Abstract
Background: Childhood vaccination is one of the most cost-effective health interventions to reduce infants’ morbidity and mortality. Yet, vaccine inequity, specifically the wealth gap, continues to be one of the main challenges in developing countries; The poorest Indonesian children have the lowest vaccination coverage. While most literature has focused on household wealth, little is known on how the fiscal capacity of the district health office (DHO) may also affect childhood vaccination coverage. We hypothesize that DHOs with higher fiscal capacity have higher childhood vaccination coverage due to their increased capability to set up service provision, which leads to a reduction of infant mortality rate (IMR).
Methods: We quantitatively assessed the effect of DHO fiscal capacity on childhood vaccination coverage and IMR in Indonesia. Fiscal capacity and IMR at the district level were determined via routine data collected by Ministry of Finance and Ministry of Health. Vaccine coverage and other variables related to IMR were obtained from the National Socio-Economic Survey, a nationally representative cross-sectional survey, from 2019 to 2021. This study only included children aged 12-23 months old. Children under 1 year were not included as they are not old enough to receive all basic childhood vaccination schedules; those above were excluded to avoid confusion with the immunization booster schedule. We performed a panel fixed-effect regression to control for time-invariant districts characteristics, adjusting for other variables related with vaccination coverage and IMR (e.g. household wealth and maternal education).
Results: The national and district-level coverage for complete basic childhood vaccination were 45.2% and 0% to 97.8% in 2019, 47% and 0% to 93.3% in 2020, 52.2% and 0% to 100% in 2021. District-level IMR (per 1,000 live births) ranged from 0.1 to 29.0 in 2019, 0.1 to 41.6 in 2020, 0.1 to 31.0 in 2021. DHO fiscal capacity did not have a statistically significant effect on childhood immunization coverage nor IMR. In a sub-group analysis, higher immunization coverage significantly reduced IMR only in high fiscal capacity DHOs (i.e., 10% increase in number of child completing basic childhood vaccination will decrease IMR by 1.5%), however it increased IMR in moderate fiscal capacity DHOs.
Conclusion: Fiscal capacity of DHOs did not seem to influence childhood immunization coverage nor IMR. These null findings suggest that higher fiscal capacity does not necessarily translate to better utilization of healthcare resources for child health. Possible explanations include other potential variables in the causal pathway (e.g. facility quality) and we did not account for DHO commitment and capability (i.e., planning, budgeting, and utilizing their budget successfully). However, the study did point to some connection between coverage and IMR in districts with variable fiscal capacities, which indicates a complex interplay between these 3 variables. In addition to demonstrating that childhood vaccination coverage is context-specific, our study adds to the limited evidence on the connection of local government’s fiscal capacity with childhood vaccination coverage and IMR. Future studies could attempt to examine this linkage in different contexts and other outcomes, along with accounting for other variables in the causal pathway.