets (ITNs) to pregnant women. We find no evidence that costsharing reduces wastage on those that will not use the product: women who received free ITNs are not less likely to use them than those who paid subsidized positive prices. We also find no evidence that costsharing induces selection of women who need the net more: those who pay higher prices appear no sicker than the average prenatal client in the area in terms of measured anemia (an important indicator of malaria). Cost-sharing does, however, considerably dampen demand. We find that uptake drops by 75 percent when the price of ITNs increases from zero to $0.75 (i.e. from 100 to 87.5 percent subsidy), the price at which ITNs are currently sold to pregnant women in Kenya. We combine our estimates in a cost-effectiveness analysis of ITN prices on child mortality that incorporates both private and social returns to ITN usage. Overall, our results suggest that free distribution of ITNs could save many more lives than cost-sharing programs have achieved so far, and, given the large positive externality associated with widespread usage of ITNs, it would likely do so at a lesser cost per life saved.

/pdf/free-distribution-or-cost-sharing-evidence-from-a-randomized-1hk9oc6jjf.pdf

Free Distribution or Cost-Sharing? Evidence from a Randomized Malaria Prevention Experiment

Objective To achieve high and equitable coverage of insecticide-treated bednets by integrating their distribution into a measles vaccination campaign. Methods In December 2002 in the Lawra district in Ghana, a measles vaccination campaign lasting 1 week targeted all children aged 9 months–15 years. Families with one or more children less than five years old were targeted to receive a free insecticide-treated bednet. The Ghana Health Service, with support from the Ghana Red Cross and UNICEF, provided logistical support, volunteer workers and social mobilization during the campaign. Volunteers visited homes to inform caregivers about the campaign and encourage them to participate. We assessed pre-campaign coverage of bednets by interviewing caregivers leaving vaccination and distribution sites. Five months after distribution, a two-stage cluster survey using population-proportional sampling assessed bednet coverage, retention and use. Both the pre-campaign and post-campaign survey assessed household wealth using an asset inventory. Findings At the campaign exit interview 636/776 (82.0%) caregivers reported that they had received a home visit by a Red Cross volunteer before the campaign and that 32/776 (4.1%) of the youngest children in each household who were less than 5 years of age slept under an insecticide-treated bednet. Five months after distribution caregivers reported that 204/219 (93.2%) of children aged 9 months to 5 years had been vaccinated during the campaign; 234/248 (94.4%) of households were observed to have an insecticide-treated bednet; and 170/249 (68.3%) were observed to have a net hung over a bed. Altogether 222/248 (89.5%) caregivers reported receiving at least one insecticide-treated bednet during the campaign, and 153/254 (60.2%) said that on the previous night their youngest child had slept under a bednet received during the campaign. For households in the poorest quintile, post-campaign coverage of insecticide-treated bednets was 10 times higher than pre-campaign coverage of households in the wealthiest quintile (46/51 (90.2%) versus 14/156 (9.0%)). The marginal operational cost was US$ 0.32 per insecticide-treated bednet delivered. Conclusion These findings suggest that linking bednet distribution to measles vaccination campaigns may provide an important opportunity for achieving high and equitable coverage of bednets.

/pdf/distributing-insecticide-treated-bednets-during-measles-5fecexhlxa.pdf

Distributing insecticide-treated bednets during measles vaccination: a low-cost means of achieving high and equitable coverage.

Summary Population coverage of insecticide-treated nets (ITNs) in Africa falls well below the Abuja target of 60% while coverage levels achieved during vaccination campaigns in the same populations typically exceed 90%. Household (HH) cost of ITNs is an important barrier to their uptake. We investigated the coverage, equity and cost of linking distribution of free ITNs to a measles vaccination campaign. During a national measles vaccination campaign in Zambia, children in four rural districts were given a free ITN when they received their measles vaccination. In one urban district, children were given a voucher, which could be redeemed for a net at a commercial distribution site. About 1700 HHs were asked whether they received vaccination and an ITN during a measles campaign, as well as questions on assets (e.g. type roofing material or bicycle ownership) to assess HH wealth. Net ownership was calculated for children in each wealth quintile. In the rural areas, ITN coverage among children rose from 16.7% to 81.1% and the equity ratio from 0.32 to 0.88 and in the urban area from 50.7% to 76.2% (equity ratio: 0.66‐1.19). The operational cost per ITN delivered was $0.35 in the rural area with direct distribution and $1.89 in the urban areas with voucher distribution. Mass distribution of ITNs through vaccination campaigns achieves rapid, high and equitable coverage at low cost.

