What Determines the District-Level Disparities in Immunization Coverage in India: Findings from Five Rounds of the National Family Health Survey

India's Universal Immunization Programme has been performing at a sub-optimal level over the past decade, with there being a wide disparity in terms of immunization coverage between states. This study investigates the covariates that affect immunization rates and inequality in India at the individual and district levels. We used data from the five rounds of the National Family Health Survey (NFHS), conducted from 1992-1993 to 2019-2021. We used multilevel binary logistic regression analysis to examine the association between demographic, socio-economic and healthcare factors and a child's full immunization status. Further, we used the Fairlie decomposition technique to understand the relative contribution of explanatory variables to a child's full immunization status between districts with different immunization coverage levels. We found that 76% of children received full immunization in 2019-2021. Children from less wealthy families, urban backgrounds, Muslims, and those with illiterate mothers were found to have lower chances of receiving full immunization. There is no evidence that gender and caste disparities have an impact on immunization coverage in India. We found that having a child's health card is the most significant contributor to reducing the disparities that exist regarding children's full immunization between mid- and low-performing districts. Our study suggests that healthcare-related variables are more crucial than demographic and socio-economic variables when determining ways in which to improve immunization coverage in Indian districts.

Challenges faced by frontline health managers during the implementation of COVID-19 related policies in India: A qualitative analysis

Background & objectives

The COVID-19 pandemic exposed the strengths and weaknesses of the healthcare systems across the world. Many directives, guidelines and policies for pandemic control were laid down centrally for its implementation; however, its translation at the periphery needs to be analyzed for future planning and implementation of public health activities. Hence, the objectives of this study were to identify the challenges faced by frontline health managers in selected States in India during the pandemic with regard to implementation of the COVID-19-related policies at the district level and also to assess the challenges faced by the them in adapting the centrally laid down COVID-19 guidelines as per the local needs of the district.

Methods

A qualitative study using the grounded theory approach was conducted among frontline district-level managers from eight different States belonging to the north, south, east and west zones of India. The districts across the country were selected based on their vulnerability index, and in-depth interviews were conducted among the frontline managers to assess the challenges faced by them in carrying out COVID-19 related activities. Recorded data were transcribed verbatim, manually coded and thematically analyzed.

Results

Challenges faced in implementing quarantine rules were numerous, and it was also compounded by stigma attached with the disease. The need for adapting the guidelines as per local considerations, inclusion of components of financial management at local level, management of tribal and vulnerable populations and migrants in COVID context were strongly suggested. The need to increase human resource in general and specifically data managers and operators was quoted as definite requirement.

Interpretation & conclusions

The COVID-19 guidelines provided by the Centre were found to be useful at district levels. However, there was a need to make some operational and administrative modifications in order to implement these guidelines locally and to ensure their acceptability.

Implementation of the national programme for prevention of mother-to-child transmission of HIV: a rapid assessment in Cacadu district, South Africa

To conduct a rapid assessment of the prevention-of-mother-to-child-transmission-of-HIV (PMTCT) programme in two of the three local service areas in Cacadu district, Eastern Cape province, South Africa, we designed an exploratory study using a mixed-methods approach. Quantitative and qualitative data on PMTCT programme implementation were collected in 2008 through a structured assessment at the 44 health facilities implementing the programme in the province. This included in-depth interviews with 11 clinic supervisors, 31 clinic programme coordinators, and 8 hospital/maternity staff members in order to examine their perceived problems and suggestions regarding PMTCT programme implementation; an assessment of the clinic registers and recording systems; a meeting with stakeholders; and one feedback meeting with clinic managers, sub-district management and other stakeholders in regard to the results of the rapid assessment. Overall, most of the national criteria for PMTCT programme implementation were fulfilled across the health facilities. However, shortcomings were found relating to health policy, health services delivery and clients' health-seeking behaviour. The findings show the need for a well-functioning health system with adequate and trained staff, a reduced staff workload, proper case recording, an improved patient follow-up system, better support for staff, the empowerment of PMTCT clients, strong leadership, and coordination and collaboration between partners.

Moving data off the shelf and into action: an intervention to improve data-informed decision making in Côte d'Ivoire

Background

Improving a health system requires data, but too often they are unused or under-used by decision makers. Without interventions to improve the use of data in decision making, health systems cannot meet the needs of the populations they serve. In 2008, in Côte d'Ivoire, data were largely unused in health decision-making processes.

Objective

To implement and evaluate an intervention to improve the use of data in decision making in Cote d'Ivoire.

