Pro-Equity Immunization and Health Systems Strengthening Strategies in Select Gavi-Supported Countries

"Findings from this mapping show the range and types of pro-equity strategies implemented in different contexts and can be useful for countries facing similar challenges to consider. This will help in the drive to achieve much-needed progress towards universal vaccination, especially in low and middle-income countries."

Particularly in developing countries, millions of children are missing out on essential vaccines due to factors such as poverty, ethnicity, gender, remoteness, and conflicts. Countries supported by Gavi, the Vaccine Alliance, have implemented a menu of context-specific strategies designed to reach underserved children and populations ("pro-equity strategies"). This paper summarises a mapping of these strategies, providing a methodology (and publicly available dashboard) that stakeholders and Gavi could use in purposefully and systematically reaching partially vaccinated and zero-dose children in the future.

The search for and mapping of pro-equity strategies was guided by a consolidated equity framework developed from an ongoing United Nations Children's Fund (UNICEF) review of health-systems-oriented strategies to improve immunisation equity outcomes, synthesised from 16 different frameworks relevant to immunisation, equity, and health systems. Thirteen Gavi-supported countries were purposively selected, with emphasis on Gavi's priority countries. (The 13 countries represent approximately 50% of all investments Gavi made to countries in 2019. These countries still have varying immunisation coverage, ranging between 41% in Chad to 94% in Kyrgyzstan.) A scoping of documents submitted to Gavi by these 13 countries revealed 258 pro-equity strategies that were implemented between 2016 and 2019.

The median number of strategies reported per country was 17. Afghanistan, Nigeria, and Uganda reported the highest number of strategies considered to be pro-equity. The framework determinants of social norms, management and coordination, and utilisation accounted for more than three-quarters of all pro-equity strategies implemented in these countries. In sum:

