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This document is a list of contributions to a special issue on immunization inequalities and the need for equity in vaccine access. The contributions include analyses of factors such as wealth inequality, gender barriers, the impact of the COVID-19 pandemic, subnational coverage, childhood immunization coverage, data triangulation, global economic benefits, geospatial analyses, timeliness of vaccinations, factors associated with vaccine uptake, parental hesitancy, and sociodemographic trends. The document emphasizes the importance of addressing structural factors and refining analytical approaches to achieve immunization equity. The Special Issue was funded in part by Gavi, The Vaccine Alliance, but the funder had no role in the writing of the Editorial. The authors declare no conflicts of interest. [Extracted from the article]

Immunization through vaccines among children has contributed to improved childhood survival and health outcomes globally. However, vaccine coverage among children is unevenly distributed across settings and populations. The measurement of inequalities is essential for understanding gaps in vaccine coverage affecting certain sub-populations and monitoring progress towards achieving equity. Our study aimed to characterize the methods of reporting inequalities in childhood vaccine coverage, inclusive of the settings, data source types, analytical methods, and reporting modalities used to quantify and communicate inequality. We conducted a scoping review of publications in academic journals which included analyses of inequalities in vaccination among children. Literature searches were conducted in PubMed and Web of Science and included relevant articles published between 8 December 2013 and 7 December 2023. Overall, 242 publications were identified, including 204 assessing inequalities in a single country and 38 assessing inequalities across more than one country. We observed that analyses on inequalities in childhood vaccine coverage rely heavily on Demographic Health Survey (DHS) or Multiple Indicator Cluster Surveys (MICS) data (39.3%), and papers leveraging these data had increased in the last decade. Additionally, about half of the single-country studies were conducted in low- and middle-income countries. We found that few studies analyzed and reported inequalities using summary measures of health inequality and largely used the odds ratio resulting from logistic regression models for analyses. The most analyzed dimensions of inequality were economic status and maternal education, and the most common vaccine outcome indicator was full vaccination with the recommended vaccine schedule. However, the definition and construction of both dimensions of inequality and vaccine coverage measures varied across studies, and a variety of approaches were used to study inequalities in vaccine coverage across contexts. Overall, harmonizing methods for selecting and categorizing dimensions of inequalities as well as methods for analyzing and reporting inequalities can improve our ability to assess the magnitude and patterns of inequality in vaccine coverage and compare those inequalities across settings and time. [ABSTRACT FROM AUTHOR]

