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Child immunization in Guatemala over time: Did health reform improve equitable coverage at the community level? XXVIII IUSSP International Population Conference in Session “Community contexts, health and mortality in developing countries”, 30 October 2017 Authors: Astrid Arriaza Andrew Amos Channon 1

Guatemala and Immunization • Immunization acknowledged to be one of the most cost effective public health interventions • Overall immunization coverage in Latin America >90% • Guatemala has never achieved high or equitable coverage • Currently 59% of children have all the vaccinations at the correct time points (MSPAS, 2015) • Introduction of NGOs* as a community based intervention to improve equity MSPAS. 2015. Encuesta Nacional de Salud Materno Infantil 2014-2015 (ENSMI 2014-2015). 2 *Non-governmental organizations (NGOs

Is there equity in immunization between communities with and without NGO intervention? • We focus upon the differences between communities with respect to political prioritization and the presence of NGOs 3

History of Child Immunization Aim: Decentralization of health Peace Agreements and 1996 services in order to reach equity Health Reform in access to public health 1997 Introduction of NGOs NGOs offer services exclusively related to antenatal care, child immunization and child growth monitoring in selected Government stops 2016 communities contracting NGOs 4

Percentage not fully immunized over time (1982-2007) 5

Definitions • Community: the smallest decentralized geo-administrative unit in Guatemala, with a population of at least 10,000 individuals (termed municipality) • Politically prioritized community: selected by the National Planning Office, based on high levels poverty and low levels of child school enrolment – Initially selected in 1997 and updated at regular intervals – These communities should get additional public budget for projects implementation 6

Data • Two national representative surveys, 1998-99 and 2008-09 Guatemalan DHS* – Child immunization data taken from official vaccination cards only • Supplementary administrative data from the Ministry of Health: – Presence of NGOs in the community and politically prioritized communities between 2003-08 – Matched carefully to the 2008-09 DHS using the 2002 census as the key 7 *Demographic and Health Survey (DHS)

Outcome variable • We test whether a 15-59-month child was fully immunized or not • Full immunization is defined as the receipt of the following vaccines before 15 months of age: – 3 doses of oral-polio vaccine, 3 doses of diphtheria- tetanus-pertussis (DPT), 1 dose of measles and 1 dose of bacille Calmette-Guerin (BCG) 8

Data and methods 2- Level Multilevel logistic regression Determinants at the Determinants at the community level (Level 2) individual level (Level 1) NGO and Antenatal Mothers Household political Region Location and post- Wealth employment size prioritized natal care status Model 1: 1998-99 Model 3: 2008- Model 2: 2008-09 09 (only)

Results • 1,728 and 8,774 children were included in the analysis of the 1998-99 and 2008-09 DHS, respectively • Full immunization coverage in Guatemala has been variable, but generally increasing over the period. – Overall 45.5% (1998/9) and 64.6% (2008/9) of children between 15 to 59 months were fully immunized 10

Factors associated with higher immunization coverage In both years: • Having pre- or postnatal care • A higher wealth (as measured by assets) • Smaller household size • Living outside a metropolitan region Significant only in 2008-09: • Mothers who are not currently working • Living in a rural area 11

Model fit and Random Effects 1998-9 DHS 2008-9 DHS 2008-9 DHS* Random effects U ( random effect at the community level) 0.58 0.56 0.54 Intra Cluster Correlation (ICC) 0.09 0.09 0.08 Model fit Aikaike Information criterion (AIC) 2434.99 13011.40 13006.88 Bayes Information criterion (BIC) 2579.59 13232.44 13222.40 * Model with NGO presence and political prioritization included 12

NGO/Prioritization in 2008-9 Odds Ratio p value Confidence Interval Politically prioritized community Yes 1.00 No 1.33 0.04 1.07, 1.65 Community with a NGO provider Yes 1.00 No 1.27 0.04 1.02, 1.58 Clear that in 2008-9 the communities that have been prioritized and have NGO involvement lag well behind 13

Why are communities with NGOs and prioritization still lower? NGOs dependent Governance NGOs functioned on the MoH anomalies (Lao, as administrators governance (Lao, 2013) (Maupin 2009) 2013) Interest of the Provided political Lack of limited health administration transparency services in office Reduced Unstable Limited number of allocation of documented HCPs* in rural funds evidence areas *Health care professionals (HCPs) Lao, Christine. 2013. Improving Access to Health Care Services through the Expansion of Coverage Program (PEC): The Case of Guatemala. Washington DC: The World Bank. Maupin, Jonathan. 2009. "‘Fruit of the accords’: Healthcare reform and civil participation in Highland Guatemala." Social Science & 14 Medicine Vol.68: 1456-1463.

What we found • Despite the introduction of NGOs, there are differentials in accessing to child immunization in Guatemala. • Individual level determinants such as antenatal care and post-natal controls increase the probability of full child immunization • The presence of NGOs within the community are associated with a reduced probability of a child being fully immunized 15

Next steps • Map NGO/prioritization communities onto 1998-9 data – Evaluate changes over time to see if gap between communities has grown/decreased • Study issues with missing data around the availability of a vaccination card • Test access to antenatal care as NGOs involved providing this service too 16

Acknowledgement • Chevening Scholarships, the UK government’s global scholarship programme, funded by the Foreign and Commonwealth Office (FCO) and partner organizations. 17

Child immunization in Guatemala over time: Did health reform improve equitable coverage at the community level? XXVIII IUSSP International Population Conference in Session “Community contexts, health and mortality in developing countries”, 30 October 2017 Authors: Astrid Arriaza, Andrew Amos Channon University of Southampton 18