• Pro-equity strategies under the determinant of social norms:
  • Identify normative positions and match the messenger to the recipient - For example: India, Kenya, and Kyrgyzstan engaged religious leaders to boost demand for immunisation services and to increase coverage; Chad involved village chiefs and community registers to promote immunisation; and Pakistan established slum health committees to serve as advocates.
  • Set up peer/women-support groups in communities to share information, promote healthy behaviour, and establish trust: For example, India implemented interpersonal communication (IPC) sessions ("Mother Meetings") to boost immunisation coverage, in addition to a vaccine hesitancy pilot in selected geographies.
  • Leverage social norms by using champions from the intended population who are generally well-liked and influential to shape perceptions peers have of vaccines - For example, in Kenya, the Cabinet secretary and polio survivors served as immunisation champions to help reduce vaccine hesitancy and speak out in favour of immunisation.
  • Carry out proactive training of journalists, especially in urban areas - For example, India, Kenya, and Kyrgyzstan engaged journalists to raise awareness on immunisation in an effort to reduce vaccine hesitancy.
  • Widen the audience for information, education, and communication (IEC) to strengthen and sustain social mobilisation - Examples include: a survey to assess the determinants of immunisation service utilisation among Ethiopian Agrarian communities; a strategy for engaging and appealing to fathers to participate in immunisation in Kenya; and an urban immunisation strategy with linkages of services for improved community empowerment in Myanmar.
  • Pursue gender-transformative approaches - For example: To overcome Ulema gender-related barriers to accessing immunisation by women, Afghanistan developed specific training for female vaccinators; Kenya adopted a strategy engaging and appealing to fathers to participate in immunisation; and Uganda reached out to men specifically through mobilisation, health education, and participatory guidance, thus empowering them to support their families in immunisation uptake and demand generation.
• Pro-equity strategies under the determinant of management and coordination:
  • Galvanise Expanded Programme on Immunization (EPI) support groups to focus on urban areas - For example, Nigeria developed immunisation session plans to include outreach and mobile sessions for urban slums in line with the Reaching Every Ward (REW) micro-plan, which is an adaptation of the Reaching Every District (RED) strategy; Pakistan developed an equity-focused integrated urban immunisation/health roadmap for Karachi; and Uganda is supporting outreach in slum areas and the establishment of village health team (VHT) systems in urban areas.
  • Create multiple strategies for negotiating access to populations affected by conflict with corridors of peace, safe havens, sanctuaries of peace, children as "zones of peace", and work with non-traditional change agents: For example, Afghanistan used a Public-Private Partnership (PPP) model to provide basic reproductive and immunisation services in remote and insecure districts of six provinces in the country.
  • Improve communication chains among health providers and between providers and supervisors, especially in conflict areas: For example: The Immunization Communication Network (ICN) in Afghanistan helps with tracking of children who have missed their vaccines; Pakistan sends targeted messages across 150 WhatsApp groups with thousands of memberships; and Nigeria's Immunization Service Delivery Accountability approach aims to address data accuracy/quality and reduce pressure on the healthcare worker to falsely report on targets.
  • Implement a health monitoring system, with a focus on conflict and urban areas: Examples include: the use of an urban immunisation dashboard and web-based data tool for reporting adverse events following immunisation (AEFIs) in India; the use of electronic community health information systems (eCHIS) in Ethiopia; the Vaccine Adverse Events Management Information System (VAEMIS) in Uganda; and the integration of an existing logistics management information systems (LMIS) with the Visibility Analytics Network (VAN) in Nigeria.
  • Develop alternative approaches to immunisation records: For example, Nigeria used reminder bracelets to improve timeliness and completeness of childhood vaccinations, while Uganda explored the use of electronic registers for immunisation integrated with HIV electronic medical records.
  • Track population and movement through satellite imagery and mobile phone data: For example, Afghanistan revised micro plans through geographic information system (GIS) and used tracking bags for defaulter tracking; India undertook GIS mapping of ward boundaries and immunisation sessions; and Kenya reported the use of GIS for equity programming in immunisation.
• Pro-equity strategies under the determinant of utilisation:
  • Adjust hours/timing of immunisation services to better serve the client/intended population: For example: Pakistan introduced business-hour vaccination sessions in urban centres; Uganda changed the timing for outreach in urban areas to weekends; and Kenya extended opening hours of health facilities in Nairobi and procured mobile clinics.
  • Tailor location of service delivery to meet the needs of caregivers, and ensure the acceptability of services for both mothers and fathers: For example, Pakistan implemented transitory point immunisation including locations like bus stations and airports; and Bangui, Central African Republic (CAR) developed, an immunisation strategy for special populations (e.g., nomads, pygmies, IDPs/refugees, fishermen, mining sites, markets).
  • Set up peer-support groups for health providers, especially in remote rural areas: For example: Women Advocates for Vaccine Access (WAVA) is a coalition of women-focused civil society organisations in Nigeria advocating for increased routine immunisation and sustainable vaccine financing; and Kenya established Health NGO [non-governmental organisation] Networks (HENNET) to provide peer support for immunisation service delivery.
  • Use reminder-recall systems, such as SMS (text message) reminders and phone calls: For example, in Afghanistan, an android-based app Zindagi Mehfooz (ZM) is used for tracking children and following up with them; Kenya implemented a nomadic strategy in Turkana to track children for vaccination, and engaged teachers, school children, and community health volunteers in tracking children who have missed their immunisation; and Uganda is using a tracking tool to track defaulters, with social media platforms (WhatsApp, Facebook, SMS) being used to transmit information to parents and caregivers.

The researchers reflect on each of these approaches, noting that the data from the country reports do not provide enough information to determine conclusively the level of impact and sustainability of these strategies. However, they are certain that, "for pro-equity strategy implementation, it is useful to look beyond national coverage and focus on disaggregated sub-national data, which is more informative in ensuring equitable access and utilization of services...An illustration could be seen in Uganda which has not shown an increase in immunization coverage over the last four years and access barriers have been reported as a primary challenge to reaching every child with vaccines....In this instance, subnational data at the districts where pro-equity strategies were implemented would have provided the best measure of success or otherwise of these strategies since national aggregates often mask subnational improvements in coverage or performance."

In conclusion: "Future efforts should seek to identify pro-equity strategies being implemented across additional countries, and to assess the extent to which these strategies have improved immunization coverage and equity."