Field Note

Immunizing the World's Children: Strong and Steady Wins the Race

By Rebecca Fields
Technical Officer, IMMUNIZATIONBasics (Academy for Educational Development)

Robert Steinglass
Technical Director, IMMUNIZATIONBasics Project, (John Snow, Inc.)

In recent years, the field of immunization has benefited from renewed interest and a remarkable infusion of resources from public and private partners. Stated priorities include closing the gap between developed and developing country immunization programs, introducing new and underutilized vaccines, and accelerating the control of certain diseases (polio eradication, neonatal tetanus elimination, measles mortality reduction). Central to these goals is the need for a routine service delivery system capable of immunizing children in the first year of life. In 2003, over 27 million children worldwide missed out on immunization during their first year of life. And in 2002, of the estimated 10.5 million children who died before their fifth birthday, 1.4 million died of vaccine-preventable diseases for which vaccination is already included in most national immunization programs.

The latest available coverage figures, for the year 2003, suggest that since the year 2000, there has been some modest progress in some parts of the world. Over two million deaths are prevented each year as the result of measles, pertussis, and tetanus immunizations alone. But there is much further to go before immunization realizes its full potential for protecting children against diseases for which effective vaccines now exist.

As more vaccines are added to immunization programs and substantial resources are invested to tailor additional vaccines for developing country use, the need for effective service delivery systems becomes increasingly urgent. The existing vaccine against Haemophilus influenzae type b (Hib), and imminent vaccines against Streptococcus pneumoniae and rotavirus have the potential to avert an estimated 1.6 million child deaths annually. But this will only happen if children receive all doses early enough in life to avoid exposure to the diseases in question.

Lessons from the Past
The late 1980s and early 1990s were marked by a dramatic increase in coverage that reflected both the development of immunization program infrastructure and ambitious campaigns designed to attain the goal of Universal Childhood Immunization (UCI) by 1990 –that is, fully immunize 80 percent of the world's children. The goal was considered in 1990 to have been achieved, although later revisions suggested that, while coverage had indeed increased dramatically from 20 percent in 1980 to approximately 73 percent by 1990, less than half of UN member states had attained 80 percent coverage.

The 1990 declaration of UCI resulted in a sense that the job of immunizing the world's children was completed, and that similar levels of global and national investment in this particular program were no longer an urgent need. With the emergence of other health priorities and a movement toward health sector reform, support for immunization programs diminished during the mid to late 1990s. During this same time, drops or stagnation in immunization coverage became apparent in many countries; in Africa, for instance, DTP3 coverage hovered near 50 percent for most of the decade. While the global acceleration of polio eradication provided visibility to immunization, the resources it attracted were directed primarily to specific accomplishments. These include disease surveillance and periodic campaigns to supply vaccine doses intended to supplement those provided by the routine immunization system. However, investments of human, financial and material resources in that routine system did not keep pace.

Renewed Attention and Resources
Serious efforts to revitalize immunization in developing countries took off in 2000 with the creation of the Global Alliance for Vaccines and Immunization (GAVI). GAVI is a public-private partnership of governments, foundations, vaccine manufacturers, research institutes, WHO, UNICEF, the World Bank and NGOs. GAVI's stated aim is to improve access to and use of both established and newer vaccines, plus accelerate the development and introduction of additional vaccines of public health importance, including pneumococcal, rotavirus, Japanese encephalitis and meningitis A/C vaccines. With an initial five-year, $750 million grant from the Bill and Melinda Gates Foundation plus grants from the U.S. Government and other sources, the Vaccine Fund of GAVI was capitalized.

Since 2001, GAVI and the Vaccine Fund have provided three types of support for immunization in over 70 of the world's poorest countries. Based upon the favorable review of proposals submitted by countries, GAVI supplies new or underutilized vaccines (including those containing hepatitis B, Hib and yellow fever); equipment or cash to assure safe injections; and immunization services support (ISS), a cash advance that can be used flexibly by countries as they see appropriate. To date, GAVI has committed more than $1 billion for these purposes, and about half that amount has been disbursed. The majority – approximately $363 million – has gone for vaccines and supplies, another $73.4 million has been disbursed for ISS funding in 52 countries, and $63 million for injection safety.

The World since GAVI: Developments and Trends in Routine Immunization since 2000
Since 2000, there have been several specific developments that impact routine immunization, either directly or indirectly. Accelerated disease control efforts for polio eradication, measles mortality reduction, and maternal and neonatal tetanus elimination have all entailed massive campaigns on a periodic basis in many countries. The introduction of new vaccines – funded largely through GAVI – has stimulated changes in immunization planning. The number of countries incorporating hepatitis B into routine immunization programs since 2000 has grown from 91 to 138, including over half the countries in the WHO/AFRO region. With the exception of the Americas, far fewer countries have adopted Hib vaccine – for example, just seven countries in Africa, nine in the Western Pacific, and none in Southeast Asia. Concerns about the relatively high cost and the limited supply of the sought-after combination vaccines containing Hib, hepatitis B and DTP have been prohibitive factors.

GAVI has also increased the attention devoted to two previously-neglected areas. The area of financial sustainability planning and implementation is a major focus in several countries, due in part to the fact that the GAVI funding that currently supports newer vaccines is expected to taper off over time. And because GAVI bases its award decisions on the reliability and quality of data, as verified by independent audits, additional effort has been devoted to evaluating and improving the quality of administrative data routinely produced by the health system.

On a global basis, WHO and UNICEF estimates of routine immunization coverage, based on the third dose of DTP vaccine, have increased from 75 percent to 78 percent between 2000 and 2003. However, this global estimate masks important regional and country level variations. In WHO's regions of the Americas, Europe and the Western Pacific (including China), DTP3 coverage has plateaued at close to 90 percent. Figures from the Southeast Asia region (including India) suggest a small increase of approximately 6 percent, from 69 percent to 73 percent. The Africa region has shown a modest but steady progress from 54 percent to 61 percent, representing an 11percent increase during these years. Of the 46 countries in WHO/AFRO, 35 have shown increases in coverage since 2000, with a mean gain of 11 percentage points according to official country reports.

In countries where improvements have been noted, what has brought them about? A common finding is that strengthening management, particularly at decentralized levels – particularly at the district level – is key. Experiences from countries vary depending on their needs and situations, but include the following:

• Improving the reliability of vaccination session frequency in Madagascar and communicating this clearly to the community; also, providing community recognition to families when their children complete the vaccination schedule


• Building the capacity of health workers to use data to better manage services and to collaborate with communities in planning services in parts of Uganda, Nigeria and Nepal


• Actively engaging NGOs in some parts of India to organize and provide services and mobilize communities, particularly to reach the most vulnerable groups


• Implementing performance contracts in Mali: local level health staff and community leaders commit to performance targets, while national level health officials and donors commit to assuring the needed resources


• Using a performance improvement approach in Guinea to diagnose and systematically improve services, starting at the facility level


• Providing districts with training on how to use data for monitoring and evaluation, how to engage community leaders, and how to better manage vaccine stocks in Kenya

1. Re-establishment of outreach services


2. Provision of supportive supervision on a regular basis


3. Strengthening of community links with health services


4. Monitoring and use of data for action


5. Effective planning and management of services.