BackgroundThe under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes).MethodsWe analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh.ResultsWe found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not.ConclusionsSubnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.Electronic supplementary materialThe online version of this article (10.1186/s12963-018-0171-7) contains supplementary material, which is available to authorized users.

Access to vaccination services for children in Kampala is high; however, vaccination uptake and timeliness decrease over time, as indicated by the high percentage of partially vaccinated children (58.6%). n Parents of partially vaccinated children stated that receiving inadequate information about immunization from health workers was a barrier to vaccination. This highlights the need for tailored health education and social mobilization efforts in Kampala taking into consideration the transient and diverse populations.n Vaccine stock-outs and long waiting times prevented parents from vaccinating their children. Stronger public-private partnerships in urban areas could help address these barriers.n A primary health care model that harnesses the strengths of the private sector can help address the barrier of hidden immunization costs that deter people from seeking immunization services.n Innovative survey methods that capture data from the highly mobile nonresidents in urban settings need to be developed as this population contributes to the pool of children that need to be immunized but also to the risk of disease outbreaks.

Background In Uganda, there are persistent weaknesses in obtaining accurate, reliable and complete data on local and external investments in immunization to guide planning, financing, and resource mobilization. This study aimed to measure and describe the financial envelope for immunization from 2012 to 2016 and analyze expenditures at sub-national level. Methods The Systems of Health Accounts (SHA) 2011 methodology was used to quantify and map the resource envelope for immunization. Data was collected at national and sub-national levels from public and external sources of immunization. Data were coded, categorized and disaggregated by expenditure on immunization activities using the SHA 2011. Results Over the five-year period, funding for immunization increased fourfold from US$20.4 million in 2012 to US$ 85.6 million in 2016. The Ugandan government was the main contributor (55%) to immunization resources from 2012 to 2014 however, Gavi, the Vaccine Alliance contributed the majority (59%) of the resources to immunization in 2015 and 2016. Majority (66%) of the funds were managed by the National Medical Stores. Over the five-year period, 80% of the funds allocated to immunization activities were spent on facility based routine immunization (expenditure on human resources and outreaches). At sub-national level, districts allocated 15% of their total annual resources to immunization to support supervision of lower health facilities and distribution of vaccines. Health facilities spent 5.5% of their total annual resources on immunization to support outreaches. Conclusion Development partner support has aided the improvement of vaccine coverage and increased access to vaccines however, there is an increasing dependence on this support for a critical national program raising sustainability concerns alongside other challenges like being off-budget and unpredictable. To ensure financial sustainability, there is need to operationalize the immunization fund, advocate and mobilize additional resources for immunization from the Government of Uganda and the private sector, increase the reliability of resources for immunization as well as leverage on health financing reforms like the National Health Insurance.

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Background: In Uganda, there are persistent weaknesses in obtaining accurate, reliable and complete data on local and external investments in immunization to guide planning, financing, and resource mobilization. This study aimed to measure and describe the financial envelope for immunization from 2012 to 2016 and analyze expenditures at sub-national level.Methods: The Systems of Health Accounts (SHA) 2011 methodology was used to quantify and map the resource envelope for immunization. Data was collected at national and sub-national level from public and external sources of immunization through key informant interviews coupled with document reviews. Data were coded using the SHA, categorized and disaggregated to detail the expenditure on immunization activities. Results: Over a five-year period, funding for immunization increased fourfold to US$ 85.6 million in 2016. The Ugandan government was the main contributor (55%) to immunization resources from 2012 to 2014. However, Gavi, the Vaccine Alliance contributed the majority (59%) of the resources to immunization in 2015 and 2016. Majority (66%) of the funds were managed by the National Medical Stores. Over the five-year period, 80% of the funds allocated to immunization activities were spent on facility based routine immunization (expenditure on human resources and outreaches). At sub-national level, districts allocated 15% of their total annual resources to immunization to support supervision to lower health centers (including distribution of vaccines). Health facilities spent 5.5% of their total annual resources on immunization to support outreaches.Conclusion: Development partner support has aided the improvement of vaccine coverage and increased access to vaccines. However, there is an increasing dependence on this support for a critical national program raising sustainability concerns alongside other challenges like being off budget and unpredictable. To ensure financial sustainability, there is need to operationalize the immunization fund, advocate and mobilize additional resources for immunization from the Government of Uganda and the private sector, increase the reliability of resources for immunization as well as leverage on health financing reforms like the National Health Insurance.