Inequality Monitoring in Immunization: A Step-by-Step Manual

Equity, which focuses on reaching groups that are often left behind, is a priority in Gavi's 2021-2025 high-level strategy. Systematic approaches to measure inequalities in immunisation provide information that can help countries tailor policies, programmes, and service provision and demand promotion to close gaps in immunisation. This manual offers an introductory-level guide to build capacity for the uptake and improvement of inequality monitoring practices in immunisation. It was created by the Equity Reference Group for Immunization (ERG), an action-oriented think tank convened by the United Nations Children's Fund (UNICEF) and the Bill & Melinda Gates Foundation.

Primarily written and designed for monitoring and evaluation (M&E) officers for immunisation, the manual presents information in a practical and straightforward way, and links readers to further, more detailed information. It includes case studies and examples; for instance, in Nigeria in 2013, children of mothers aged 20-34 years who were highly educated and living in a wealthy household in the South South region were 300 times more likely to be immunised than were children with teenaged mothers with no education and living in economically poor households in the North West region.

The manual is organised in 5 main sections, each corresponding to a step of inequality monitoring:

1. Determine scope of monitoring: After defining a "target population" for monitoring, identify a broad range of relevant health indicators and dimensions of inequality (categorisations upon which population subgroups are formed, such as wealth, education, region, sex, etc.).
2. Obtain data: Identify data sources that contain information about the health indicators and dimensions of inequality identified in Step 1.
3. Analyse data: Calculate health estimates by population subgroups and make comparisons between the levels of health in those subgroups.
4. Report results: Use written reports, multimedia presentations, policy briefs, or online interactive platforms to share the results of health inequality monitoring with the desired audience. ("Having a clear understanding of the audience, including their abilities, interests and needs, will help to make the communication of the results more effective.")
5. Knowledge translation: Promote the use of this evidence to inform policies, programmes, and practices, so as to help decision-makers: identify priority areas for action to reduce inequalities, integrate equity considerations into immunisation activities, and identify opportunities for intersectoral collaboration.

Although inequality monitoring is described as a step-by-step process, in reality, the implementation of these steps is iterative in nature, and requires contextualisation within the setting in which it is being applied.

Appendices include:

• Appendix 1. Additional resources
• Appendix 2. Monitoring, Evaluation and Review Framework
• Appendix 3. Double disaggregation
• Appendix 4. Data sources for immunization coverage
• Appendix 5. Overcoming limited data availability
• Appendix 6. Complex measures of inequality
• Appendix 7. Multiple regression analysis and compounded vulnerability
• Appendix 8. Case study: reporting inequalities in immunization
• Glossary of terms