Further, Faster, Fairer: Reaching Every Last Child with Immunisation

"Breaking down the barriers that drive exclusion is possible - but requires renewed political leadership, commitment and investment. Actors at all levels have a responsibility to ensure that every last child can realise their right to immunisation."

Noting that every child has the right to immunisation as part of his or her right to health, this Save the Children report argues that domestic policy and resource choices must ensure that immunisation and other essential health services reach every last child, working towards Universal Health Coverage (UHC). Considering that 19.4 million children under 1 year old - 1 in 7 - are still excluded from the full benefits of immunisation, Save the Children is concerned that the 2011-2020 Global Vaccine Action Plan (GVAP), now at its midpoint, is off track. The report also explores global factors that affect countries' ability to reach children in communities that are systematically excluded from progress, including a fairer and more equitable global tax system, development aid that is fit for purpose, access to affordable vaccines, and a research agenda that responds to the needs of countries where children are left behind. It also looks at issues such as ensuring accountability to children and tackling household and community-level barriers to reaching them with services. Further, Faster, Fairer puts forward recommendations for governments, development partners, the private sector, and civil society to help drive this agenda forward.

This report aims to help all stakeholders understand who and where these excluded children are. It highlights that nearly 60% of unimmunised children are in just 10 countries (the Democratic Republic of Congo (DRC), Ethiopia, India, Indonesia, Iraq, Nigeria, Pakistan, the Philippines, South Africa, and Uganda). It shows that within a country, these excluded children are from the economically poorest households, from marginalised ethnic groups, live in neglected and/or rural areas of a country, and are affected by conflict. Factors such as socioeconomic circumstances, politics, and policies determine access to immunisation services, and these factors play out at multiple levels - from the household to the international arena - with resulting inequalities in outcomes. For example, a child whose mother has secondary education or higher is nearly 3 times as likely to be immunised in Indonesia compared with a child whose mother has no education. Various contributing factors are explored in the report, such as political decisions that may lead to certain areas of a country or groups of people being left behind. "There is often insufficient political will and action to put in place policies and systems that are sufficiently and equitably resourced and implemented, so that people in neglected areas can be reached with immunisation and other essential health services."

Case studies in text boxes throughout the report are illustrative. For example, in Syria, routine immunisation coverage almost halved between the onset of the conflict in 2010 (80%) and 2015 (41%). More than half of the 1.8 million children born since the start of the conflict have not been immunised. Polio re-emerged in 2013, after 14 years with no reported cases, and measles outbreaks have also been reported. Vulnerable populations in Syria and in refugee camps in neighbouring countries face disease outbreaks. In contested and opposition-held areas, children are missing out on immunisation due to the unpredictable security situation and difficulties in delivering services. In these areas, polio campaigns have been carried out by health workers employed by local health councils, with the support of international non-governmental organisations (NGOs) operating across borders from neighbouring countries. For example, an NGO-led Early Warning Network (ACU-EWARN) was established in sentinel sites in June 2013 to monitor vaccine-preventable diseases and polio cases. Some international NGOs have used platforms established through small-scale vaccination campaigns in the area to carry out social mobilisation, including cholera awareness campaigns, assessment of locations for new humanitarian assistance projects, and the sharing of information on new health services.

The report looks at the combination of intersecting economic, social, and political factors that lead to exclusion, ranging from direct discriminatory actions to a lack of action and political prioritisation. Save the Children asserts that key actors at all levels - decision-makers, service providers, and the private sector - must be held accountable for providing services to which all are entitled and for creating an enabling environment for this to be possible. With improved data, countries would be better able to identify which children are being left behind, and where they can find children who have not been immunised, including specific vulnerable and excluded groups. This is also vital in order to track progress, so that governments can be held accountable. Along this thread, Save the Children argues that communities - including excluded groups and children themselves - and civil society organisations (CSOs) must be empowered to demand their rights and to meaningfully engage in policy-making, designing and implementing strategies and budget processes linked to immunisation and health. "They are often excluded from discussions and decisions about important matters that affect them. Communities must have a voice in decision-making, as they could play an important role in helping to identify immunisation gaps and solutions. This can foster ownership, promote accountability and lead to higher coverage. Better partnerships between governments and CSOs would help make this happen (Box 10). Communities and CSOs must also be empowered to hold governments accountable on their commitments."

Other communication-related issues explore in the report focus on household-and community-level barriers to reaching every last child, such as gender barriers. For example, discrimination, isolation, and gender norms can restrict a woman's or girl's movement in public, limiting her ability to access immunisation and health services. Research indicates that as women become more empowered, immunisation coverage increases. Furthermore, Save the Children holds that insufficient, inappropriate, and poorly communicated information on immunisation is a barrier to accessing services. Information may not be communicated in the local language or in languages spoken by minority, marginalised, or migrant groups, or may be transmitted in ways that exclude some groups (for example, economically poorer households may not see public health campaigns on TV, while illiterate families cannot access written materials). Where information is available, it may not be appropriate in terms of social norms, beliefs, and values. The source of information is also important. A number of studies - in Ethiopia, Haiti, India, Kenya, and Turkey, for instance - have revealed that people's health-seeking behaviours were more responsive to information from members of their own community rather than from formal sources. Where information and communications are inadequate to promote the benefits of immunisation, or where they are used to fuel negative perceptions and resistance, this can lead to low immunisation coverage and pockets of children that have not been immunised. For example, traditional and local beliefs around illnesses may influence perceptions about the usefulness of immunisation. There might be suspicion around the motivations for vaccination campaigns. These may be fuelled or worsened by rumours that are either fostered within communities or are politically motivated.

The report concludes with a series of recommendations - for national governments, for development partners, for the private sector, and for civil society. For instance: Empower and engage communities and civil society organisations to engage in immunisation planning, delivery, monitoring, and accountability mechanisms.