Reaching Every Child in Humanitarian Settings (REACH) Project

To meet its objective of reaching zero-dose children, the project includes the following approaches and strategies:

• NGO-led model: This model represents a paradigm shift by departing from the top-down model that relies on the reach of national health systems and instead leverages NGOs and local actors who have the infrastructure, experience, and access to deliver services in humanitarian settings.
• Mapping of zero-dose children: At the start of the project, the REACH Consortium characterised and mapped the population of zero-dose children. This mapping of where zero-dose children live has been crucial to understanding contextual barriers to immunisation and designing strategies to sustainably reach zero-dose and under-immunised children with vaccination services. In REACH's operating areas, the IRC and partners estimate that among a total population of 2.23 million children under five identified, 1.23 million (54.9%) qualify as zero-dose. Another 420,000 children (18.6%) qualify as under-immunised. Based on the population data and the reach of existing government vaccination efforts, 156 districts in Ethiopia, Somalia, South Sudan, and Sudan were selected for implementation. These districts include conflict settings, regions under partial or no government control, and regions with large populations of internally displaced people (IDPs), refugees, and nomadic communities.
• Hyper-responsive and context-specific implementation: The project relies on a community-driven approach to understand barriers to access as well as reasons for zero-dose children. It also works with community members, especially women, to implement community-based activities and to ensure community participation in every step of the project.
• Overcoming barriers to access: This strategy has been achieved through the following:
  • Optimised delivery locations - Service locations and delivery tactics, including the use of fixed, mobile, and cross-border mass vaccination campaigns, are determined using geospatial information systems (GIS) and population data. By differentiating delivery strategies, REACH seeks to overcome access barriers and bring vaccination services directly to children and their caregivers.
  • Cold chain innovations - To ensure vaccines are able to reach the optimised delivery locations, REACH is leveraging new cold chain technology such as refrigerated and rechargeable Indigo Backpacks. These packs provide an uninterrupted cold chain for up to five days and enable healthcare workers to deliver immunisations in even the most remote and difficult-to-reach communities. The consortium will continue to pilot new innovations as they emerge.
  • Humanitarian access negotiations - The project uses humanitarian negotiators who engage in discussions with governments and armed groups to broker access to communities that are inaccessible. The REACH team, for example, successfully negotiated humanitarian access to reduce the percentage of inaccessible communities from 84% to 37%. REACH is employing a phased delivery approach, where service delivery begins in accessible locations while humanitarian access is being negotiated in partial and inaccessible locations.
• Overcoming economic barriers to participation: Travelling to facilities that are far away, missing work, and/or lack of childcare disincentivises participation. The project therefore developed the following strategies (using a client-centred approach) to ensure participation:
  • Integrated services - REACH is working to integrate immunisation into health and non-health programmes to ensure participation and improve communities' health and well-being in both the immediate and long-term. For example, childhood and livestock immunisation may be provided in one location, such as a market, so that families can care for both their children and livelihoods at the same time, providing both health and economic benefits. Partners are also integrating health programmes to provide services, including nutrition, and vaccines in one place.
  • Optimised delivery locations: To reduce the opportunity cost for caregivers (a concern cited by caregivers) to take advantage of immunisation services, the project increased the locations of immunisation services in remote, conflict-affected, cross-border, nomadic, and missed communities.

In the first 6 months of the project's implementation phase, the Reach Consortium delivered routine immunisations (diphtheria, tetanus, and pertussis, or DPT, and meningococcal conjugate vaccine, or MCV) to 298,559 children in Somalia, Ethiopia, Sudan, and South Sudan.

Context: The Horn of Africa experiences low rates of immunisation due to ongoing and overlapping challenges of sustained conflict, food insecurity, porous borders, and limited health infrastructure. The lack of government control in some areas and/or active conflict leads to interrupted or halted service provision and also limits the mobility of the population, especially women and children. These challenges create the need for unique interventions to deliver immunisations at scale and to close the vaccination gap. In particular, interventions that are hyper-responsive and context-specific are required.

The Zero-dose Immunization Program (ZIP): Despite progress in making immunisation more accessible to low-income communities over the last two decades, World Health Organization (WHO)/United Nations Children's Fund (UNICEF) estimates of national immunisation coverage (WUENIC) data show that 25 million children worldwide did not receive one or more doses of lifesaving vaccinations in 2021. Of these children, 18 million have never been vaccinated at all, leading to high under-five mortality rates. This group of children is referred to as “Zero Dose Children,” and they are particularly concentrated in the Sahel and the Horn of Africa, where over 5.2 million of them reside across 11 countries.

These 5.2 million children are not receiving life-saving vaccinations due to no or limited access to the health system as a result of conflict, climatic events such as drought and seasonal floods, and movement of populations for different reasons. These communities are often characterised by food insecurity, violence, displaced people, refugees and cross-border migration.

ZIP was launched by Gavi, the Vaccine Alliance, to help governments reach these vulnerable children. The programme consists of two projects, RAISE 4 Sahel and REACH, led by two consortia of organisations with expertise in operating in complex contexts. To achieve its objectives, Gavi is partnering with non-traditional and diverse partners such as non-governmental organisations and local civil society organisations to reach families and children in areas that governments cannot access, such as cross-border settings and conflict areas.