Child immunization rates doubted

Inflation seen in poorest nations

WASHINGTON - Many of the world's poorest countries have for decades routinely exaggerated the number of children being immunized against disease, apparently driven by political pressure and, more recently, financial incentives.

That is the finding of a huge analysis that has provoked heated discussion even before its publication today in The Lancet, a European medical journal.

Since 1986, progress in childhood immunization in the developing world has been only half that officially reported by governments in the developing world. Not only are year-to-year improvements overstated, but the total percentage of children immunized is far lower than publicly acknowledged, the study found.

The two-decade trend masks extreme variations, with some countries overstating their gains four- and five-fold, and a few countries understating them.

The analysis, which compares official immunization coverage with what was found in house-to-house surveys, casts a shadow on the emerging strategy of "pay-for-performance" in global health assistance. It suggests that the pioneering Global Alliance on Vaccines and Immunizations may have paid out twice as much in performance rewards as it should have - $290 million instead of $150 million.

Of 51 countries that have received reward payments since the alliance was founded in 1999, six overestimated immunization gains by a factor of four, 10 overestimated them by a factor of two, and 23 by less than two. Eight underestimated their progress. The alliance has suspended reward payments to all countries, pending more review.

"By early next year, we will modify, drastically change, or possibly put in place a new system of incentive performance," Julian Lob-Levyt, the executive director, said Thursday from London after a two-day meeting with the alliance's partners to discuss the findings.

He noted there was no suggestion any money has been diverted for personal gain.

The alliance was started with a $750 million "seed grant" from the Bill and Melinda Gates Foundation. Ironically, the new analysis, done by researchers at the University of Washington led by Christopher Murray, was also funded by the Gates Foundation. The study is an example of how health statistics can vary depending on their source, and possibly also with the interests of the people generating them.

"Is there intent? We can't say, " Murray said. "All we can say is that there is over-reporting, and the over-reporting occurs in the presence of financial incentives."

Murray and his colleagues examined coverage with diphtheria, tetanus, and pertussis vaccine. Children should get three doses of it before their first birthday. They compared three sources of data - the official account of children vaccinated reported by governments; the "best estimate" made by the World Health Organization and UNICEF, which adjust the official counts if they find them implausible; and surveys, usually underwritten by independent agencies, that scientifically sample a population.