Wealth Inequity

Key Evidence: The use of antenatal care (ANC) services among pregnant adolescents in low- and middle-income countries, including tetanus toxoid vaccination, was lowest among women who lived in rural areas, had completed less education, and who were of poorer wealth quintiles.

Key Evidence: In a Southwest state of Nigeria, children in the poorest category (quintile) of households were 14 times more likely to be partially immunized or not immunized, and those in the next poorest category were eight times more likely to be partially immunized or not immunized than children in the wealthiest group, after adjusting for factors such as education, religion, and ethnicity.

Key Evidence: In India, a multi-strategy community intervention, the National Rural Health Mission (NRHM) was successful in reducing disparities between pregnant women who had an institutional delivery in urban and rural areas. Geographic inequities reduced from 22% to 7.6% and socioeconomic disparities declined from 48.2% to 13%. Post the NRHM period, the difference between the number of children with full vaccination i.e., Bacillus Calmette Guerin (BCG) vaccine for tuberculosis, 3 doses of Diphtheria Pertussis and Tetanus vaccine (DTP), 3 doses of Oral Polio Vaccine (OPV), and measles vaccine, in urban and rural areas was observed to be non-significant.

Key Evidence: A study looking at the impact of pneumococcal vaccine introduction and scaling up pneumonia treatment in Ethiopia found that 30-40% of all deaths averted by these interventions would be expected to occur in the poorest wealth quintile. Scaling up PCV13 to levels achieved with DTP3 in Ethiopia would be expected to avert nearly 3000 child deaths and 60,000 episodes of pneumococcal pneumonia annually, not including any potential herd benefit. A publicly financed program to scale up pneumococcal vaccines would cost about US$40 per year of healthy life gained.

Key Evidence: A study of the impact of measles vaccine in Bangladesh found that unvaccinated children in the poorest quintile were more than twice as likely to die as those from the least poor quintile. In addition, vaccination reduced socioeconomic status-related mortality differentials

Key Evidence: Rates of vaccination in all studied countries were highest and risk mortality lowest in the top two wealth quintile’s coverage. Countries differed in the relative inequities in these two underlying variables. Cost per DALYs averted is substantially greater in the higher quintiles. In all countries, the greatest potential vaccine benefit was in the poorest quintiles; however, reduced vaccination coverage lowered the projected vaccine benefit.

Key Evidence: A cost-effectiveness analysis of rotavirus vaccination in Pakistan found that, if rotavirus vaccination coverage was equally high across regions and income groups, the percent reduction in deaths due to rotavirus would be 4 times greater in the highest risk regions than in the lowest-risk regions, and would be 3-4 times greater among children in the poorest versus the wealthiest households.

From the VoICE Editors: Expanding vaccination coverage among the poorest and most vulnerable children would substantially increase the overall impact of rotavirus immunization in Pakistan. 

Key Evidence: A study of measles vaccine in Bangladesh found that children from the poorest quintile were more than twice as likely to die than those from the least quintile in the absence of measles vaccination. The difference in mortality between unvaccinated and vaccinated was statistically significant (p<0.10) and robust across alternative measures of socioeconomic status.

Key Evidence: A modeled analysis of the potential impact of pneumococcal conjugate vaccine (PCV) in India estimated that the greatest reduction in deaths due to PCV vaccination would be among the poorest segments of the population. Assuming a vaccination coverage rate of 77% (the current DTP3 coverage rate), PCV would prevent nearly 2.5 times as many deaths per 100,000 children under five in the 2 poorest income quintiles than in the 2 wealthiest groups (313 vs. 134), and nearly 3 times as many deaths per 100,000 if coverage reaches 90% (446 vs. 167).

From the VoICE Editors: The model used was specific to the epidemiology, health system situation, and population characteristics of India. 

Key Evidence: A package of 5 vaccines was delivered, and it was found that children from poorer households benefited more in terms of health outcomes from immunization than did those from relatively wealthier households. Results suggest that most of the risk of dying before age five can be eliminated with full immunization in the severely health-deprived setting.

Key Evidence: A group of experts evaluated a number of maternal, neonatal, and child health interventions for equity across wealth quintiles using data from 1990-2006. Immunization was found to have the narrowest differences in coverage of services between the poorest and wealthiest children. In other words, of the interventions evaluated, immunization was the most equitable across income groups.

Key Evidence: Children in U.S. families living below the poverty line have significantly lower rotavirus vaccination rates than children at or above the poverty line (67% vs. 77%).

Key Evidence: Non-Somali children in Kenya in the poorest households were nearly three times as likely to be unvaccinated than children from middle-income households, while wealthier children were significantly less likely to be unvaccinated.

Key Evidence: In India, inequities in vaccination coverage exist between states, within states, and in urban vs. rural settings. Lower parental education resulted in lower coverage, girls had lower coverage than boys and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.

Key Evidence: In a systematic review of qualitative research from low- and middle-income countries, women’s low social status was shown to be a barrier to their children accessing vaccinations. Specific barriers included access to education, income, resource allocation, and autonomous decision-making related to time. The authors suggest that expanding the responsibility for children’s health to both parents (mothers and fathers) may be one important element in removing persistent barriers to immunization often faced by mothers.

Key Evidence: Globally, coverage of the third dose of DTP is 15% higher among children in the highest compared to lowest wealth quintile. However, this masks differences of up to 64% in the most inequitable countries (Nigeria).

Key Evidence: Inequity in vaccination coverage in India was found between states, within states, and in urban vs. rural. Lower parental education resulted in lower coverage, girls had lower coverage than boys, and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.

Key Evidence: In a study designed to explore the association of maternal education and empowerment with childhood polio vaccination rates in Pakistani mothers, it was observed that the highest percentage of completely vaccinated children (72.6%) was seen among mothers of the richest quintile, followed by 63.4%, 58.0%, 49.8%, and 39% for the richer, middle, poorer, and poorest wealth quintiles, respectively.

Key Evidence: In Tanzania, poverty was found to have a negative effect on receiving vaccines on time (at the recommended age). Children in the wealthiest quintile experienced 19% fewer delays for BCG vaccination, 23% fewer delays for the third dose of DTP vaccination, and 31% fewer delays for the first dose of measles-containing vaccine compared to children of the poorest quintile.

Key Evidence: A group of experts evaluated a number of maternal, neonatal, and child health interventions for equity across wealth quintiles using data from 1990-2006. Immunization was found to have the narrowest differences in coverage of services between the poorest and wealthiest children (28% higher coverage in the highest wealth quintile compared to the lowest). By contrast, indicators of treatment coverage for children sick with diarrhea and pneumonia were nearly 60% higher in the highest wealth quintile compared to the poorest. This means that poor children are at a much greater disadvantage with respect to receiving treatment for pneumonia and diarrhea than they are for receiving vaccines to prevent these infections.

Key Evidence: A package of 5 vaccines was delivered, and it was found that children from poorer households benefited more in terms of health outcomes from immunization than did those from relatively wealthier households. Results suggest that most of the risk of dying before age five can be eliminated with full immunization in the severely health-deprived setting.

Key Evidence: A study modeling the economic impact of 10 childhood immunizations in 41 low- and middle-income countries found that the bulk of poverty averted through vaccination occurs in poor populations. For most of the vaccines in the study, at least 40% of the poverty averted would occur in the poorest wealth quintile. Particularly for pneumonia, more than half of the two million deaths averted by pneumococcal and Hib vaccines would occur in the poorest 40% of the population.