2015 Assessment Report of the Global Vaccine Action Plan

"Global partners need to strengthen country accountability."

The Strategic Advisory Group of Experts (SAGE) Working Group (WG) facilitates a yearly SAGE independent review of the implementation of the Decade of Vaccines (DoV)' Global Vaccine Action Plan (GVAP) and assessment of progress. In December 2010, all countries committed themselves to the goals and strategies of the GVAP, by 2020: to eliminate maternal and neonatal tetanus, measles, congenital rubella, syndrome and polio; to free all children from vaccine-preventable diseases no matter where they live; and to explore the potential for vaccines to save more lives. As requested by the World Health Organization (WHO) Member States, SAGE presents, in this midline report of the DoV, an objective assessment of progress on implementation of the GVAP to date.

At the October 2015 meeting, SAGE found that the DoV "is not on course to achieve its true potential", yet stressed that leadership and accountability systems in countries, regions, and at the global level can take the GVAP forward towards success.

The SAGE DoV GVAP Assessment Report 2015 outlines some of the problems that are holding back progress in the DoV. For example, due to war and natural disasters, there are internally displaced children who cannot access immunisation services and areas where ongoing fighting makes vaccination very challenging. The issue of inequity also arises with regard to maternal and neonatal tetanus, "a stark reminder of the shocking inequity in healthcare provision"; the target of eliminating this disease by the end of 2015 "will almost certainly be missed". Furthermore, "[t]he world needs to get serious about the goal to eliminate measles along the lines of what countries, regions and global partners have mobilized to rid the world of polio. Rubella needs to be included in a new strategy so that both goals can see real progress."

Several isolated examples of success are described in the report. For example, Africa has not had a case of wild poliovirus since August 2014, and Nigeria is no longer a polio-endemic country, leaving just two: Afghanistan and Pakistan. Polio resources were brought to bear in containing the outbreak of Ebola virus in Africa. Factors SAGE has identified as common to successful endeavours include:

• Quality data: For instance, data informed India's maternal and neonatal tetanus elimination strategy in many ways, including determining education and training needs so that health workers and nurses would be in place - 500,000 frontline health workers were trained - to upgrade primary health care clinics to accommodate birth care in response to community demand and to integrate immunisation and antenatal care.
• Community ownership: "In Africa, polio eradication has been transformed by involvement of community leaders at local and district levels and by armies of community workers, even in countries with chronic disruption like Somalia. India's success with maternal and neonatal tetanus similarly relied heavily on community health workers and civil society organizations. The key factor is that volunteers are from the communities in which they work."
• Vaccines available: If a child arrives ready for vaccination and there is no vaccine, a demotivated caregiver will not return, which means that large numbers of under-immunised children are at risk.

SAGE explains that the way forward must focus on leadership and accountability, which needs to occur at 3 levels: in countries, in WHO regions, and at the global level. As Nigeria fought to become polio-free, "[t]he country and its technical partners established and enforced clear accountability systems, to measure results, reward those who achieve them, and to discipline or part company with those who did not." The report provides a case study of India's Mission Indradhanush (Rainbow) through which, during 4 months in 2015, the campaign vaccinated an additional 6.65 million children and 1.86 million pregnant women. "The Indian Government resourced Mission Indradhanush and was committed to its success at the highest level. The Prime Minister made a national statement. The Minister for Health wrote to all frontline health workers involved in the programme. This was followed up by district and local leaders. Another aspect of leadership was community-based. Research had suggested awareness and apprehension were key factors in children being missed for vaccination. The strategy to recruit an army of local community health workers who played a key social mobilization role combined with others such as translation to local language to aid success, along with an integrated media strategy."

In brief, SAGE recommends that:

1. Countries have annual plans for immunisation consistent with the GVAP and relevant regional vaccine action plans. The Ministries of Health, Finance and other pertinent ministries should establish an annual process for monitoring and accountability at national and subnational levels. An independent body, for example the National Immunization Technical Advisory Group (NITAG), should be tasked with monitoring. Yearly, each country should share with WHO regional offices its monitoring report, which should also include sharing of best practices.
2. Once regional vaccine action plans are finalised (by December 2015), WHO regional offices establish a process of annual progress review through their regional technical advisory groups and report to the respective Regional Committees. The resulting reports should be made available annually to SAGE.
3. Global, regional, and national development partners align their efforts to support countries in strengthening their leadership and accountability frameworks and in implementing their national plans.
4. DoV secretariat agencies report to SAGE in 2016 on their supporting activities conducted in the 10 countries where most of the unvaccinated and under-vaccinated children live. This annual reporting mechanism should include discussion of those reports in regional technical advisory groups.
5. WHO and the United Nations Children's Fund (UNICEF) convene a meeting of global partners and the remaining 21 countries with maternal and neonatal tetanus to agree on an action plan, resources, and respective responsibilities so that the goal is achieved by 2017.
6. The recommendations of the mid-term review of the global measles and rubella strategic plan to be conducted in 2016, once endorsed by SAGE, be taken into account in refining plans and for monitoring and enhancing quality of plan implementation.
7. Global, regional, and country development partners coordinate and align their efforts to support countries to immunise more children by strengthening their healthcare delivery systems, combined with targeted approaches to reach children consistently missed by the routine delivery system.
8. WHO provide guidance for countries and partners on implementation of immunisation programmes and immunisation strategies during situations of conflict and chronic disruption.
9. This report be presented at the World Economic Forum in Davos, Switzerland, where the Decade of Vaccines was launched.

"The 2016 report should aim to highlight those activities that were game-changers at global, regional and country levels."

Click here for the 24-page report in PDF format in English.
Click here for the 28-page report in PDF format in French.
Click here for the 30-page report in PDF format in Russian.
Click here for the 28-page report in PDF format in Spanish.