Health spending and vaccination coverage in low-income countries

BackgroundRoutine childhood immunization is a cost-effective way to save lives and protect people from disease. Some low-income countries (LIC) have achieved remarkable success in childhood immunization, despite lower levels of gross national income or health spending compared to other countries. We investigated the impact of financing and health spending on vaccination coverage across LIC and lower-middle income countries (LMIC). MethodsAmong LIC, we identified countries with high-performing vaccination coverage (LIC+) and compared their economic and health spending trends with other LIC (LIC-) and LMIC. We used cross-country multi-year linear regressions with mixed-effects to test financial indicators over time. We conducted three different statistical tests to verify if financial trends of LIC+ were significantly different from LIC- and LMIC; p-values were calculated with an asymptotic {chi}2 test, a Kenward-Roger approximation for F tests, and a parametric bootstrap method. FindingsDuring 2014-18, LIC+ had a mean vaccination coverage between 91-96% in routine vaccines, outperforming LIC- (67-80%) and LMIC (83-89%). During 2000-18, gross national income and development assistance for health (DAH) per capita were not significantly different between LIC+ and LIC- (p > 0{middle dot}13, p > 0{middle dot}65) while LIC+ had a significant lower total health spending per capita than LIC- (p < 0{middle dot}0001). Government health spending per capita per year increased by US$0{middle dot}42 for LIC+ and decreased by US$0{middle dot}24 for LIC- (p < 0{middle dot}0001). LIC+ had a significantly lower private health spending per capita than LIC- (p < 0{middle dot}012). InterpretationLIC+ had a difference in vaccination coverage compared to LIC- and LMIC that could not be explained by economic development, total health spending, nor aggregated DAH. The vaccination coverage success of LIC+ was associated with higher government health spending and lower private health spending, with the support of DAH on vaccines.