/pdf/integrating-insecticide-treated-bednets-into-a-measles-3c6evwi2tu.pdf

Integrating insecticide-treated bednets into a measles vaccination campaign achieves high, rapid and equitable coverage with direct and voucher-based methods

DONNEES DE BASE La distribution de masse, gratuite (rattrapage) de moustiquaires traitees aux insecticides (MTI) durant les campagnes de vaccination contre la rougeole, permet la couverture immediate, etendue et equitable a la fois pour les MTI et pour le vaccin contre la rougeole. Le maintien d'une couverture etendue au cours du temps necessite l'acces continue et a long terme a de nouvelles moustiquaires (maintien). Nous avons investigue les effets de trois annees de campagne de rattrapage suivie d'un marketing social base sur la clinique, pour le maintien continue de la couverture et de l'usage des MTI. METHODES En decembre 2002, les MTI ont ete distribues a tous les enfants participant a une campagne de vaccination contre la rougeole dans un district rural du Ghana. Au cours des trois annees suivant la campagne, le district a commence a offrir des MTI a un prix subventionne aux femmes enceintes visitant les cliniques prenatales. Ce schema de maintient n'est seulement devenu totalement operationnel que deux ans apres la campagne. Une enquete sur la couverture a ete menee pendant 38 mois apres la campagne en utilisant une methode standard d'echantillonnage a deux niveaux. RESULTATS La couverture en moustiquaires etait haut elevee grâce aux contributions combinees du rattrapage et du maintien. 475 menages dans l'etude avait au moins un enfant de moins de cinq ans. Parmi ces menages, la couverture etait de 95,6% pour n'importe quel type de filet, 83,8% pour un filet obtenu via la campagne de promotion et 73,9% pour un MTI. De tous les enfants, 95,7% dormaient dans un menage ayant un filet, 86,1% dormaient dans un menage ayant un filet obtenu via la campagne. Tous les filets disponibles n'etaient pas utilises car seuls 59,6% des enfants dormaient sous une MTI. La source des filets etait dans 77,7% des cas, la campagne et dans 20% des cas, les cliniques habituelles. Compare aux menages qui ont participe a la campagne, les menages avec des enfants nes apres la campagne avaient des taux plus eleves de possession de filets (75,1% contre 67,7%; P = 0,04). L'equite etait elevee car le rapport entre la couverture dans la quintile la moins riche et celle dans la quintile la plus riche etait de 0,95 pour la possession de MTI et de 1,08 pour l'usage des MTI. Ces taux de couverture et d'usage etaient similaires a ceux precedemment rapporte dans une etude avec 5 mois de suivie post campagne et qui suggerait aucune diminution sur trois ans. CONCLUSION Un niveau de couverte elevee et d'usage de MTI a ete atteint et maintenu par une campagne sequentielle de masse basee sur la communaute par un rattrapage et un maintien de la distribution au niveau de la clinique. Les filets de la campagne de promotion ont couvert pratiquement tous les menages existants alors que la distribution au niveau de la clinique fournissait des filets pour les nouveaux espaces de sommeil survenus apres la campagne. Comme les filets peuvent etre partages et la plupart des enfants sont nes dans des familles ayant deja un filet, le nombre de nouveaux filets requis pour maintenir la couverture etendue est substantiellement inferieur au nombre d'enfants nouveau-nes. La strategie de rattrapage/ maintien combinant des campagnes de masse pour les enfants et la distribution aux femmes enceintes au niveau des cliniques est une strategie efficace pour atteindre et maintenir une couverture etendue en terme de filets. Assurer l'usage approprie des filets demeure un autre defi.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-3156.2007.01862.x

Sustained high coverage of insecticide‐treated bednets through combined Catch‐up and Keep‐up strategies

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(05)67216-9.pdf

Public-health impact of accelerated measles control in the WHO African Region 2000–03

Despite achieving and sustaining global measles vaccination coverage of about 80% over the past decade, worldwide measles remains the fifth leading cause of mortality among children aged <5 years. In May 2002, the United Nations Special Session on Children endorsed the goal of reducing measles deaths by half by 2005. Countries and World Health Organization (WHO) regions that adopted aggressive measles control or elimination strategies have shown excellent results. In 2001, countries in the Americas reported an all time low of 537 confirmed measles cases. Substantial progress in measles control has also been achieved in the WHO Western Pacific Region, in seven southern African countries, and in selected countries in WHO European, Eastern Mediterranean, and Southeast Asian regions. The ongoing measles disease burden and availability of safe and effective measles mortality reduction strategies make a compelling case to complete the unfinished agenda of measles immunization.

Mark Grabowsky

Papers

Distributing insecticide-treated bednets during measles vaccination: a low-cost means of achieving high and equitable coverage.

Integrating insecticide-treated bednets into a measles vaccination campaign achieves high, rapid and equitable coverage with direct and voucher-based methods

Sustained high coverage of insecticide‐treated bednets through combined Catch‐up and Keep‐up strategies

Public-health impact of accelerated measles control in the WHO African Region 2000–03

The Unfinished Measles Immunization Agenda