Objective To develop a primary health-care monitoring framework and health outcome indicator list, and field-test and triangulate indicators designed to assess health reforms in Kerala, India, 2018-2019. Methods We used a modified Delphi technique to develop a 23-item indicator list to monitor primary health care. We used a multistage cluster random sampling technique to select one district from each of four district clusters, and then select both a family and a primary health centre from each of the four districts. We field-tested and triangulated the indicators using facility data and a population-based household survey. Findings Our data revealed similarities between facility and survey data for some indicators (e.g. low birth weight and pre-check services), but differences for others (e.g. acute diarrhoeal diseases in children younger than 5 years and blood pressure screening). We made four critical observations: (i) data are available at the facility level but in varying formats; (ii) established global indicators may not always be useful in local monitoring; (iii) operational definitions must be refined; and (iv) triangulation and feedback from the field is vital. Conclusion We observe that, while data can be used to develop indices of progress, interpretation of these indicators requires great care. In the attainment of universal health coverage, we consider that our observations of the utility of certain health indicators will provide valuable insights for practitioners and supervisors in the development of a primary health-care monitoring mechanism. [phrase omitted] [phrase omitted] Objectif Mettre au point un cadre de suivi des soins de sante primaires ainsi qu'une liste d'indicateurs de resultats en sante. Tester sur le terrain et recouper les indicateurs congus pour evaluer les reformes sanitaires dans le Kerala, en Inde, en 2018 et 2019. Methodes Nous avons utilise une methode de Delphes modifiee pour elaborer une liste de 23 indicateurs destines a surveiller les soins de sante primaires. Nous avons eu recours a une technique d'echantillonnage aleatoire en grappes a plusieurs degres pour selectionner un district dans chacun des quatre groupes de districts, puis pour choisir a la fois un centre de medecine familiale et un centre de soins de sante primaires dans chacun des quatre districts. Nous avons teste les indicateurs sur le terrain et les avons recoupes a l'aide des donnees des etablissements, ainsi que d'une enquete de population realisee aupres des menages. Resultats Nos donnees ont montre des similarites entre les donnees des etablissements et celles de l'enquete dans le cas de certains indicateurs (tels que l'insuffisance ponderale a la naissance et les services de verification des antecedents). Neanmoins, d'autres indicateurs ont affiche des divergences (notamment au niveau des maladies diarrheiques aigues chez les enfants de moins de 5 ans et du depistage de l'hypertension arterielle). Nous avons formule quatre observations critiques: (i) les donnees sont disponibles au sein des etablissements, mais sous differents formats; (ii) les indicateurs mondiaux predetermines se revelent parfois inutiles dans le cadre d'un suivi a l'echelle locale; (iii) les definitions operationnelles doivent etre affinees; et enfin, (iv) il est indispensable de proceder a un recoupement des informations et de recolter les avis sur le terrain. Conclusion Nous avons constate que, meme si les donnees peuvent etre exploitees pour mettre au point des indices de progres, interpreter ces indicateurs requiert beaucoup d'attention. En vue d'instaurer une couverture maladie universelle, nous estimons que nos observations relatives a l'utilite de certains indicateurs de sante fourniront des renseignements precieux aux praticiens et aux superviseurs dans le developpement d'un mecanisme de suivi des soins de sante primaires. [phrase omitted] Objetivo Elaborar un marco de supervision de la atencion primaria de salud y una lista de indicadores sobre los resultados en la salud, asi como realizar ensayos de campo y triangular los indicadores previstos para evaluar las reformas sanitarias en Kerala, India, 2018-2019. Metodos Se aplico un metodo Delphi modificado para elaborar una lista de indicadores que incluye 23 elementos para supervisar la atencion primaria de salud. Ademas, se empleo una tecnica de muestreo aleatorio por conglomerados de etapas multiples para seleccionar un distrito de cada uno de los cuatro conglomerados de distritos y, a continuacion, se selecciono una familia y un centro de atencion primaria de cada uno de los cuatro distritos. Se realizaron ensayos de campo y se triangularon los indicadores mediante el uso de datos de los centros y una encuesta domiciliaria basada en la poblacion. Resultados Los datos obtenidos revelaron similitudes entre los datos de los centros y los de las encuestas para algunos indicadores (por ejemplo, el peso bajo al nacer y los servicios de control previo), asi como diferencias para otros (por ejemplo, las enfermedades diarreicas agudas en ninos menores de 5 anos y la evaluacion de la presion arterial). Se formularon cuatro observaciones criticas: i) los datos estan disponibles a nivel de los establecimientos, pero en distintos formatos; ii) los indicadores globales establecidos no siempre son utiles para realizar una vigilancia local; iii) las definiciones operativas se deben perfeccionar; y iv) la triangulacion y las observaciones en el terreno son vitales. Conclusion Se observa que, si bien los datos se pueden usar para elaborar indices de progreso, la interpretacion de estos indicadores requiere gran atencion. Se cree que las observaciones obtenidas sobre la utilidad de ciertos indicadores de salud permitiran a los profesionales y a los supervisores comprender mejor el desarrollo de un mecanismo de vigilancia de la atencion primaria de salud para lograr la cobertura sanitaria universal., Introduction Under the thirteenth general programme of work and the triple billion targets, (1) the World Health Organization (WHO) aims to increase the number of people benefitting from universal health [...]

