Kirsten Mathieson
Lara Brearley
Publication Date
December 1, 2012

Save the Children United Kingdom (UK)

Noting that one child in five around the world misses out on basic vaccinations, this report identifies country-level strategies to reach the unreached. It also identifies factors at the global level that will help to create a more conducive environment for countries to achieve and sustain universal immunisation coverage. It is a call to action for the Decade of Vaccines to ensure that inequalities in immunisation are addressed so that no child dies from preventable or treatable causes.

It argues that while immunisation campaigns have been very successful, more comprehensive systems are needed to achieve and sustain high and equitable immunisation coverage. It looks at the importance of strengthening routine immunisation systems to overcome inequalities and explores how, through immunisation, more equitable access to other essential health interventions can be extended for the children who need these services most.

Key considerations for strengthening routine immunisation that are discussed in the report include: effective and integrated use of outreach; investments in frontline health workers (including addressing issues of motivation and performance); innovations to strengthen supply chains and service delivery; specific initiatives such as Reaching Every District; and engagement and empowerment of communities to demand immunisation and to shape delivery mechanisms to increase uptake and improve the quality and supply of immunisation services.

Approaches to strengthening routine immunisation and addressing inequalities are described here as being varied and context-specific. Successful progress is often the product of multiple factors, including direct drivers (e.g., a cadre of community health workers) or broader enabling factors (e.g., political commitment and leadership). According to the report, factors are often interconnected and operate at different levels of the country and health systems. For instance, a national commitment to health, including immunisation, which is reflected in increased resource allocation, may be associated with improved routine immunisation. Other strategies identified include: bringing services closer to the community; driving demand for vaccination through information dissemination (e.g., increasing awareness, promoting participation); changing practices in fixed sites (e.g., providing immunisation when patients are seen for illness or other reasons); and using innovative management practices (e.g., working with other partners, peer learning, better use of data, and community information).

For example:

  • In Bangladesh, Dr. Asm Amjad Hossain won the first Gates Vaccine Innovation Award in 2012 for reaching more children in two low-performing districts by implementing a register system to track and locate pregnant mothers and by introducing simple yet effective improvements, such as adding the phone numbers of vaccinators at the top of immunisation cards. "His methods increased immunisation coverage by 15 percentage points in a single year."
  • In Bihar, India, efforts have been made to redesign the vaccine carrier box to incorporate multiple functions such as storage of routine immunisation paraphernalia, easy transportation, and a collapsible work surface. This has presented the opportunity to expand this to a "Vaccine-Plus" kit, adding equipment to support other maternal and child health interventions. A social map, identifying landmarks and where key members of the community (for example, local midwives, priests, barbers, teachers) live, is sent to the health worker's mobile device, along with a list of potential recipients, helping the health worker identify pregnant women, newborns, and migrating populations. The health worker can also provide minimal data to register recipients by calling into an Interactive Voice Response Service using his or her mobile device.
  • The Health Extension Programme (HEP) was introduced in Ethiopia in 2003 with the aim of improving access to health services in rural areas through the work of government-paid, community-based and -focused Health Extension Workers (HEWs). HEWs deliver immunisation services at newly constructed health posts, as well as through outreach and house-to-house visits. They also organise sessions to raise awareness about vaccination in communities. According to organisers, the programme has led to increasing geographic and social access to health services and has created a favourable context for progress on immunisation coverage. HEWs have also become focal points in their communities for health in general and have built trust and rapport with communities to encourage the use of immunisation and other primary health services. The focus on strengthening community structures (e.g., networks of community volunteers and supporting their links to health service activities) "has also meant that local governments and local volunteers are increasingly involved in health and development activities, including immunisation."

One section of the report focuses specifically on community engagement/empowerment (pages 14-15). There, the authors explain why providing information is important but that efforts must go beyond this, and communities must also be empowered to demand the services to which they are entitled. "Community-based workers and volunteers play a key role in empowering, educating and communicating with communities, changing attitudes and behaviour, building trust in the health system and generating demand for good-quality services." Community participation in accountability structures and processes is also important. They note that civil society organisations have a role to play in supporting communities to be able to do this, such as through the use of community scorecards to monitor the quantity and quality of health services provided. Other mechanisms may include, for example, local health committees and groups, and patients' rights charters.

At the global level, the report identifies how donors, the private sector, and other institutions can do much more to support countries to achieve and sustain universal immunisation coverage. Strategies discussed here involve research and development (R&D) agendas that respond to the needs of the economically poor and most vulnerable, as well as technologies and vaccine packaging that work in economically poor and remote locations. It also looks at the importance of ensuring countries have sustainable access to sufficient supply of vaccines at affordable prices. This can be done by increasing competition to bring down prices, including through technology transfers to emerging market producers. It also looks at opportunities for pooled procurement.

Finally, Immunisation for All makes a series of recommendations to governments, development partners, the private sector, and civil society.


Global Immunization News (GIN) [PDF], sent to The Communication Initiative on December 5 2012; and emails from Kirsten Mathieson to The Communication Initiative on December 18 2012 and February 13 2013. Image credit: Jane Hahn/Panos for Save the Children