Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants

"Understanding the context, including the different vulnerabilities and barriers faced by a particular community, as well as building human-centred designs will be critical to appropriately reach the remaining unimmunised children."

Reaching zero-dose (ZD) children, defined as children who have not received a first dose of the diphtheria, tetanus, and pertussis (DTP1) vaccine, is considered to be important for achieving universal health coverage, especially in low- and middle-income countries (LMICs) . However, ZD children face complex and overlapping deprivations, with several proximal, distal, and greater contextual determinants (e.g., gender, conflict, and health systems factors) at play. This paper reviews Health System Strengthening (HSS) proposals submitted by Gavi-supported countries to document and learn more about pro-equity interventions and to understand how these investments can help us prioritise interventions moving forward.

All HSS proposals submitted by Gavi-supported countries from 2014 to 2021 inclusively were reviewed. Pro-equity interventions were mapped to an analytical framework representing Gavi 5.0 programmatic guidance on reaching ZD children and missed communities. Of the 56 proposals included, 51 (91%) included at least one pro-equity intervention. The most common interventions were conducting outreach sessions, tailoring the location of service delivery, and partnerships. Outreach sessions in countries were often planned along with microplanning and community engagement activities as a "bundle" of interventions. These patterns align with the observation that one of the main bottlenecks to getting children immunised reported in the proposals was the long distances to health facilities. Sustainability concerns and cost-effectiveness of conducting outreach and mobile sessions as compared to other long-term strategies were rarely discussed in the HSS proposals.

Three of the top six most common categories aimed to generate demand at the community level (community-level education activities, communication strategies to generate demand, and engaging community and/or religious leaders to promote immunisation). Interventions addressing demand-side barriers included, for example, tailored immunisation sensitisation activities to different groups (women, religious, etc.), and conducting information, education, and communication (IEC) sessions in priority districts with communities, including educational chats, film showings, and outdoor theatres. On the supply side, several countries invested in transportation and cold chain equipment for their most hard-to-reach districts.

Less than one-third of the proposals (17/56) explicitly addressed gender-related barriers. Of those, 16 included gender-responsive interventions (e.g., employing female health workers may facilitate enhanced immunisation service acceptance and uptake), and 5 proposed gender-transformative ones (e.g., one country planned to have community health workers promote a gender approach with the involvement of fathers for the vaccination of children in households).

The results showed that several proposals focused on reaching remote-rural and hard-to-reach areas, but few prioritised the other Equity Reference Group for Immunisation (ERG) settings, namely urban economically poor and conflict-affected areas. It is estimated that 28% of un- or under-vaccinated children lived in urban and peri-urban areas, and up to 15% lived in conflict-affected areas in 2020. It would thus be beneficial to pay special attention to those populations, according to the researchers.

The researchers also found that the theory, or rationale, behind the selection of specific pro-equity interventions in the HSS proposals was often not provided. When it was provided, it was generally for unique interventions that were not commonly used by countries, such as immunisation ambassadors programmes and the tool "My Village My Home" implemented in a few countries. The failure to clearly explain the rationale can make it difficult to assess the relevance and intended effects of interventions in different contexts.

Reflecting on the findings, the researchers note that several of the interventions listed in the proposals were not considered pro-equity according to their definition ("tailored or targeted approaches towards un- or under-immunised children and missed communities"), but they could become so if they were tailored to specific populations. For example, social mobilisation activities to generate demand aimed at the entire population of a country through mass media could become pro-equity by adapting the messaging to specific communities. Along the same lines, capacity building of health workers could become a pro-equity intervention if the health workers received adapted training on interpersonal relations with specific vulnerable groups such as refugees, for example, or if they served a low-performing area. "In short, countries do not necessarily have to go back to the drawing board to design 'pro-equity' interventions but should build on existing interventions and tailor and target them to areas and/or populations with large numbers of ZD children." Also: "Having a clear and common definition of what constitutes a pro-equity intervention would be important to avoid working in silos and to help test the effectiveness of pro-equity approaches in reaching zero-dose children."

The researchers indicate that further mapping should be conducted to provide a more complete picture of pro-equity strategies being implemented in those countries beyond interventions funded by Gavi through HSS grants. In addition to exploring new interventions, research could investigate how to better design and implement commonly used interventions such as the ones identified in this mapping (e.g., outreach sessions, tailoring the location of service delivery, microplanning and community-level education activities) and adjust them to better reach ZD children.

In conclusion: "The findings can help identify specific interventions on which to focus future evidence syntheses, case studies and implementation research and inform discussions on what may or may not need to change to better reach ZD children and missed communities moving forward."