Trends in immunisation inequity: evidence, rights, and planning
Authors: Enrique Delamonica
Journal: The Lancet Global Health (2016)

In The Lancet Global Health, Ahmad Hosseinpoor and colleagues1Hosseinpoor AR Bergen N Schlotheuber A et al.State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys.Lancet Glob Health. 2016; (published online Aug 3.)http://dx.doi.org/10.1016/S2214-109X(16)30141-3PubMed Google Scholar provide a status report on global disparities in rates of immunisation with three doses of diphtheria–tetanus–pertussis (DTP3) vaccine in children of different socioeconomic status (measured by quintiles of estimated physical assets). As in previous similar studies,2Minujin A Delamonica E Mind the gap! Child mortality differentials by income group. In: Cornia GA, ed. Harnessing globalisation for children: a report to UNICEF.https://www.unicef-irc.org/research/ESP/globalization/chapter3.pdfGoogle Scholar there were large and significant disparities between children from the richest and poorest households. As sufficient comparable household surveys became widely available for cross-country trend analysis at the turn of the century, data for immunisation and other health indicators have consistently pointed in the same, disheartening direction.2Minujin A Delamonica E Mind the gap! Child mortality differentials by income group. In: Cornia GA, ed. Harnessing globalisation for children: a report to UNICEF.https://www.unicef-irc.org/research/ESP/globalization/chapter3.pdfGoogle Scholar These inequities are not declining through time. The paper advances knowledge about inequity trends in immunisation in two complimentary ways. First, it contributes novel and hitherto unassessed empirical evidence from more than 50 countries about the magnitude of disparities among children of different socioeconomic groups. Additionally, it offers updated confirmation of trends that have been outlined and documented for more than 10 years: progress in immunisation rates is all too often slower (at best) for poorer children than richer ones—often the observed changes among the poorest children are not statistically significant at all. This lack of progress for the most marginalised groups leads to two seemingly contradictory messages. On the one hand, increasing immunisation does not naturally, automatically, or often occur in an equitable way. For various reasons (political, economic, social, cultural), the opposite is the case. On the other hand, however, there are sufficient cases of countries that have succeeded in reducing these inequities. Even if they are a minority, they show it is indeed possible to accelerate national average immunisation rates while reducing disparities. At least two issues require further elucidation in the analysis of inequities in immunisation in particular, and health in general. There is a need to explore and carry out sensitivity analyses using different methods to group and rank households according to their wealth. For instance, the use of principal component analysis (PCA), as Hosseinpoor and colleagues did, has been criticised, given the kind of variables and indicators usually found in typical household surveys—ie, they are dichotomous variables that do not follow a normal distribution. Although simple alternatives exist,3Hancioglu A Performance of alternative approaches for identifying the relatively poor and linkages to reproductive health.in: Lerner S Vilquin E Reproductive health, unmet needs and poverty: issues of access and quality of services. Committee for International Cooperation in National Research in Demography, Paris2005Google Scholar, 4Gordon D Howe LD Galobardes B et al.Authors' response to: Alternatives to principal components analysis to derive asset-based indices to measure socio-economic position in low- and middle-income countries: the case for multiple correspondence analysis.Int J Epidemiol. 2012; 41: 1209-1210Crossref Scopus (10) Google Scholar, 5Reidpath D Ahmadi K A novel nonparametric item response theory approach to measuring socioeconomic position: a comparison using household expenditure data from a Vietnam health survey, 2003.Emerg Themes Epidemiol. 2014; 11: 9Crossref PubMed Scopus (6) Google Scholar, 6Vandemoortele M Measuring household wealth with latent trait modelling: an application to Malawian DHS data.Soc Indicators Res. 2014; 118: 877-891Crossref Scopus (20) Google Scholar they are not applied as often as PCA-based indices. Clearly, using a different method to determine quintiles would result in different ranking of households. How stable are they to changes in method? Are the estimated absolute and relative gaps the same when different groups are formed by using alternative methods? Moreover, are the substantial conclusions in terms of the trends maintained under different household rankings? Second, additional work is required to analyse the correlation and reinforcing mechanisms across dimensions of disparities other than income or wealth—ie, gender, ethnicity, location (including urban), parents' education, parents' employment status, and type of economic activity. The ways in which the various forms of exclusion interact with each other is related to the concepts of multiple burden and intersectionality in the antidiscrimination legal literature.7Crenshaw K Mapping the margins: intersectionality, identity politics, and violence against women of color.Stanford Law Rev. 1993; 43: 1241-1299Crossref Google Scholar These points are not purely of academic interest. They are important for practice and to guide "bottom up" interventions, formulating health policy goals in distributional terms, and progressive realisation of the right to health.8Gwatkin D Health inequalities and the health of the poor: what do we know? What can we do?.Bull World Health Organ. 2000; 78: 1PubMed Google Scholar People do not live in quintiles (whichever way they are measured or analysed). They live in communities with criss-crossing axes of exclusion and disparities. Moreover, while no government agency, public servant, or politician is responsible for quintiles, they are mandated to serve (and they can be held accountable to) citizens who live in particular districts. Thus, it is important to identify them (through the joint analysis of quintiles and geographic location) to be able to properly design focused interventions within a universal approach.9Evans TM Whitehead M Diderichsen F Bhuiya A Wirth M Challenging inequities in health: from ethics to action. Oxford University Press, New York2001Crossref Scopus (145) Google Scholar Another practical implication refers to the way that work-plans, targets, and milestones in programmes and interventions by non-governmental organisations, international agencies, and governments are usually set up on the understanding that universality cannot be achieved in the short run. Consequently, they aim to achieve coverage of X% of the population. In a misapplication of progressive realisation, they seldom realise that attempting a goal of X% is equivalent to having an explicit goal of excluding 100–X%. Moreover, this is done with complete disregard to mentioning or analysing which 100–X% of the population is doomed to wait for coverage or even which selection criteria will be applied to decide it. It is no wonder, then, that very few countries have managed to reduce disparities, as planners and policy-makers constantly fail to apply an equity approach.10Vandemoortele J Equity begins with children.in: Minujin A Nandy S Global child poverty and well-being: measurement, concepts, policy and action. Policy Press, Bristol2012Crossref Google Scholar Studies like the one by Hosseinpoor and colleagues1Hosseinpoor AR Bergen N Schlotheuber A et al.State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys.Lancet Glob Health. 2016; (published online Aug 3.)http://dx.doi.org/10.1016/S2214-109X(16)30141-3PubMed Google Scholar should help to change these dismal trends in policy design and results for children. I declare no competing interests. State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveysOverall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations. Full-Text PDF Open Access