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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 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]

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]