Negotiators join vaccinators protecting children in the world’s toughest regions
Combining humanitarian skills with geospatial mapping gave nearly 200,000 kids in the Horn of Africa life-saving vaccines for the first time ever.
- 24 January 2024
- 7 min read
- by Priya Joi
The Horn of Africa, a cluster of countries in the eastern-most tip of the continent, has seen decades of war. Somalia is experiencing a protracted civil war ongoing since 2009, Sudan is right now in the midst of a horrific conflict, which has also impacted its southern neighbour South Sudan, and Ethiopia is only just recovering from years of bloodshed. As well as the millions of lives lost, millions more have been displaced, facing extreme shortages of food and water. Climate change is affecting the area badly, with extreme droughts and flooding exacerbating existing instability.
Against this backdrop, delivering health care services such as vaccinations – essential to protect children against deadly childhood diseases – can be virtually impossible.
While many low- and middle-income countries have developed vaccine programmes that successfully reach children in even the most remote areas, in regions characterised by extreme levels of conflict territories may be near-impenetrable. Many of the children live in communities or camps that are beyond the reach of government services or existing immunisation programmes.
"It was crucial for them to incorporate humanitarian negotiators in the vaccination team. “You don’t normally see this, as health care workers are the ones who go out and deliver vaccinations.”
– Mesfin Teklu Tessema, IRC’s Global Health lead
This means that millions of children never receive a single dose of vaccine, becoming so-called "zero-dose" children. When their families are on the move to escape conflict or look for food and water, it can be impossible for traditional outreach services to know where they are or to find them.
That's why in 2022, Gavi launched ZIP, the Zero-Dose Immunization Programme, with US$ 100 million in funding, to deliver vaccines across the Sahel and Horn of Africa and serve those communities beyond the reach of national health systems. The programme began operating in January 2023, and results from the first six months show that it is already delivering results.
Zero-dose numbers rising
This was a programme designed to be different. With the pandemic pushing the number of zero-dose children up for the first time in decades, and escalating conflicts hampering efforts to bring that number back down, "doing more of the same was not going to get us a different result," as Alexa Reynolds, Head of ZIP, told VaccinesWork. It was clear that an innovative approach was necessary.
Gavi set up a US$ 500 million Equity Accelerator Fund aimed at helping to reduce the number of zero-dose children by 25% by 2025, and by 50% by 2030. Within this envelope, US$ 100 million was set aside for ZIP to target communities living beyond the reach of governments.
Rather than using Gavi's usual approach of working through government health systems, this would be led by two INGO-led (international non-governmental organisation-led) consortia, with ZIP being funded separately. Two implementing partners, the International Rescue Committee (IRC) and World Vision International, were chosen to reach zero-dose children in the Horn of Africa and the Sahel regions respectively. As of 2021, there were more than 5.2 million zero-dose children living across the 11 target countries.
In the Horn of Africa, where the IRC-led REACH (Reaching Every Child in Humanitarian Settings) consortium project operates, more than half of the 2.71 million children under five (1.23 million or 54.9%) have never received a vaccine in their life. Another 420,000 children (18.6%) qualify as under-immunised, meaning they have not received their full schedule of vaccinations and remain vulnerable to preventable infectious diseases.
Based on the population data and the reach of existing government vaccination efforts, key locations in Ethiopia, Somalia, South Sudan and Sudan were selected for implementation.
Humanitarian expertise
Reynolds says that the partners were chosen for their "humanitarian expertise and ability to negotiate access to communities, often working with local grassroots NGOs who have a presence on the ground".
It was crucial for them to incorporate humanitarian negotiators in the vaccination team. "You don't normally see this, as health care workers are the ones who go out and deliver vaccinations," says Mesfin Teklu Tessema, IRC's Global Health lead.
Once they've gained access, they need to be able to get hold of vaccines. The national supply chain doesn't reach many of the conflict-ridden areas, says Tessema, and so getting vaccines to that last mile required a complex process of negotiation, as well as work by Gavi and UNICEF to have vaccines sent to the IRC hubs.
The next challenge is knowing where to find the children who need these vaccines. The team relied on geospatial mapping to pinpoint populations and to understand the distribution of people in relation to the health service point – are they near a clinic or far away – and adapt their response accordingly, says Mesfin. To deliver vaccines effectively, they trained more than 2,000 community and frontline health workers.
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"Building trust with communities is fundamental," says Mesfin, and "we realised that for communities lacking other essential services, we needed to address humanitarian needs beyond solely focusing on immunisation."
In the Horn of Africa, extreme food insecurity means delivering nutrition alongside immunisation. This is a smart way to "build on existing programmatic footprints", adds Reynolds, as delivering what people are asking for "can get you access and interest at the community level".
Making progress
The skill of the humanitarian negotiators is manifest in IRC's results so far, says Mesfin. "When we started this programme, almost 84% of the localities were not accessible for delivering immunisation. Through successful negotiation, we reduced this percentage to 37%."
All of this has meant that in the first six months of the implementation, the Gavi REACH consortium has delivered DPT1 (diphtheria, pertussis and tetanus-containing vaccine) to 200,000 children and MCV1 (measles-containing vaccine) to about 300,000 children in Ethiopia, Somalia, Sudan and South Sudan.
Innovating in immunisation
While this initiative has brought vaccines to children who would never otherwise have received them, it is an important proof of concept that shows that for populations in deeply inaccessible, conflict-ridden areas, a different approach to vaccination programmes is essential.
"Integrating vaccines with other humanitarian services is what is going to deliver results. Expecting health systems to magically cover all children just doesn't work – this is why immunisation rates in these countries have stagnated at around 80% for decades," says Mesfin.
Reynolds agrees. "There can be a kind of magnetic pull to delivering vaccines as they always have been done, but we have the evidence that this doesn't work in these kinds of settings."
“Integrating vaccines with other humanitarian services is what is going to deliver results. Expecting health systems to magically cover all children just doesn’t work – this is why immunisation rates in these countries have stagnated at around 80% for decades.”
– Mesfin Teklu Tessema, IRC’s Global Health lead
More importantly, she says, we now have proof that using an approach that combines humanitarian expertise with robust microplanning and an alternative supply chain is highly effective.
Global health agencies will also need to examine what areas need to be strengthened in these contexts, says Reynolds. "We often focus on health systems strengthening in low-income countries, but that is not going to take us where health systems won't go. Understanding who you want to reach and what the barriers are is important, or else we won't make progress, no matter how much money we pour into it."
Looking at the issue broadly will also mean focusing on under-immunised children; tunnel-vision zero-dose programming will not solve the problem, she adds.
Taking a wider lens is critical in a situation where few health services have gone to plan, says Mesfin. In the Ethiopian states of Tigray, Amhara and Afar, for instance, interruptions in primary health care due to conflict have meant children have been without vaccines for up to five years.
Yet the policy for catch-up vaccine programmes is to target only children aged two and under, meaning that there is little funding for catch up immunisations for kids who may be five years old and still in need of essential vaccines. "A change in this policy would be transformative, since it represents a significant missed opportunity," says Mesfin. Similarly, changes in policy to allow humanitarian actors to be funded to deliver vaccines directly would allow for agile immunisation responses in conflict-ridden settings, he says.
Immunisation has always been plagued by an issue of equity, and those in greatest need of vaccines are often the least likely to get them. Through this work, says Mesfin, "We have a real opportunity to address equity in a meaningful way."