Background: Accredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts. Methods: We conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software. Results: Our study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local selfgovernments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done. Conclusion: The CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge. [ABSTRACT FROM AUTHOR]

Background The People’s Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history. Methods We employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning. Results Two CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM’s frontline health workers, ASHAs, emerged as leaders in LSGs. Conclusion The synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation – these contradictions may vex progress going forward and warrant further study. [ABSTRACT FROM AUTHOR]

India’s experience with the National Rural Health Mission (NRHM) is notable on account of nationally formalising – at scale – community action in service delivery,monitoring, and planning of health services. A study was undertaken to document and create a historical record of NRHM’s ‘communitization’ processes. The oral history method of the Witness Seminar was adopted and two virtual seminars with five and nine participants, respectively, were conducted, and supplemented with 4 in depth interviews. Analysis of transcripts was done using ATLAS.ti 22 with the broad themes of emergence, evolution, and evaluation and impact of ‘communitization’ under NRHM. This paper engages with the theme of ‘emergence’ and adopts the Multiple Streams Framework (MSF) conceptualised by John Kingdon for analysis. Key findings include the pioneering role of boundary spanning decision makers and the Jan Swasthya Abhiyan (JSA) in advocacy and design of ‘communitization’ structures, and the legacy of rights based social mobilizations and state-civil society partnerships in health during the 1990s influencing the ethos underlying ‘communitization’. Democracy, leadership from the civil society in policy design and implementation, and state-civil society partnerships are linked to the positive results witnessed as part of ‘communitization’ in NRHM. [ABSTRACT FROM AUTHOR]

Introduction: Kerala, a south Indian state, has often been cited globally as a model for better health outcomes at low cost but faces unique challenges in achieving Universal Health Coverage (UHC). To propel the efforts in achieving UHC, the Government of Kerala announced the "Aardram" health reform initiative, emphasising improving the quality of primary care service delivery. The reforms started in 2017, and in the first stage, 170 of 848 Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The facilities were provided with additional doctors, nurses, and paramedical staff; the working hours were extended, and the range of services offered increased. In support of these processes, we carried out a facility assessment to assess differences between upgraded FHCs and existing PHCs. Materials and Methods: We conducted a facility-based cross-sectional assessment in eight primary care facilities of Kerala, FHC (N=4) and PHCs (N=4) from June to October 2019. A structured questionnaire covering utilisation and coverage of selected priority services for various populations and health outcome data was filled out by health staff to report data for the financial year 2018-19. Data were analysed in Microsoft Excel spreadsheets for easy analysis and replication by state stakeholders. Results: Coverage indicators such as full antenatal care and full immunization coverage were not appreciably different in FHCs as compared to PHCs. However, key reform-related differences were observed. On average, FHCs had 0.8 medical officers and one staff nurse per 10,000 population, whereas PHCs had 0.7 medical officers and less than 0.4 staff nurses per 10,000 population, even as the size of populations served by these human resources varied greatly across both types of facilities. The number of outpatient department visits per 10,000 population annually was 11,343 persons in FHCs and 9,580 persons in PHCs. FHCs also provided additional services such as screening for depression and chronic obstructive pulmonary disorders. Conclusion: Aardram primary healthcare reforms are still in their early days and appear to be associated with improved service coverage at the institutional level. However, some patterns are uneven: reforms should be carefully documented, and population-level impacts monitored over time. [ABSTRACT FROM AUTHOR]

