Assessing Vaccination Delivery Strategies for Zero-Dose and Under-Immunized Children in the Fragile Context of Somalia

"In Somalia, prioritization and local know-how remain critical in reducing vulnerability and delivering equitable child health and immunization services for marginalized and neglected population groups."

Somalia is one of 20 countries in the world with the highest numbers of zero-dose children. The country's fragile and fragmented health system, unclear governance structure, and limited health financing - let alone its humanitarian health emergencies - hamper access to and demand for vaccines. In light of the weak health information system in the country and the lack of systematic and accurate data, this study aims to identify who and where zero-dose and under-vaccinated children are and what vaccine delivery strategies exist to reach zero-dose children.

The qualitative study was conducted in three geographically diverse regions of Somalia representing rural/remote populations, nomadic/pastoralists, internally displaced persons (IDPs), and the urban economically poor. Between July 2022 and March 2023, the researchers conducted 17 key informant interviews (KIIs) with Ministry of Health (MoH) officials and non-governmental organisation (NGO) staff. Fifty-two vaccinators and community members participated in three focus group discussions (FGDs) (one FGD in each study site) between December 2022 and February 2023. All of the 17 KII respondents were male, yet the majority of the participants (83%, n = 43) in the FGD were female - "shed[ding] some light on gender disparities in senior leadership positions" and indicating that "Somali women's voices and perspectives are missing in the higher policy and decision-making spaces in the Somalian health system." The data were analysed using the GAVI Vaccine Alliance IRMMA framework.

Official statistics such as civil registrations do not exist in Somalia. However, the KIIs and FGDs identified three population groups as having a high proportion of zero-dose and under-immunised children:

• Nomadic populations: Delivering immunisation services to pastoralist areas requires resources and capacities that the government believes they cannot afford.
• IDPs in camps: Immunisation service availability - in particular, the lack of service provision at convenient times - is described as a major barrier for this population.
• Communities living in Al-shabaab-controlled areas: Study participants noted that large segments of the population living in the Jubbaland and Galmudug regions are inaccessible due to conflict, security reasons, and fear of abduction of healthcare workers.

The participants also mentioned urban economically poor and minority groups to communities with high zero-dose and under-immunised children. The participants described the diversity of this subgroup and how poverty, social norms and behaviours, and lack of awareness could underpin their vulnerability and constitute barriers to their access to immunisation services. One vaccinator voiced her dissatisfaction with the limited social mobilisation and engagement with the urban economically poor. She said, "Some of the poor families in the neighbourhood of this health centre do not bring their children to the health facility for immunization. I talked to one family who said that they were not fully informed of the benefits of vaccination. Since their children were healthy, thanks to Allah, they did not think they needed to bring them to the health center."

Participants shared examples of various engagement approaches and interactions with the community, including establishing regular contact with community leaders and elders, local government officials, and businesspeople. They stressed the importance of knowledge about power structures in the community and the selection of individuals with such knowledge and good standing in the community to be social mobilisers. They mentioned a network of trained social mobilisers under the Somalia Social Mobilization Network (SOMNET), which was deployed across the country. An evaluation report on the network in 2017 detailed the role of SOMNET in community engagement, community-level risk communication, social mobilisation, and health promotion at the national, state, regional, and district levels. One respondent had the view that the number of mobilisers is not sufficient: "The people who work on raising awareness are very few in comparison to the community and size of the areas to be served. Awareness is the first and most important step to sensitize the community and promote acceptance. Hiring people who the community can trust and is willing to learn from them is very crucial if the awareness raising has to succeed."

The participants suggested that one of the main reasons for the low vaccine uptake in Somalia could be due to vaccine hesitancy among different groups in the community. They noted that, while misconceptions about vaccine safety and risks are real issues that need to be addressed, it is simplistic and unhelpful to attribute the cause of the multifarious forms of vaccine hesitancy merely to misinformation and individual-level decisions. One FGD participant laid strong emphasis on trust and described the important role of well-known community members in awareness-raising for immunisation programmes.

The participants described engagement and collaboration among different stakeholders via the Health Cluster and other State and regional coordination meetings. However, decision making was not evenly distributed but rather skewed towards the higher level, where the federal MoH, World Health Organization (WHO), and the United Nations Children's Fund (UNICEF) dominate power and resources.

Despite the increasing awareness about zero-dose and under-immunised children, participants discussed the government's lack of clear strategies and plans to address them. A MoH official cited inadequate resources and capacity as the main challenge. While most of the participants from the MoH argued that there was a high level of political leadership and strong support for immunisation, some of the community members and vaccinators were skeptical. One community member said in an FGD: "I think it would send a powerful signal of support if the top political, clan and religious leaders were seen taking their children to health facilities for immunization, not just a minister cutting ribbon or putting vaccine drops into a child's mouth for the start of immunization campaign."

The participants commented on the participation of local NGOs in planning and decision-making spaces and argued that local organisations should have a greater role in designing local strategies and interventions to deliver immunisation services, as they have good knowledge and experience about the context and enjoy a strong relationship with communities.

Thus, this study demonstrates the importance of considering the diversity of context, subgroup characteristics, and social dynamics in the development of policies and delivery strategies, which can boost immunisation uptake among these communities - thereby increasing chances for locating and engaging with communities and promoting equity. The study has reinforced the argument that understanding the political, social, and economic barriers of these subgroups will help avoid the mistake of adopting one-size-fits-all policies and approaches for discrete contexts, locations, communities, and States.

In conclusion: "Better governance and coordination at different levels, adequate resources, using alternative routes of service delivery to communities where the government cannot reach, generating demand with understandable vaccine information, and more robust evaluation methods are several options that should be considered....Last but not least, improving the availability and quality of immunization data...will be critical for identifying where and how many zero-dose and under-immunized children are in Somalia and ensuring effective planning, delivery and evaluation of immunization interventions."