It is estimated that about 8.8 million children younger than 5 years died in 2008, and that about half of these deaths occurred in sub-Saharan Africa
. According to the WHO, at least 63% of these deaths could have been prevented by vaccination
. Health interventions like vaccination programmes should obviously be implemented in places where they are most needed. WHO has advocated the Reaching Every District (RED) approach as a way to improve immunization performance
. The RED approach includes several operational components designed to improve uptake in every district, including supportive supervision and on-site training. The RED approach also encourages countries to utilise statistics on the uptake of vaccines to analyse the distribution of un-immunized children.
The context of this study is Malawi, a low income country with a population of about 13 million of which 84,7 percent live in rural areas
. Vaccination of children is done by local health facilities, either at clinics or at mobile outreach personnel including Health Surveillance Assistants (HSAs), who cover every village in Malawi
[5, 6]. The vaccination is free of charge. However, there is a substantial shortage of health personnel in Malawi and one person may therefore be responsible for a large number of people. The information and follow up may therefore be insufficient, especially in rural areas, and vaccinations may either not be given on time or not at all. In addition, significant stock-outs of BCG and DPT vaccines at the central level were reported in 2007
The purpose of this paper is to identify regions in Malawi in which uptake of vaccines is significantly below or above the national average, and to suggest explanations for the regional variations in vaccine uptake displayed in the 2007 Welfare Monitoring Survey.
Vaccine uptake may markedly differ between regions for several possible reasons. The key question is why these variations exist. Vaccinations are delivered in local contexts, by professionals and semi-professionals supported by authorities at higher regional levels in an organizational hierarchy. Material or infrastructural resources such as the availability, accessibility and quality of local health care facilities may play a significant part in explaining regional variations. Based on a Nigerian survey, Antai and collaborators found that families in regions with a relatively high proportion of births delivered in hospitals had higher vaccination rates
. A similar finding is also reported in another cross-sectional study from Nigeria
. It follows that variations in vaccine uptake can be conceived of as indicators of performance in health care. These are socially constructed features of the local environment that provide opportunities for families.
Travelling distance to health care facilities have been found to be strongly correlated with vaccination uptake
. Regional inequalities in health worker density may also exist, as evidence from Tanzania has suggested
Other community level processes that are relevant for vaccine uptake presuppose some form of social interaction. Knowledge and the diffusion of knowledge about vaccination opportunities is one case in point. It is documented that knowledge and discussions about vaccination improve uptake
. The relative proportion of literate adults in local communities may also have a general positive effect on the presence of health knowledge in local communities
. Literacy not only improves the situation for those that have an education, but might also have an effect on the uptake of vaccines for those that are not literate but live in regions with a relatively high proportion of literacy.
A considerable bulk of health research has traced the connections between vaccine uptake and socio-cultural characteristics of individuals and households
. Several studies, in particular from South Asia, have documented severe gender inequalities and strong preferences toward male offspring due to cultural or traditional customs
. This phenomenon has not been observed in sub-Sahara. However, one study from rural Malawi has reported a lower mortality among 1–2 year old rural male children
. Other factors at the individual and household level, such as parental education, literacy and occupation may be important, as well as indicators of cultural factors including belief and trust in health professionals. Uptake tends to be lower in households with lower socioeconomic status and in households characterized by general poor living conditions such as poor housing, sub-standard sanitary or fresh-water facilities
[8, 12, 17–21]. These factors may affect individual’s demand for vaccinations as well as their propensity to accept the offer of vaccination. In addition, people are to varying degrees embedded in the localities they reside. People with larger social networks are more likely to receive information about vaccines. The relationship between social capital and health is well known
, but the consequences for uptake of immunization is less well understood.
According to compositional explanations, regional variations in vaccine uptake occur because individuals or households with low vaccine uptake tend to be geographically clustered. Accordingly, we attempt to empirically assess the relative importance of compositional explanations by including factors such as educational attainments, illiteracy and level-of-living indicators of the household (income, water and toilet facilities) in the empirical analysis. Furthermore, we include information about individual’s relations with, and access to, local health facilities. In addition to individual-level information based on the 2007 welfare monitoring survey, we also include regional-level variables that describe variations health care and level-of living conditions.