Background: The movement toward systems thinking and complexity-informed evaluation has been ongoing for some time. COVID-19 has increased the salience of contextually aware, adaptive forms of evaluation. Purpose: Drawing very specifically upon experiences in the Global South, this article presents our reflections on competencies that have been integral to a collaboration involved with developmental health systems evaluation in India. Setting: This work is based on our experience over 3 years of providing monitoring, evaluation, research and learning (MERL) to a large philanthropic organization's portfolio of health systems work in India. Intervention: Not applicable. Research Design: Not applicable. Data Collection and Analysis: Not applicable. Findings: We identify three types of evaluator competencies that derive from complexity-driven practice in a developing country. The first competency relates to deriving evidence in contexts where there are very few traditional forms of data. The second competency is related to skills required to play a convening role across varied stakeholders. The final competency relates to operational adaptiveness while evaluating an ecosystem with few constants. The pandemic created a natural experiment that required a reexamination of priorities in the unique context of reliable donor support in uncertain times. These three capacities are in fact interdependent and could only be developed iteratively, over time. Building competencies isn't simply about capacity building but rather requires a recognition of the diversity of skills and worldviews that need to be encompassed within our MERL functions for today's complex, discontinuous health systems. [ABSTRACT FROM AUTHOR]

Background: Kerala, a south Indian state, has a long and strong history of mobilisation of people's participation with institutionalised mechanisms as part of decentralisation reforms introduced three decades ago. This history formed the backdrop of the state's COVID-19 response from 2020 onwards. As part of a larger health equity study, we carried out an analysis to understand the contributions of people's participation to the state's COVID-19 response, and what implications this may have for health reform as well as governance more broadly. Methods: We employed in-depth interviews with participants from four districts of Kerala between July and October, 2021. Following written informed consent procedures, we carried out interviews of health staff from eight primary health care centres, elected Local Self Government (LSG, or Panchayat) representatives, and community leaders. Questions explored primary health care reforms, COVID responses, and populations left behind. Transliterated English transcripts were analysed by four research team members using a thematic analysis approach and ATLAS.ti 9 software. For this paper, we specifically analysed codes and themes related to experiences of community actors and processes for COVID mitigation activities. Results: A key feature of the COVID-19 response was the formation of Rapid Response Teams (RRTs), groups of lay community volunteers, who were identified and convened by LSG leaders. In some cases, pre-pandemic 'Arogya sena' (health army) community volunteer groups were merged with RRTs. RRT members were trained and supported by the health departments at the local level to distribute medicine and essential items, provided support for transportation to health facilities, and assisted with funerary rites during lockdown and containment period. RRTs often comprised youth cadres of ruling and opposition political parties. Existing community networks like Kudumbashree (Self Help Groups) and field workers from other departments have supported and been supported by RRTs. As pandemic restrictions eased, however, there was concern about the sustainability of this arrangement as well. Conclusion: Participatory local governance in Kerala allowed for the creation of invited spaces for community participation in a variety of roles as part of the COVID 19 response, with manifest impact. However, the terms of engagement were not decided by communities, nor were they involved more deeply in planning and organising health policy or services. The sustainability and governance features of such involvement warrant further study. [ABSTRACT FROM AUTHOR]

Background: Demand for rapid evidence-based syntheses to inform health policy and systems decision-making has increased worldwide, including in low- and middle-income countries (LMICs). To promote use of rapid syntheses in LMICs, the WHO's Alliance for Health Policy and Systems Research (AHPSR) created the Embedding Rapid Reviews in Health Systems Decision-Making (ERA) Initiative. Following a call for proposals, four LMICs were selected (Georgia, India, Malaysia and Zimbabwe) and supported for 1 year to embed rapid response platforms within a public institution with a health policy or systems decision-making mandate. Methods: While the selected platforms had experience in health policy and systems research and evidence syntheses, platforms were less confident conducting rapid evidence syntheses. A technical assistance centre (TAC) was created from the outset to develop and lead a capacity-strengthening program for rapid syntheses, tailored to the platforms based on their original proposals and needs as assessed in a baseline questionnaire. The program included training in rapid synthesis methods, as well as generating synthesis demand, engaging knowledge users and ensuring knowledge uptake. Modalities included live training webinars, in-country workshops and support through phone, email and an online platform. LMICs provided regular updates on policy-makers' requests and the rapid products provided, as well as barriers, facilitators and impacts. Post-initiative, platforms were surveyed. Results: Platforms provided rapid syntheses across a range of AHPSR themes, and successfully engaged national- and state-level policy-makers. Examples of substantial policy impact were observed, including for COVID-19. Although the post-initiative survey response rate was low, three quarters of those responding felt confident in their ability to conduct a rapid evidence synthesis. Lessons learned coalesced around three themes – the importance of context-specific expertise in conducting reviews, facilitating cross-platform learning, and planning for platform sustainability. Conclusions: The ERA initiative successfully established rapid response platforms in four LMICs. The short timeframe limited the number of rapid products produced, but there were examples of substantial impact and growing demand. We emphasize that LMICs can and should be involved not only in identifying and articulating needs but as co-designers in their own capacity-strengthening programs. More time is required to assess whether these platforms will be sustained for the long-term. [ABSTRACT FROM AUTHOR]

