Closing the Immunity Gap

Every child has the right to health and should have the opportunity to survive, develop, and reach their potential in the context of Universal Health Coverage (UHC).

Who can disagree?

Every child has the right to be immunized, but closing the immunity gap needs everyone to go beyond a) technical ‘group think’ comfort zone rhetoric; b) dusty plans lying in bottom drawers; and c) attending national and global health cocktail parties. We all need to better understand the reasons for inertia to addressing immunization inequities and actually reach marginalized populations with what they need. Marginalized communities have the greatest disease burden and the least resources to respond to infection.

An immunity gap is everybody’s business: it leads to increased disease incidence, outbreaks and deaths from preventable disease– all of which have no respect for borders.

Investment in vaccines and the systems that deliver them is one of the best deals in health, with a rate of return of $16 for every $1 invested. The world’s best merchant bankers or hedge fund managers are hard-pressed to find such returns. Immunization programs reach communities that often cannot be reached by other programs; 85% of the world’s infants receive DPT3 vaccine. Most vaccines are delivered through routine immunization services, in primary healthcare settings in fixed or outreach sites, supplemented (when necessary) with either campaigns or intensified child health days. Many lessons can be learned from immunization systems delivery platforms.

Yet, not all communities benefit equally from vaccination.

Inequities are related to differences in wealth, where communities live (rural/urban), ethnicity and birth order. Marginalized communities such as nomads or poor populations living remotely, urban poor and migrants and ethnic minorities all face challenges to accessing vaccination and other primary healthcare services. These challenges include geography, affordability, transport, cultural barriers, lack of awareness and poor, non-existent or non-responsive services.

Local authorities and communities usually know where vulnerable and marginalized communities live. Reviews show why children remain unimmunized and we know what works and what does not to increase immunization rates and other primary healthcare interventions. Terminologies have been defined, metrics have been crafted and the issues of reaching the under-served have been promoted over many years.  There is new hope within the Universal Health Coverage initiative that puts the needs of the poor and marginalized at its center and there is renewed interest in integrated people-centered approaches to health planning.

Yet inequities in access to vaccination persist and, in many contexts, are increasing, thereby increasing the immunity gap and risk for disease outbreaks.

How can this be so? Why is there so much inertia?

Too many of us are too comfortable in our technical program or disease-specific silos.  The rhetoric we hear, often from like-minded individuals and institutions, falsely reassures us that we are doing well. But we all need to get out of these comfort zones, overcome our complacency and challenge ourselves to be more accountable to serving marginalized populations who cannot access vaccination and other primary healthcare interventions. We may be able to do this by focusing on three issues:

Challenge “group think” by bringing unspoken issues openly onto the table: Issues that are openly discussed with their ‘quick win’ solutions include lack of resources (solution: write proposals and advocate), low or weak human resources (solution: training), weak supply chains (solution: expert advice and purchase commodities) and competing political priorities (solution: money for advocacy and communication).  Two issues that are often left off the table are:

• Donor and development partner top-down approaches: These often bypass, or are not in line with, Government health systems or priorities; may displace domestic funding and increase competition with other priorities. This leads to unsustainable fragmentation and even less focus on the needs and engagement of marginalized communities, thereby increasing the immunity gap. Using the Sustainable Development Goals (SDGs) UHC agenda, behaviors outlined in the International Health Partnership (IHP+) and people-centered integrated primary healthcare approaches to strengthen health systems are all ways of getting community needs prioritized and more holistically addressed; and
• Resistance to collaboration with or connection to the broader health system, primary healthcare or other sectors: Fragmented funding sources creating inflexible work plans and reputations of individual and institutions made by single diseases are all disincentives to reaching out to make connections. To address inequities, leaders must straddle programs and sectors and include civil society representation from marginalized communities in decision-making processes.  Links between global academic thinkers and field level implementers and civil society urgently need to be strengthened.
  

Reorient systems, as part of the UHC agenda to focus on identifying and addressing the needs of the most marginalized communities, by prioritizing a few key practical actions that can address their needs.  The unimmunized will not be reached with papers or plans alone. Since 2002, many immunization programs have successfully implemented the Reaching Every District and Reaching Every Community approaches in an effort to sustainably increase vaccination rates. These approaches can help re-orient planners and implementers to address the needs of marginalized communities, beyond a single disease control paradigm. The approaches include:

• Partnering with communities to ensure they are part of the planning, implementing and monitoring of services, such as defaulter tracing or newborn tracking and developing appropriate messaging for parents. Services can be more appropriate and acceptable; fear of vaccines, dropout and missed opportunities all decrease when communities are effectively empowered and engaged;
• Use of community-owned data to map and prioritize actions can increase program efficiency and immunization rates, by using more accurate denominators and monitoring which can help prioritize the needs of the unimmunized; and
• Microplanning and resource allocation at local and sub-district levels can help tailor approaches and use local resources to address the needs of marginalized communities. This ensures that programs are designed with the needs of the underserved in mind.

Crash a cocktail party or two and encourage key decision-makers to:

• Be more open to integration at service delivery level: Integration has the potential to increase efficiency and demand for services; even more so if planned and implemented across sectors. It takes time to coordinate and collaborate, but in the long run, it beats short term competition. Delivering multiple programs in primary health care settings to address the needs of the most marginalized is possible. Immunization programs can lead the way, especially with their practical and logistics-focused planning that can target marginalized communities.
• Get away from unsustainable disease elimination/eradication paradigms that bypass Government-owned systems. Instead, put marginalized communities at the center of planning and implementation. Look for opportunities that are not necessarily donor-driven, but actually owned and funded by local and Government resources as much as possible

Immunization programs can lead ways of increasing sustainable and effective access to multiple primary healthcare care interventions for marginalized communities. Whilst remaining true to UHC and IHP+ principles, the Reach Every District and Community strategies actually identify, prioritize, involve and reach marginalized communities. These practical, bottom-up approaches implement people-centered healthcare, which leads to sustained ownership and more acceptable and appropriate services. In turn, this reduces dropouts, missed opportunities, the immunity gap, disease burden and risk of outbreaks.

Address the immunity gap by getting practical: bring unspoken issues up, reorient health systems, gate crash a cocktail party and be more accountable to marginalized communities.

Written by Craig Burgess