Executive summary
Immunisation saves lives and is undoubtedly one of the most successful and cost-effective health interventions, with far-reaching benefits. Improved coverage has contributed to the impressive 50% drop in child deaths globally between 1990 and 2015, from 12.7 million deaths to 5.9 million. The benefits of immunisation will have a greater impact among excluded communities, which typically have low access to healthcare and high vulnerability to disease, and where the financial burden of illness has a greater impact on household poverty.
Save the Children estimates that closing the equity gap based on household wealth inequalities in 52 low- and middle-income countries could save 800,000 more lives between now and 2020.
ONE IN SEVEN CHILDREN EXCLUDED FROM IMMUNISATION
There have been important improvements in coverage of immunisation services over the past decade, with 86% of children globally now receiving the most basic vaccinations. But progress has recently stagnated and 19.4 million children under one year old – one in seven – are still excluded from the full benefits of immunisation. These children are disproportionately found in some parts of the world and in certain countries. National data, however, does not tell the full story of inequalities. To focus on the seventh child exposes the systematic exclusion taking place within some countries.
That seventh child is being unfairly left behind because of where they were born or live. He or she is from the poorest of households, from a marginalised ethnic group, living in a neglected or rural area, or affected by conflict. In Nigeria, for example, a child from a wealthy household is 11 times more likely to be immunised than a child from a poor household, while coverage is nine times higher among Igbo children than Fulani children.
These exclusions are interrelated. Children from poorer households or a specific ethnic group are often geographically concentrated in neglected areas. Globally, two-thirds of children who have not been immunised live in conflict-affected countries. The fact that children from certain groups or living in certain areas of a country are persistently left behind is not accidental. It is the direct result of policies and programmes that exclude some groups of children – whether by design or neglect – and a failure to prioritise these children and the communities and areas in which they live. These communities are missing out on the financial and human resources needed to deliver immunisation and other health services. Unless we do things differently, we will continue to fail every seventh child and further entrench systematic inequalities that leave him or her behind. This injustice cannot continue. Earlier in 2016, Save the Children launched an ambitious new global campaign to help end exclusion and ensure that Every Last Child survives and thrives.
SHIFTING THE DEBATE TO A DOMESTICALLY DRIVEN AGENDA
Global attention on childhood immunisation has, to date, mainly focused on donor aid and multilateral mechanisms, such as Gavi, the Vaccine Alliance. But most of the political decisions that are excluding children are being made at national and, in some cases, sub-national levels. We argue that these domestic policy and resource choices must ensure that immunisation and other essential health services reach every last child, working towards Universal Health Coverage (UHC).
Domestic investment has played a critical role in health progress over the past decade, accounting for 75% of total health expenditure in the average low-income country.9 As we move into the era of the Sustainable Development Goals (SDGs), there is growing recognition that domestic investment is critical to achieving universal services that leave no one behind. National governments have primary responsibility for their countries’ economic and social development. While aid will continue to be important for some countries, this must be a catalyst for domestically-driven change.
STRENGTHENING IMMUNISATION AS PART OF UHC
Essential health services, including immunisation, should be available to all, including the poorest and most marginalised children and communities.
This must be reflected in national and sub-national strategies and actions, including immunisation policies and plans that prioritise excluded groups.
These groups must be visible at all levels of policy and planning; there will need to be strong political commitment and accountability to ensure that required services are provided.
Strong health systems are needed to ensure that good-quality services are available, accessible and acceptable. This will help drive high, sustainable and equitable coverage of immunisation and other essential health services across the continuum of care, including for excluded groups. Immunisation can show the value of a UHC approach, but will require programmes to truly incorporate UHC ideals into the way they provide services, especially around prioritising the needs of the poorest and most excluded groups.
FAIR FINANCING FOR IMMUNISATION AND HEALTH
There is a need for increased and equitable public investment in immunisation and health systems. This is to ensure that programmes are sustainable and that routine immunisation and other essential health services reach every last child, especially those in the most remote and neglected areas. Investment is vital, both for the purchase of vaccines and to strengthen health systems (including cold chains) to deliver vaccines and immunisation services.
However, maximising the value of investment will depend on governments creating the fiscal space to allocate additional resources to immunisation and health system strengthening.
While greater domestic responsibility and resources are important, development aid will continue to play a role in some countries for the time being. This aid must be fit for purpose to support countries to reach every last child, including responding to the changing nature of poverty and rising inequalities in middle-income countries. The other side of the coin is how that money is spent. Global funding must do more to support countries to strengthen health and immunisation systems to deliver UHC, rather than just deliver disease-specific and vertical interventions.
