Vaccination coverage and inequalities in childhood immunisation in Ethiopia: a secondary analysis of the PMA national longitudinal survey

Abstract

OBJECTIVE: The aim of this study was to assess vaccination coverage and inequalities in childhood immunisation among children aged 12 months in Ethiopia. DESIGN: Performance monitoring for action Ethiopia implemented a nationally representative first-cohort longitudinal survey (2019-2021), collecting data at baseline, 6 weeks, 6 months and 1 year post partum to monitor reproductive, maternal, newborn and child health indicators. SETTINGS: The study was conducted from five Ethiopian regions: three predominantly agrarian (Amhara, Oromia and Southern Nations, Nationalities and Peoples), one pastoralist (Afar) and one urban (Addis Ababa). PARTICIPANTS: The weighted sample comprised 1888 participants for full vaccine coverage (FVC) and 1677 for both incomplete vaccine coverage (IVC) and dropout rate (DOR) between pentavalent-1 and pentavalent-3 vaccines. OUTCOME MEASURES: The vaccine coverage and inequalities were assessed using three indicators: FVC, IVC and DOR (between the first and third doses of the pentavalent vaccine). Key dimensions of inequality included maternal age, economic status, education level, place of residence and subnational regions. The analysis was conducted using Health Equity Assessment Toolkit Plus software, employing seven summary measures of inequalities: Difference, Ratio, Population Attributable Risk, Population Attributable Fraction, Slope Index of Inequality, Relative Index of Inequality and the Theil Index. RESULT: The study found that only 29.1% of 12-month-old children in Ethiopia had received full vaccination, whereas 67.2% had incomplete coverage and the DOR between the first and third doses of the pentavalent vaccine was 34.3%. Both simple and complex inequality measures revealed a high level of inequality in childhood immunisation indicators across wealth, education, place of residence and regions. FVC was higher among children of higher socioeconomic status and urban residence, whereas IVC and DOR were disproportionately higher among children from the poorest households, mothers with no education, rural residents and disadvantaged regions. CONCLUSIONS: Childhood immunisation coverage in Ethiopia remains low and marked by high inequality. Higher rates of incomplete vaccination and vaccine dropout are disproportionately concentrated among children from low socioeconomic backgrounds, rural residents and disadvantaged regions. These disparities reflect substantial health inequities in childhood vaccinations as they are unfair and avoidable with appropriate interventions. The study underscores that addressing socioeconomic and geographic inequalities could substantially improve the national immunisation coverage and accelerate progress towards universal health coverage targets.