Social Determinants of Childhood Immunization in Ghana: Equity Impact Analysis

Background Equity is a fundamental principle underlying the global immunization program. Ghana has among the highest rates of childhood immunisation coverage in Sub-Saharan Africa. This study analyses full immunization coverage, calculates immunization dropout rate, and estimates the equity impact by child, maternal, socioeconomic, geographic and place of birth characteristics. Methods We analysed full immunization coverage (1-dose BCG, 3-dose DPT-HepB-Hib (Pentavalent), 4-dose polio, 3-dose pneumococcal (PCV3), 2-dose rotavirus, 1-dose measles (MCV1) and 1-dose Yellow Fever vaccines) of 1127 and 1705 children aged 12–23 months from the 2014 Ghana Demographic Health Survey and the 2018 Ghana Multiple Indicator Cluster Survey respectively. Mean coverage was disaggregated by socioeconomic (household wealth), maternal (maternal age at birth, maternal marital status, maternal education, and maternal exposure to media), sex of child and place of birth characteristics. Concentration indices estimated income-related inequalities and multiple logistic regression assessed the association between full immunization coverage and dimensions of inequality. Results Full vaccination coverage was 75.5% [72–79] and 73% [CI:69–76] in 2014 and 2018 respectively. Penta1 recorded the highest coverage of 96% [95–98] and 95% [CI:93–96] in 2014 and 2018 respectively. OPV0 recorded the lowest coverage of 77.5% [74.3–80.5] and 74.5% [71.0-77.6] in 2014 and 2018 respectively. The immunization dropout rate for Penta1 to measles was 10.4% in 2018. Children born in a health facility had 84% higher odds of being fully immunised compared to children born at home. Children in Possession of a health card had 83% higher odds of complete immunization and children born to mothers aged 25–29 years had 84% higher odds of being fully immunised compared to children born by mothers age < 25. Income related inequalities were pronounced in OPV0 with concentration indices of 0.27 and 0.22 in 2014 and 2018 respectively. Significant inequalities were pronounced in urban residence and children without a health card with concentration indices of 0.2 and 0.4 respectively. Conclusions Ghana’s immunization coverage is below the target levels and significant income-related inequalities exist. Health system and maternal-level health interventions will have the highest impact in promoting equity for the benefit of underserved children. As Ghana prepares to exit as a beneficiary of Gavi, monitoring and evaluation systems need to be strengthened.