AN ENABLING GLOBAL ENVIRONMENT FOR COUNTRIES TO MAKE PROGRESS
Several global factors affect countries’ ability to fund their own development, so these must also be addressed if they are to speed up progress on immunisation. These factors include access to affordable vaccines, and a research agenda that responds to the needs of countries where children are left behind. More needs to be done to make sure that vaccines are affordable for countries so that immunisation gains can be expanded and sustained.
Greater efforts are needed to ensure that the right vaccines and presentations are developed, in addition to innovative technologies and equipment to expand access in remote and neglected areas.
Vaccine manufacturers clearly have a role to play.
However, given that immunisation is a global public good, the world needs increased public investment and incentive models for research and development (R&D) that work for resource-poor settings and that will help us reach every last child.
GREATER ACCOUNTABILITY TO CHILDREN
Greater accountability to children, their families and communities is vital so that every last child can access and utilise immunisation and other essential health services. Key actors at all levels – including decision-makers, service providers, and private sector companies – must be held accountable.
Unfortunately, we do not have a full picture of which children are missing out on immunisations, because many children are simply not counted among the data. However, the absence of disaggregated coverage data in many countries is compounded by the fact that millions of children are not accounted for in the first place. Globally, 230 million children under the age of five – that’s one in five children – were not registered at birth. If we do not know who or where these children are, programmes and services cannot be properly designed to reach every last child. Countries must step up their efforts to make sure that every last child is counted.
Communities (including excluded groups and children themselves) and civil society organisations (CSOs) must be empowered to demand their rights and to meaningfully engage in the design and implementation of policies, programmes and budgets. They must have a voice in the decisions that affect them, helping to identify immunisation gaps and solutions. They must also be empowered to hold governments accountable for delivering on their commitments.
ADDRESSING HOUSEHOLD- AND COMMUNITY-LEVEL BARRIERS
As well as supply-side issues, demand-side constraints at household and community levels (such as gender inequality and lack of knowledge about the importance of immunisation and how to access services) will need to be addressed if every last child is to be reached. Gender-related barriers drive exclusion and affect the likelihood of a child of either sex being immunised. Women are usually responsible for looking after children; therefore, any gender barriers they face are likely to affect their children too. These barriers vary by country and context, but tend to be more pronounced in resource-poor settings.
Better information and communication are also critical. Where communities know their rights, are aware of the benefits of health services, know where, when and how to access services – and crucially – where they trust the service providers, vaccination coverage is higher. To increase demand for and utilisation of services, families must be equipped with the right knowledge about the importance of immunisation, their right to immunisation, and where and when to access services.
REACHING EVERY LAST CHILD
We must ensure that every last child – regardless of where they are born, and their level of poverty or social exclusion – has access to immunisation as an early priority in building UHC. Every child has the right to immunisation as part of their right to health. It is the responsibility of actors at all levels to ensure that all children can realise their right to immunisation, by breaking down the barriers that drive exclusion. It is possible – it just requires renewed political leadership, commitment and investment.
We must act now. At the midpoint of the 2011–2020 Global Vaccine Action Plan (GVAP) – when progress has slowed and is off track – more must be done to strengthen commitments and accelerate action.
WE CALL ON NATIONAL GOVERNMENTS TO:
- prioritise achieving universal immunisation coverage and reaching every last child, turning political commitments into action to accelerate progress
- strengthen policies and actions so that they prioritise children left behind, including reviewing policies that may inadvertently exclude some children
- strengthen immunisation systems as part of comprehensive primary healthcare (PHC), particularly in poor, under-served and excluded areas
- increase public investment in immunisation as part of growing health budgets, ensuring equitable allocation of resources to neglected regions
- improve data collection, including disaggregated data, to identify which children are being excluded so that strategies can be designed to reach them
- empower communities and civil society organisations to engage in immunisation planning, delivery, monitoring and accountability mechanisms.
WE CALL ON DEVELOPMENT PARTNERS TO:
- support countries to strengthen immunisation systems and the wider health system, and to increase domestic fiscal space for health and immunisation
- ensure strong civil society representation in monitoring and accountability processes.
WE CALL ON THE PRIVATE SECTOR TO:
- make vaccine prices affordable, for Gavi countries and middle-income countries
- increase the transparency of vaccine prices not only for Gavi-procured vaccines, but for all vaccines from all manufacturers.
WE CALL ON CIVIL SOCIETY TO:
- work with governments to support and strengthen immunisation and health systems, prioritising equity and those left behind
- hold governments accountable for delivering on health, immunisation and financing commitments
- engage in monitoring and accountability frameworks at local, national, regional and global levels.