Will more inputs improve the delivery of health services? Analysis of district vaccination coverage in Pakistan

In order to determine whether physical resources or technical inputs can make a difference to the delivery of health services, we carried out a study that examined the large variation in district level vaccination coverage in Pakistan. Vaccination coverage was assessed by district-wise cluster surveys and the predictor variables were collected from census data and from a survey of 99 district health offices. Information was collected on basic supplies, physical infrastructure, management, training, socio-economic variables, and a variety of other indicators. Univariate and multivariate analyses were carried out. A model including female literacy rate, TV ownership, and provincial dummies explained 48% of the variation in DTP3 coverage. Very few of the other variables examined were significantly correlated to coverage. Possible explanatory variables like adequacy of syringe and vaccine supply, the number of vaccinators per capita, recent training of managers, frequency of supervision, availability of micro-plans, and turnover of managers were not correlated with coverage. While the Government of Pakistan has ensured that many physical resources and technical inputs have been provided to the district health offices, this does not appear able to explain the relatively low overall coverage or the variation between districts. Bolder initiatives and innovations are likely needed to improve delivery of basic health services.