Achieving Equity in Immunization through Reaching Every Community

A UNICEF Initiative

100

80

60

40

20

0

Global African American Eastern Mediterranean European South East Asian Western Pacific

84 82 79 80 80

76 77 75 73 73 73 73 73 70 70 69

64

56 52 50

45

38

25 23 20

83 83 83

72 72 72 72 72

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Great progress with global

vaccination coverage, but more

needed in some regions

% D

TP

3 c

overa

ge

20 23 25

3845

50 5256

6469

7672 707073 7372 72 7272 73 7373 75 77 7880 80 8384 84 8383 84

0

20

40

60

80

100

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

% D

TP

3 c

overa

ge

Global High income Middle income Low income

Vaccination coverage is highest

and correlated with country

income

Source: WHO/UNICEF coverage estimates 2013 revision. July 2014

Immunization Vaccines and Biologicals, (IVB), World Health Organization.

194 WHO Member States. Date of slide: 28 July 2014.

202325

38

455052

56

6469

76727070

7373727272727373737577788080838484838384

0

20

40

60

80

100

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2104

2015

2016

2017

2018

2019

2020

% D

TP

3 c

overa

ge

The expansion of vaccination coverage

UCIRapid scale-

up in

coverage

Consolidationstagnating coverage

(in %)

Launch of GAVIModest coverage

gains, and focus on

new vaccines

Reach the fifth childCoverage improvement, portfolio

expansion, and integration with

broader disease control

Adapted from: L. Brearley et al. Vaccine 31S(2013) B103-B107

Focusing on the un-reached, where there are

inequities in wealth…

0 10 20 30 40 50 60 70 80 90 100

Centr Afr Rep

Chad

D.R. Congo

India

Liberia

Madagascar

Mozambique

Nigeria

Pakistan

Viet Nam

Yemen

2010

2004

2010

2005

2007

2008

2011

2011

2012

2010

2006

DTP3 Coverage (%)

DTP3 Coverage among lowest and highest wealth quintiles, selected countries

Immunization inequities by population characteristics, Madagascar, 2011

100

90

80

70

60

50

40

30

20

10

Madagascar (63%)

Boys (63.1)

Girls (62.6)

Urban (87)

Rural (59)

Secondaryeducation or more (80)

No formal instruction (47)

Birth Order 2nd (68)

Birth Order 6+ (50)

Mother’s education

Wealthiest quintile (74%)

Poorest quintile (49%)

% DTP3

Coverage ratio: 1.01CI: 0.94 –1.07

Coverage ratio: 1.35CI: 1.20 –1.51

Coverage ratio: 1.47CI: 1.39 –1.56

Coverage ratio: 1.69CI: 1.54 –1.86

Coverage ratio: 1.51CI: 1.35 –1.69

Coverage ratio: 3.44CI: 2.30 –5.16

Itasy Region (89)

Menaberegion (26)

OR: 1.02CI: 0.82 –1.17

OR: 2.0CI: 1.60 –2.68

OR: 4.52CI: 3.22 –6.35

OR: 2.99CI: 2.21 –4.04

OR: 4.48CI: 3.41 –5.88

OR: 25.1CI: 9.72 –65.8

Source: MDG survey, 2013; CI refers to 95% confidence interval; OR = Odds ratio

Inequities in Immunization take many forms

Why Equity & Immunization Matter

“Disease burdens tend to be

disproportionately

concentrated in more

marginalized populations,

reaching more people will

not only achieve a greater

degree of equity, but will

also achieve a greater health

impact and contribute to

economic development”

UNICEF – ideally placed to address immunization inequities

“In everything it does, the most disadvantaged children and the countries in greatest need have priority”

UNICEF’s Reaching Every Community Strategy

1. Identify children who suffer from immunization inequities & describe their

social/gender/geographical characteristics

2. Micro plans that reduce inequities by ensuring every community is accounted

for & receives immunization sessions appropriate to people served

3. Innovative solutions (including new technologies) that overcome problems of

inequities including social distance

4. Systems to monitor disadvantaged community immunization status

5. Commitment & allocation of resources to reduce immunization inequities at

the level they can be overcome, within Health Centres & communities

UNICEF’s Reaching Every Community Strategy

1. Identify children who suffer from immunization inequities & describe their

social/gender/geographical characteristics

2. Micro plans that reduce inequities by ensuring every community is accounted

for & receives immunization sessions appropriate to people served

3. Innovative solutions (including new technologies) that overcome problems of

inequities including social distance

4. Systems to monitor disadvantaged community immunization status

5. Commitment & allocation of resources to reduce immunization inequities at

the level they can be overcome, within Health Centres & communities

1) Identifying children & inequities

Mozambique – children in remote areas

0 20 40 60 80 100Vaccination coverage Pentavalent3 (DTP3) ( % )

