Authored by: Heidi Reynolds
A focus on knowledge translation and learning and how past progress was achieved can lay the foundation for accelerated progress in the future.
Reaching zero-dose children – children who have not received life-saving vaccines against disease – is fundamental to achieving greater health equity particularly since such children, their families, and their communities often face multiple deprivations and health service gaps. Both acute and systemic challenges affect communities with disproportionate numbers of zero-dose children, and how such challenges intersect can vary widely across and within countries. While no single solution is likely to overcome all these challenges, a vital step toward better understanding and implementing what works to reach zero-dose children begins with a strong focus on peer-to-peer learning and analytics from a positive outlier lens.
As highlighted by a recent article in Vaccines, countries or subnational locations that substantially reduced the prevalence of zero-dose children – as proxied by the percentage of under-one children without any doses of diphtheria-tetanus-pertussis vaccine (no-DTP) – during prior time periods may offer further insights into the policy, program, and/or contextual factors behind such gains. Examining these trends could help identify specific immunization practices or programs for adaption in contexts with less historical progress, with key policy and implementation questions including:
- What are successful policy and programmatic decisions that drive equitable declines in the number of zero-dose children, including by geography and other factors?
- How do countries align and re-align strategies to meet changing contextual needs and barriers?
With this work, we compared both national and subnational declines in no-DTP prevalence for 56 low- and lower-middle-income countries. Between 2000 and 2019, countries achieving the largest reductions across these geographic measures included the Democratic Republic of the Congo, Ethiopia, India, Bangladesh, and Burundi. Importantly, these countries had different starting points in 2000, as well as trajectories through 2019 for both national levels of no-DTP and subnational no-DTP gaps. The strategies used by these countries and corresponding lessons in improving childhood vaccination, especially around expanding service reach to unvaccinated children, may be applicable to other settings. Nonetheless, more progress is possible – and necessary – in locations still experiencing high levels of zero-dose children.
How can such ‘positive outlier’ analysis be useful for vaccine delivery?
One way is to apply this methodology to equity dimensions beyond a geographic lens. Factors such as gender, education, wealth, ethnicity/race, religion, among others can differentially affect how easy or difficult vaccination access and delivery is for caregivers and health workers. Gavi, the Vaccine Alliance, has explicitly invested in better identifying, differentiating, and targeting zero-dose children and under-immunized communities for its 2021-2025 strategy. This emphasis on intersectionality – the idea that different individual inequalities can be mutually reinforcing and compounding for people who experience them – aims to pinpoint the types of interventions that could effectively address multiple deprivations, as well as the types of norms and practices that promote transformative, sustainable change.
Another way would be to conduct targeted subnational analyses and work with program implementers to better understand why no-DTP prevalence has declined in some areas but not others. Such work could be particularly impactful since solutions in one context (e.g., conflict or conflict settings) may be able to unblock barriers similar settings elsewhere.
Fundamental to such learning and knowledge translation is the establishment and support of platforms by which cross-country collaboration and sharing can occur. Gavi’s Zero-Dose Learning Hub is a new mechanism to generate, synthesize, and share findings across countries, with a focus on identifying and reaching zero-dose children and missed communities. Through targeted stakeholder engagement, country-led learning agendas, and strengthened processes around evidence translation among program implementers, the Zero-Dose Learning Hubs aim to catalyze faster, long-term improvements in childhood vaccination.
Globally, we have faced setbacks in childhood immunization in the last few years, from pandemic-related disruptions to pre-pandemic plateaus in coverage and continued challenges around vaccine hesitancy. To enable faster recovery and greater access to life-saving vaccines, we must harness the power of not only robust data and analytics, but also meaningful engagement and action around how to put evidence and knowledge to use in policy and program implementation. Data and evidence on their own will never be enough to effectively improve vaccination access and delivery; we must also support the iterative learning processes and knowledge exchange needed to address the complex needs and demands of zero-dose children and missed communities. Characterizing pathways to greater vaccination equity, while supporting the platforms by which effective knowledge translation and cross-country learning can be supported, will help pave the way toward ensuring all children can fully benefit from vaccines.
Dr. Heidi Reynolds is a Senior Specialist for Evaluation and Learning at Gavi, the Vaccine Alliance.