Fulfilling a Promise: Ensuring Immunization for All in Africa

"Ensuring that children are able to live healthy lives and maximize their full potential depends on governments and their partners – local, national and international – closing funding gaps, increasing country ownership and ensuring financial sustainability of immunization programs."

Prepared by a team led by the World Health Organization (WHO) Offices for the African and Eastern Mediterranean Regions, this report examines immunisation progress and challenges across the continent since global leaders declared the Decade of Vaccines and launched the 2011-2020 Global Vaccine Action Plan (GVAP). It was released ahead of the Ministerial Conference on Immunization in Africa, held in Addis Ababa February 24-25 2016, which brought together ministers of health and other line ministers as well as parliamentarians to commit to providing universal access to immunisation and strengthening of vaccine delivery systems. The evidence in this report could be useful to a communicator seeking to advocate for attention to commitments and actions that will be necessary to ensure the future envisioned by the GVAP, such as by ensuring hard-to-reach children have equitable access to lifesaving vaccinations.

Through various charts and figures throughout, the resource paints a mixed picture of the state of immunisation among Africa’s children. On the positive side, routine immunisation coverage has increased considerably across Africa; average diphtheria-tetanus-pertussis (DTP3) coverage increased from 57% in 2000 to 80% in 2014. "Africa has gone more than a year and a half without a case of wild polio, a monumental milestone that reflects the contributions of political leaders, health officials and communities across the continent." Furthermore, measles deaths declined by 86% between 2000 and 2014. Because measles is a highly infectious virus, control requires more than 95% coverage with two doses of measles-containing vaccine (MCV) across all districts. (In 2014, while the coverage of one dose of MCV in Africa was 74%, coverage of two doses of MCV was only 19%.) Finally, the GVAP goal for the introduction of new vaccines is on track to be met in large part due to the contribution of countries in Africa. Many countries in Africa have introduced multiple new vaccines, such as pneumococcal conjugate vaccine and rotavirus vaccine, at the same time. It is noted that, to ensure country ownership and to guide vaccine decision-making when it comes to the introduction of new vaccines, many countries have set up independent technical advisory groups, as recommended by the GVAP. "Campaigns to raise awareness around the importance of immunization, including Africa Immunization Week, have contributed to these successes." A case study in the resource provides an example from Rwanda, which highlights the power of high-level political engagement with immunisation combined with a broad commitment to strengthening health systems.

Despite considerable progress in expanding access to vaccines in Africa, one in five children on the continent still does not receive life-saving immunisations. Africa's routine immunisation coverage of 80% is the lowest of any region in the world. Three critical diseases - measles, rubella, and neonatal tetanus - that have been eliminated or nearly eliminated in most regions of the world, remain widespread in Africa. (See pages 20-21 of the resource for a country-level overview of DTP3 coverage and vaccine introduction.) Many countries have fragile health systems that have buckled under sudden crises, such as armed conflict or major disease outbreaks (e.g., the Ebola outbreak). In addressing such challenges, one key factor in Mozambique's progress in delivering vaccines to health centre facilities has been "the engagement of national and provincial leaders at the Ministry of Health who have demonstrated openness to new and different approaches to supply chain models, based on evidence generated by modeling of the supply chain as well as global best practices."

In addition to addressing health systems constraints (e.g., poor infrastructure, insufficient numbers of health workers), a text box in the report notes that addressing individual, family, and community factors associated with missed and untimely immunisations can help improve immunisation coverage. A systematic review of studies conducted in low- and middle-income countries cited here found that gender inequality can be an underlying aspect of low demand for immunisation. "The researchers found that the low social status of women negatively affects access to vaccination for women because of their limited decision-making power over resources and lack of autonomy....For this reason, vaccine coverage could be improved in some settings by involving fathers and communities in vaccination activities. Understanding the social determinants of immunization coverage is an important exercise that allows policymakers and health program managers to improve and refine immunization program strategies."

Other challenges remain, such as ensuring sustainability of the polio eradication programme's success in Africa, including improvements in coverage of the oral polio vaccine (OPV), sustained surveillance and outbreak response capacity, and introduction of the inactivated polio vaccine (IPV) into routine immunisation systems. Also, considering that "understanding national vaccine coverage is critically important for monitoring the performance of immunization programs, identifying areas within immunization systems that require improvements, and preparing for the introduction of new vaccines", estimates of national immunisation coverage are needed but yet limited by their data collection methods – namely, reviewing immunization cards in the home, asking the caretaker about immunisation history, or both together. "These challenges are compounded in resource-poor settings."

The report notes that there is growing evidence of the economic and social benefits of immunisation, which is well recognised by Gavi, the Vaccine Alliance, an international public-private partnership committed to the mission of saving lives and protecting health by expanding access to vaccines in the world's economically poorest countries. Research suggests that meeting the projected costs of national immunisation programmes is worth 16 times the original investment. At the community level, avoiding the costs associated with a vaccine-preventable disease can help keep whole families out of poverty. Section 6 of the report provides details about the issue of financing immunisation in Africa.

The report has informed a ministerial declaration that was open for signatures during the conference in Addis Ababa, Ethiopia. The declaration honors the progress of recent years, while also committing to universal access to immunisation and strengthening of vaccine delivery systems. After the conference, the declaration will be presented to the Assembly of African Head of States and Governments at the 26th Summit of the African Union, to be held in June 2016. "World Health Organization and African Union call on the continent to unite to make vaccines a priority for Africa's future..."