Advancing Immunization Coverage and Equity: A Structured Synthesis of Pro-Equity Strategies in 61 Gavi-Supported Countries

"The dissemination of these findings can...promote knowledge and expertise sharing between countries and can serve as a base for strategic planning and scale-up of interventions promoting equitable immunization programs..."

Health inequities are significant drivers of gaps in immunisation coverage and challenges in reaching the most under-served communities in low- and middle-income countries (LMICs). To identify country approaches to reach underimmunised and zero-dose children, these researchers undertook a structured synthesis of pro-equity strategies across 61 countries receiving programmatic support from Gavi, the Vaccine Alliance.

The researchers extracted data from 174 Country Joint Appraisals and Multi-Stakeholder Dialogue reports (2016-2020). We identified strategies via a targeted keyword search, informed by a determinants of immunization coverage framework. Strategies were synthesized into themes consolidated from UNICEF's Journey to Health and Immunization (JTHI) and the Global Routine Immunization Strategies and Practices (GRISP) frameworks. They identified 607 unique strategies across 61 countries and 24 themes.

Strategies targeting JTHI step 4 (Point of Service, n = 328 [44%]), step 1 (Knowledge, Awareness and Beliefs, n = 181 [25%]) and step 3 (Preparation, Cost and Effort, n = 98 [13%]) were the most common. Countries less frequently reported strategies targeting step 5 (Experience of Care, n = 58 [8%]), step 2 (Intent, n = 54 [7%]) and step 6 (After-Service, n = 20 [3%]) For example, strategies relevant to step 1 (Knowledge, Awareness and Beliefs) targeted the determinants Social Norms (n = 161 [22%]) and Human Resources (n = 21 [3%]). The themes most commonly identified at this step were: engaging local leaders to address misinformation and raise awareness (n = 84 [12%]) and use of communication strategies to address misinformation and raise awareness (n = 76 [10%]). For example, in Lao People's Democratic Republic, community leaders and village health volunteers have been reaching out to mothers in known high-risk villages by engaging them to understand their own personal views and potential hesitancy regarding immunisation. Moreover, in Indonesia, a communication campaign was developed to advocate for measles and rubella immunisation through short films, SMS (short messaging service, or text) blast messages, art/graphic design, and communication channels (Facebook, Twitter, WhatsApp, etc.).

Other communication-centred strategies are those used at step 5 (Experience of Care), which were most often related to the theme of adjusting service delivery approach and engaging community to ensure acceptability (n = 44 [6%]). A strategy under this theme was implemented in Ethiopia with the use of community outreach agents to perform the community-based monitoring of children eligible for vaccinations, thus engaging community leaders and volunteers. Moreover, among the strategies at step 2 (Intent) was the use of incentives to improve staff motivation and performance (n = 41 [5%]). For example, in South Sudan, 465 vaccinators and 24 supervisors were trained in interpersonal communication (IPC) skills. In the category of step 6 (After-Service), where the most common themes were strengthening accountability, trust, and communication for mobilisation (n = 12 [2%]), an example is the adverse events following immunisation (AEFI) training conducted in multiple countries (e.g., Nicaragua, Eritrea, Mozambique, and Myanmar).

The study also identified strategies addressing gender-related barriers to immunisation and prioritising specific types of communities. A few select examples related to the most common theme identified in the mapping (engaging local leaders to address misinformation and raise awareness) are highlighted in the paper. For example, in Malawi, mother care groups (village head chiefs, women volunteers) were created by Malawi Health Equity Network (MHEN) in hard-to-reach areas, urban slums, and refugee camps. The groups' activities involve defaulter tracing (door-to-door), health education, IPC, and advocacy at the community level. In Pakistan, a prototype on immunisation in slums of one union council (UC) in Lahore was developed and implemented locally. Through this approach, 12 slum health committees were established with participation from local community notables, religious leaders, teachers, and local government representatives for advocacy and social mobilisation among slum communities. Moreover, in Nigeria, the Women Advocates for Vaccine Access (WAVA), a coalition of women-focused civil society organisations, was formed to advocate for increased routine immunisation and sustainable vaccine financing.

Opportunities for future strategy development can be found in the least-common themes identified: health workers from the communities they serve, and security measures to allow immunisation services to happen safely in conflict-affected areas. Strategies to address these themes can be guided by the GRISP areas focused on the mobilisation of people (through engaging communities) and maximising reach (through designing services to effectively deliver vaccines to all priority groups and improve equity), respectively.

There are also opportunities for strategy development at the JTHI steps for which the study found fewer strategies (Intent, Experience of Care, and After-Service). For instance, immunisation intent is related to the caregiver's decision-making power and self-efficacy, which is influenced by societal gender norms and roles. An ecological framework can be useful in identifying gaps and interventions targeting individual and household factors affecting women's decision-making process, including health literacy and capacity for negotiation within households and within healthcare settings.

The paper outlines future directions for this work, such as an analysis of the country-level impact of these strategies on immunisation inequities and continued efforts to categorise strategies based on key dimensions, such as relevance to key populations (urban, remote rural, and conflict) and gender considerations.

Findings have been incorporated into a learning tool and searchable database of pro-equity strategies, which can serve as a resource and a guide to other countries who want to improve their immunisation coverage and equity.