Poorest

ZambeziaProvince

Illiterate mother

Rural

Boys

Richest

Mother with secondary education

Maputo Province

Urban

Girls

Geographic inequities

1) Identifying children & inequities

Liberia –children in poverty

• UNICEF supported immunization equity

analysis in May 2013

– Children in poorest households found to have

lowest coverage

– 1/3 of children were in the national capital

esp. urban poor communities

• UNICEF has developed an urban

immunization strategy and is supporting

the MOH with implementation

© UNICEF/NYHQ2007-0574/Pirozzi

1) Service delivery bottlenecks, Atsimo Andrefana region, September 2013, Madagascar

Source: DTP3 coverage: MDG survey 2013; Other data: Health Facility study, UNICEF 2014

UNICEF’s Reaching Every Community Strategy

1. Identify children who suffer from immunization inequities & describe their

social/gender/geographical characteristics

2. Micro plans that reduce inequities by ensuring every community is accounted

for & receives immunization sessions appropriate to people served

3. Innovative solutions (including new technologies) that overcome problems of

inequities including social distance

4. Systems to monitor disadvantaged community immunization status

5. Commitment & allocation of resources to reduce immunization inequities at

the level they can be overcome, within Health Centres & communities

2) Micro plans inclusive of all children

Madagascar

• UNICEF assessments found lack of quality micro planning at health facility level

• UNICEF has developed micro planning tool that focuses on equity gaps, including budget calculator

© UNICEF/NYHQ2009-1234/Pirozzi

2) Micro plans inclusive of all children

Cambodia

• UNICEF and WHO supported using measles SIA to assess community immunization coverage through card checks

• Updating HF micro plans to prioritize these communities & link to GAVI HSS funds for outreach

Formula used ( 0-80%)

Full PartialNon/no

card

Yellow

card

checked

No.full / No.checked x

100%

1 ភ្ន ំព្រាល ព្ព្រៃសន្ទះ Rural HTR 11 4 5 20 55%

2 ភ្ន ំព្រាល ដសី Rural HTR 9 3 6 12 75%

3 ភ្ន ំព្រាល ដសីអ ិត Rural HTR 5 0 4 7 71%

4 ភ្ន ំព្រាល ភ្ន ំព្រាល Rural HTR 3 1 1 5 60%

5 ភ្ន ំព្រាល បាយសី Rural HTR 14 6 2 20 70%

6 ភ្ន ំព្រាល អន្លង់រក្សា Rural HTR 6 5 2 8 75%

7 ភ្ន ំព្រាល សំបូ Rural HTR 3 9 12 25%

8 ភ្ន ំព្រាល ស្ព្រសម្អម្ Rural HTR 3 8 3 14 21%

9 ភ្ន ំព្រាល ភ្ន ំសព ង Rural HTR 3 1 1 5 60%

10 ភ្ន ំព្រាល ក្សាលឡាន្ Rural HTR 8 2 4 10 80%

11 ភ្ន ំព្រាល សទ ឹងព្រតង់ Rural HTR 11 6 3 20 55%

12 ភ្ន ំព្រាល ទួលខ្ពស់ Rural HTR 12 8 20 60%

13 ភ្ន ំព្រាល ថ្នល់បត់ Rural HTR 10 9 19 53%

14 ភ្ន ំព្រាល ដូង Rural HTR 13 2 5 20 65%

15 ភ្ន ំព្រាល បឹងព្រៃលឹត Rural HTR 8 2 5 15 53%

16 ភ្ន ំព្រាល ផ្សាព្រៃំ Rural HTR 11 3 1 15 73%

17 ភ្ន ំព្រាល អូរអិល Rural HTR 8 5 0 13 62%

No Name of HC

List of high risk village of Pailin province , 2014

Name of Village HRC type

Yellow Card Check - HRCs

UNICEF’s Reaching Every Community Strategy

1. Identify children who suffer from immunization inequities & describe their

social/gender/geographical characteristics

2. Micro plans that reduce inequities by ensuring every community is accounted

for & receives immunization sessions appropriate to people served

3. Innovative solutions (including new technologies) that overcome problems of

inequities including social distance

4. Systems to monitor disadvantaged community immunization status

5. Commitment & allocation of resources to reduce immunization inequities at

the level they can be overcome, within Health Centres & communities

3) Innovative solutions to overcome inequities and social distanceMozambique - UNICEF supported:

