Health and Immunisation Services for the Urban Poor in Selected Countries of Asia

Per 2016 data, an estimated 63 million people live in slum communities in the 6 countries discussed in this commentary: Cambodia, Indonesia, Mongolia, Myanmar, the Philippines, and Vietnam. The emergence between 2014 and 2016 of substantial vaccine-preventable disease (VPD) outbreaks in major cities of the region, along with evidence of substantial coverage gaps between wealth quintiles in urban areas, are raising questions about the effectiveness and equity of immunisation programming in rapidly urbanising areas. This commentary describes and analyses strengths and weaknesses of the existing urban health and immunisation strategy, drawing on the findings of country case studies published by the United Nations Childrens Fund (UNICEF); the summary below focuses on communication-related elements of the analysis.

The commentary examines: social conditions and demographic trends amongst the urban economically poor in East Asia; demographic trends in urban areas; immunisation coverage and vaccine preventable diseases in urban areas; and evidence of VPD outbreaks in urban areas in Asia. Among the dimensions of vulnerability are lack of knowledge of VPDs and the benefits of vaccination.

In response to the elevated public health risk in these communities, there have been some innovations in operational strategy in urban settings, although most of these initiatives are project-related and externally funded. Selected examples include:

• In Indonesia, a pilot project in Jakarta is trialling communication, monitoring, and management strategies in high-risk areas of Jakarta, with some promising coverage improvement reported.
• Mongolia developed a revitalised Reaching Every District (RED) strategy in 2010, focusing on high-risk identification, household visits to the urban economically poor, and social sector and civil society collaborations to expand access through improved civil registration. Several evaluations there have demonstrated the potential of the approach to improve immunisation and other health service access for the urban economically poor.
• Also designed in 2010, Myanmar's "reaching every community" approach focuses on mapping of high-risk areas and on analysis of risk in terms of social distance and not just physical distances.
• In the 1970s and 1980s, many of these countries, including Myanmar, Mongolia, and Vietnam, built a primary healthcare system based on a rural health model that featured, among other components, primary care centres and village volunteers networked into a "social mobilisation" communication approach.
• In the Philippines, advocacy meetings with local chief executives are proposed to accelerate the urban immunisation strategy specifically, but how local governments are held accountable for financing and results are not made clear.

The researchers note that, despite these and other promising innovations, there are significant gaps in strategic policy and planning initiatives to tie down accountability and financing within policy or strategic planning documents, or in health system procedures.

Figure 2 in the paper (see above) outlines various aspects of an enabling environment for urban health management that the researchers assert would need to be addressed in order to develop sustainable management and delivery systems. Community engagement is a critical component of this governance model, given the weak political position occupied by urban slum dwellers. Related to the latter: A review of published studies on vector control in urban settings cited in the paper recommends a joint approach involving policymakers and scientists, along with a call for increased political commitment and citizen engagement strategies.

In conclusion, critical issues for attention for urban health services access include reaching consensus on accountability for management and resourcing of the strategy, as well as inclusion of an urban economically poor approach within the planning and budgeting procedures of Ministries of Health and local governments. The researchers stress that advancement of local partnership and community engagement strategies to inform operational approaches for socially marginalised populations are also urgently required. Such developments will be reliant on development of municipal models of primary health care that have clear delegations of authority, adequate resources, and institutional capabilities to implement.