Childhood immunization programmes have lost ground, with an estimated 25 million children under the age of 1 not receiving a third dose of diphtheria-tetanus-pertussis-containing vaccine (DTP3) in 2021 - the highest number for more than a decade; 18 million of these children did not even receive the first dose of DTP vaccine (zero-dose children) [[5]]. Immunization, hailed as one of the most successful public health interventions in the world, has contributed to major advancements in health as well as social and economic development [[1]]. Inequality in Immunization: Holding on to Equity as We "Catch Up" There is an established and growing evidence base on exemplars of action on immunization equity, particularly among Gavi-supported countries, but also in other contexts with successful immunization programmes [[26], [35], [37]]. [Extracted from the article]

Global health research reflects and can either perpetuate or challenge the complex power hierarchies and inequities that characterize our health systems and the societies in which they are situated. The imperative to embed equity in health research aligns with broader efforts globally to promote equitable partnerships among researchers, and between researchers and the communities potentially impacted by their research, or with whom knowledge is co-produced. We describe lessons learnt from piloting a heuristic and diagnostic tool for researchers to assess integration of equity considerations into their research practices. The '8Quity' tool comprises eight domains of equity we developed which roughly correspond to the typical stages in the research process—from team formation to capacity strengthening, research ethics and governance to relationships with research partners, participants and stakeholders beyond the project period. Resources that detail how this can be done on a practical level are also shared, corresponding to each of the eight domains. We acknowledge that tools like 8Quity may be helpful, even necessary, but are insufficient for the broader societal changes required to ensure equity in the research enterprise. However, by firmly setting intentions and accountabilities within our research practices, we (as researchers) can play a role, however modest, in turning the tide of the injustices that leave some communities behind. [ABSTRACT FROM AUTHOR]

Arts-based programs have improved HIV-related knowledge, attitudes, and behavior in general and at-risk populations. With HIV transformed into a chronic condition, this study compares patients at consecutive stages of receiving antiretroviral treatment, coinciding with exposure to a radio-and-theater-based educational program (unexposed [N = 120], just exposed [N = 77], Exposed a month ago [N = 60]). Exposure was associated with significantly higher HIV-related knowledge (15-20%, all p less than 0.01), lower levels of stigma (2-7% lower, all p less than 0.10), and over four times the adjusted odds of asking doctors questions about HIV (p = 0.07). Higher dose of exposure was associated with lower felt stigma (28% reduction per message recalled), greater odds of consistent condom use (adjusted odds ratio [AOR]: 1.12, p = 0.01), doctor-patient communication (AOR: 1.20, p = 0.003), peer advice-giving (AOR: 1.18, p = 0.03) and HIV-related advocacy (AOR: 2.35, p = 0.07). Similar partnerships between arts-based nongovernmental organizations and government hospitals may improve patient outcomes in HIV treatment settings.

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants. [ABSTRACT FROM AUTHOR]