The Governance of Childhood Vaccination Services in Crisis Settings: A Scoping Review

"[N]either crisis-affected populations nor private health sector providers in crisis-affected countries seem involved in deciding which vaccines are offered, how to deliver them, and to whom. This is despite wide acknowledgement that meaningful participation of crisis-affected populations in the design of humanitarian responses is likely to result in timely, appropriate, and effective humanitarian responses..."

Crisis-affected populations are particularly vulnerable to elevated morbidity and mortality from infectious diseases. Children in these settings are often also deprived of other essential services and face socio-economic and gender disparities that may limit vaccination services access or demand. With multiple and largely autonomous global, national, and local actors and often-limited governmental effectiveness in crisis-affected countries, decision-making around vaccination services often lacks structure and transparency. This review describes the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigates how the governance of childhood vaccination is defined, understood, and practised.

The researchers performed a scoping review of 193 peer-reviewed articles and grey literature that focused on 41 crises between 2010 and 2021. The data or information reported in the included documents ranged from 2005 to 2022. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines.

The review identified various interpretations of governance, often implying hierarchical authority and regulation. None of the definitions encountered in the reviewed documents acknowledged that the governance of childhood vaccination, like other global health issues, involves formal and informal, vertical and horizontal processes among multiple stakeholders within and outside crisis-affected countries. The review revealed two strategic actors with sufficient power to set relevant vaccination goals and guidelines: the World Health Organization (WHO) and the Global Polio Eradication Initiative (GPEI), the latter of which plays a vital role in influencing vaccination efforts in conflict-affected areas where polio eradication is challenging, such as Afghanistan, Pakistan, and Nigeria. The fact that decision-making spaces tend to involve a limited set of actors, especially national governments, WHO, the United Nations Children's Fund (UNICEF), and select global organisations, leaves little room for other stakeholders, including crisis-affected populations.

Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. The researchers argue that these findings may be partially explained by insufficient incorporation of collaboration, equity, shared strategic vision, and accountability principles - four universal principles of good global governance generally and health specifically.

Distrust among vaccination actors, particularly international agencies towards national governments, was observed in multiple instances, such as concerns about the government's expertise and leadership capacity for polio eradication in Afghanistan. Among the solutions suggested by authors of reviewed articles are as follows: motivating governments to implement recommendations, adopting a supportive attitude towards governments, investing in their capacity, and facilitating inclusive discussions to build better partnerships between state and non-state actors.

Some authors of articles included in the review described the consequences of existing governance problems on vaccination efforts. One consequence is slow or hesitant vaccination responses that are not consistent with the aim of timely prevention. One recommendation: devolving decision making to frontline staff for more flexible responses. Other authors associated governance problems with inappropriate vaccination intervention design that does not always align with the actual needs of crisis-affected areas, is not informed by guidelines or a framework, or does not sufficiently address the root causes or prioritise vaccination. Suggestions to address these issues include introducing the WHO's decision-making framework for vaccination in acute humanitarian emergencies to national and sub-national health authorities and implementing generic multi-antigen mass vaccination campaigns in all acute crises.

In short: "While a unifying definition of governance may not be necessary, an appreciation of the true nature of governance by actors is essential to shed light on opportunities for fully harnessing the resources and capabilities of involved actors that enable new forms of collective action....This will also allow a recognition of the importance of including critical actors, such as crisis-affected communities, who are excluded from current governance structures."

The researchers outline several potential implications of the findings for programming and future research. For example, they suggest that better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. Furthermore, "research that elicits the perspectives of crisis-affected communities and other excluded actors on their current and desired participation in the design and planning of childhood vaccination interventions is paramount."

In conclusion: "improving accountability requires first addressing meaningful and equitable participation in governance. This will ensure that accountability mechanisms account for the power and influence of the different actors involved."