• 200,000 people reached through Multimedia Mobile units in media dark areas with debated video sessions promoting access to basic services and healthy behaviours

• Community Radios: weekly FFL programmes produced in 10 community radios in Zambezia

• Approx. 70,000 people engaged in participatory community theatre sessions in 4 high priority districts

3) Innovative solutions to overcome inequities and social distance

Uganda –

• mTrack is an SMS-based disease surveillance and medicine tracking system at all 5,000 health facilities and through 8,000 health workers

• e.g. SMS poll for feedback on:– Awareness of new vaccine introduction (PCV) –

3500 response in 24 hours (cost 150 USD)

– Cold chain functionality – 1862 health facilities within 48 hours (cost 150 USD)

– Vaccine stock outs – 1700 responses with 52% reporting stock outs of current vaccines

• Can also be used for community reporting model to improve accountability

3) Madagascar’s response to lack of access: Days of Intensified Routine Immunization (JIVR)

-

20,000

40,000

60,000

80,000

100,000

120,000

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Annee 2010

Annee 2011

Annee 2012

Mother and

Child Health Week

Mother and

Child Health Week

Days of

intensified

RI

Days of

intensified

RI

Days of

intensified

RI

Days of

intensified

RI

Source :Service de Vaccination

UNICEF’s Reaching Every Community Strategy

1. Identify children who suffer from immunization inequities & describe their

social/gender/geographical characteristics

2. Micro plans that reduce inequities by ensuring every community is accounted

for & receives immunization sessions appropriate to people served

3. Innovative solutions (including new technologies) that overcome problems of

inequities including social distance

4. Systems to monitor disadvantaged community immunization status

5. Commitment & allocation of resources to reduce immunization inequities at

the level they can be overcome, within Health Centres & communities

4) Monitoring community immunization status

• Immunization systems measure coverage

at provincial/district/HCs

– Fail to recognize inequities in underserved

communities

– Children in underserved communities usually

unregistered, therefore rarely accounted in

aggregate data

– Need simple mechanism used by health care

workers to measure inequities in

immunization at community level

– Monitoring of full immunization status of

children in underserved communities as part

of routine reporting

Chad 2013 - Are these extra children vaccinated the most vulnerable?

4) Monitoring community immunization status

Cambodia• UNICEF

supported trial based on LQA & card check in high risk communities

• Integrates both child and mother immunization status

UNICEF’s Reaching Every Community Strategy

1. Identify children who suffer from immunization inequities & describe their

social/gender/geographical characteristics

2. Micro plans that reduce inequities by ensuring every community is accounted

for & receives immunization sessions appropriate to people served

3. Innovative solutions (including new technologies) that overcome problems of

inequities including social distance

4. Systems to monitor disadvantaged community immunization status

5. Commitment & allocation of resources to reduce immunization inequities at

the level they can be overcome, within Health Centres & communities

Increasing Commitment & resources for Health Centres & Communities

• A rapid assessment approach to identify financial bottlenecks to the flow, use and tracking of immunization funds.

• Improve predictability and targeting (ring-fencing) of funds to implementing routine immunization services

• UNICEF has carried out proof of concept testing in Madagascar, Indonesia, Uganda, as well as preliminary work in Mozabique

Financial bottlenecks contribute to poor implementation & low coverage, e.g. Madagascar

• Some preliminary results Madagascar (2014)

1. Disbursements to health centers are in cash; no formal banks available.

2. Disbursed budget at times is lower than planned or approved budgets

3. Immunization funds not protected/ring-fenced and get used for other purposes

• Some impacts

– Low compliance with approved immunization plans and budgets.

– Funding delays impact outreach the unreached stay unreached

– Resource use does not follow microplans

– Fragmented resource availability: not all funds available at same time

– Poor tracking reduces managers’ ability to know what funds actually ‘buy’.

30

• Some solutions:

– Rapid SMS to alert district/province/nat’l level if outreaches can’t occur as planned due to lack of fuel, funds, vaccines, AND staff

– Community registers that must be signed by outreach staff, as quality/equity check to ensure at risk communities receive outreach

– High level political advocacy (with partners) to agree on PoA to increase predictability of routine immunization financing

31

Financial bottlenecks contribute to poor implementation & low coverage, e.g. Madagascar

Summary

• Tackling inequities is key to increasing immunization coverage.

• An equity approach will require using more “granularity” in identifying unreached children, and in defining strategies

•

THANK YOU