Design

From 2008 to 2012, Cote d'Ivoire sought to improve the use of national health data through an intervention that broadens participation in and builds links between data collection and decision-making processes; identifies information needs; improves data quality; builds capacity to analyze, synthesize, and interpret data; and develops policies to support data use. To assess the results, a Performance of Routine Information System Management Assessment was conducted before and after the intervention using a combination of purposeful and random sampling. In 2008, the sample consisted of the central level, 12 districts, and 119 facilities, and in 2012, the sample consisted of the central level, 20 districts, and 190 health facilities. To assess data use, we developed dichotomous indicators: discussions of analysis findings, decisions taken based on the analysis, and decisions referred to upper management for action. We aggregated the indicators to generate a composite, continuous index of data use.

Results

From 2008 to 2012, the district data-use score increased from 40 to 70%; the facility score remained the same – 38%. The central score is not reported, because of a methodological difference in the two assessments.

Conclusions

The intervention improved the use of data in decision making at the district level in Côte d'Ivoire. This study provides an example of, and guidance for, implementing a large-scale intervention to improve data-informed decision making.

Impact of a decision-support tool on decision making at the district level in Kenya

BACKGROUND

In many countries, the responsibility for planning and delivery of health services is devolved to the subnational level. Health programs, however, often fall short of efficient use of data to inform decisions. As a result, programs are not as effective as they can be at meeting the health needs of the populations they serve. In Kenya, a decision-support tool, the District Health Profile (DHP) tool was developed to integrate data from health programs, primarily HIV, at the district level and to enable district health management teams to review and monitor program progress for specific health issues to make informed service delivery decisions.

METHODS

Thirteen in-depth interviews were conducted with ten tool users and three non-users in six districts to qualitatively assess the process of implementing the tool and its effect on data-informed decision making at the district level. The factors that affected use or non-use of the tool were also investigated. Respondents were selected via convenience sample from among those that had been trained to use the DHP tool except for one user who was self-taught to use the tool. Selection criteria also included respondents from urban districts with significant resources as well as respondents from more remote, under-resourced districts.

RESULTS

Findings from the in-depth interviews suggest that among those who used it, the DHP tool had a positive effect on data analysis, review, interpretation, and sharing at the district level. The automated function of the tool allowed for faster data sharing and immediate observation of trends that facilitated data-informed decision making. All respondents stated that the DHP tool assisted them to better target existing services in need of improvement and to plan future services, thus positively influencing program improvement.

CONCLUSIONS

This paper stresses the central role that a targeted decision-support tool can play in making data aggregation, analysis, and presentation easier and faster. The visual synthesis of data facilitates the use of information in health decision making at the district level of a health system and promotes program improvement. The experience in Kenya can be applied to other countries that face challenges making district-level, data-informed decisions with data from fragmented information systems.

Impact of a decision-support tool on decision making at the district level in Kenya

BACKGROUND

In many countries, the responsibility for planning and delivery of health services is devolved to the subnational level. Health programs, however, often fall short of efficient use of data to inform decisions. As a result, programs are not as effective as they can be at meeting the health needs of the populations they serve. In Kenya, a decision-support tool, the District Health Profile (DHP) tool was developed to integrate data from health programs, primarily HIV, at the district level and to enable district health management teams to review and monitor program progress for specific health issues to make informed service delivery decisions.

METHODS

Thirteen in-depth interviews were conducted with ten tool users and three non-users in six districts to qualitatively assess the process of implementing the tool and its effect on data-informed decision making at the district level. The factors that affected use or non-use of the tool were also investigated. Respondents were selected via convenience sample from among those that had been trained to use the DHP tool except for one user who was self-taught to use the tool. Selection criteria also included respondents from urban districts with significant resources as well as respondents from more remote, under-resourced districts.

RESULTS

Findings from the in-depth interviews suggest that among those who used it, the DHP tool had a positive effect on data analysis, review, interpretation, and sharing at the district level. The automated function of the tool allowed for faster data sharing and immediate observation of trends that facilitated data-informed decision making. All respondents stated that the DHP tool assisted them to better target existing services in need of improvement and to plan future services, thus positively influencing program improvement.

CONCLUSIONS

This paper stresses the central role that a targeted decision-support tool can play in making data aggregation, analysis, and presentation easier and faster. The visual synthesis of data facilitates the use of information in health decision making at the district level of a health system and promotes program improvement. The experience in Kenya can be applied to other countries that face challenges making district-level, data-informed decisions with data from fragmented information systems.