Improving Urban Immunization Service Delivery: Guidance, Practice, and Sustainable Solutions

Increased urbanization has created a pressing need for immunization strategies and guidelines specifically developed for urban populations. We work extensively in urban settings and have gained a nuanced understanding of the demand for and barriers to access and use of health services. We identify and understand priorities, preferences, concerns, and attitudes of urban families and those who serve them; set urban plans, policies, and targets; and allocate resources for health.

Targeted interventions—such as extended hours for health centers to accommodate working parents and strengthening community engagement around culturally acceptable health outreach services—can help to bridge a few of the gaps.

JSI builds capacity of and strong coalitions among civil society, the private sector, and government health stakeholders. We engage civic authorities in immunization systems for sustainable and equitable vaccination of the urban poor.

Aerial view of a community in Haiti.

“Parents are now more motivated since vaccines are available, and services have improved. Mothers reported being satisfied with the services because the vaccines are available and there is a special line for vaccination in the room.” – Health Worker, Rosalie Rendu Health Facility (Cite Soleil, Haiti) 

COUNTRY EXPERIENCES

Cross-cutting

Much of this rapid urbanization is taking place in Africa and Asia bringing social and economic transformation, including large numbers of poor, mobile populations. For over 30 years, JSI has strengthened routine immunization systems around the globe to provide regular, reliable and equitable access to and use of life-saving vaccines to the most vulnerable populations.

Technical experts from JSI and the London School of Hygiene and Tropical Medicine (LSHTM) will work alongside colleagues from various departments within the Ministry of Health, the Immunization Interagency Coordination Committee (ICC), and other organizations that are working on urban equity issues. These documents identify cross-cutting conclusions from the analyses and synthesize JSI’s experiences for countries to adapt to their specific contexts. 

Ghana

In Ghana, rapid urbanization has led to an increase in the number of people living in financially constrained settlements. The country’s urban population grew more than three-fold between 1984 and 2014, increasing the number of under-immunized children in these areas. Yet there is little information on the geographic delineation of urban poor areas in Ghana, as well as inadequate data on immunization coverage among urban poor populations and the underlying factors contributing to pockets of lower coverage.  

To identify potential factors contributing to low immunization rates in urban poor communities, JSI, in collaboration with the Ministry of Health and the Ghana Health Service (GHS), conducted a situational analysis in seven major metropolitan areas across five regions in Ghana between January and July 2017.

DRC

Many infants and families in urban areas of the Democratic Republic of the Congo (DRC) do not receive vital health services such as immunization. To address these inequities in the megacity of Kinshasa, JSI worked with the Ministry of Health and urban municipalities to strengthen routine immunization (RI) service delivery through locally tailored solutions. This involved the adaptation of the Reaching Every District (RED) approach and identification of steps to ensure the quality of care and reduce dropouts in urban environments, notably with the provision of services to urban poor communities. 

Haiti

Based on the findings from the situational analysis, JSI discussed strategies tailored to strengthening vaccination programs in urban environments with partners through a participatory and elaborate process. A number of strategies and activities were designed, and an implementation plan and budget were developed and approved in order to pilot the implementation of these strategies in Cité Soleil. The Ministry of Public Health and Population Haiti, through the National Coordination Unit of the Vaccination Program and with funding from Gavi, established a partnership with JSI in order to strengthen the routine immunization system in Cité Soleil. The objective of this partnership is to increase access to and use of vaccination services in Cité Soleil, with the ultimate goal of reduction in the morbidity and mortality linked to vaccine-preventable diseases, and an improvement in the health of children 0-5 years old.

In the second phase of the Gavi Urban Immunization project, JSI upgraded the model to address weaknesses identified through monitoring and assessment, strengthened successful practices, and began rolling out short and long term interventions in the urban immunization model. This phase serves a target population of 7,306 in Cite Soleil commune, and is focused on developing tools, processes and building capacity of the EPI program that can be used to scale-up implementation at all levels.

Phase I 

Phase II

Indonesia

Like many other countries, Indonesia is experiencing rapid urbanization, especially in Jakarta. JSI collaborated with the Centre for Health Research Universitas Indonesia from June to September 2019 to conduct a diagnostic assessment to identify the barriers contributing to low coverage in Jakarta municipalities and prioritize potential interventions to address the immunization needs of urban communities. 

Pakistan

From December 2018 to March 2019, John Snow Research & Training Institute, Inc. (JSI) collaborated with the Government of Sindh’s EPI unit, through support from Gavi, the Vaccine Alliance, to conduct a situational analysis of routine immunization in Karachi. This comprehensive assessment of EPI services in Karachi thoroughly reviewed the components and structure of the routine immunization (RI) delivery system, vaccination coverage and monitoring, current resources and stakeholders involved (including existing public, private, and community services); and identified the gaps in knowledge and resources, barriers and shortcomings in governance, demand generation, and service delivery.

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