Far too many children continue to miss out on lifesaving vaccines, and there are significant vaccine coverage inequities within and between countries. Reaching children in humanitarian and conflict-affected settings is a particular challenge; in 2025, more than half of the estimated 13.5 million zero-dose children (defined as those not receiving their first dose of diphtheria, tetanus, and pertussis vaccine) lived in fragile or conflict countries.
Fragile and humanitarian settings are marked by conflict, weak governance, institutional fragility, or recurrent crises, which severely disrupt social, economic, and health systems. According to the World Health Organization, populations in these settings, particularly women and children, face heightened risks, with disruptions to essential services limiting access to health care, food, and water; reaching them with these services requires integrated, adaptive responses.
In 2019, the Gates Foundation launched the Routine Immunization Strengthening Program (RISP), working in subnational areas of ten countries with low routine immunization coverage and high polio risk. RISP focused on country-led and tailored efforts to strengthen routine immunization.
The program partners provided technical assistance across a range of support areas, including implementation support, service delivery, performance management and data systems, community engagement, and microplanning. As the project navigated the COVID-19 pandemic and countries emerged to face routine immunization coverage challenges, it became clear that countries could learn from each other’s experience.
RISP Learning Consortium
In 2023, the Gates Foundation partnered with PATH to lead the RISP Learning Consortium (LC). The RISP LC focused on synthesizing evidence across program countries to identify what works (and what does not work) to strengthen routine immunization programs.
This approach provided a granular understanding of why certain interventions worked in specific contexts. Unlike larger evaluations, where we learn about the effectiveness of an intervention, the robust, theory-driven mixed-methods approach of the RISP LC revealed the specific drivers of change. With this information, PATH and RISP LC partners focused more on the elements and factors that allow for scale-up, adaption, and use in diverse settings. Similarly, this allowed partners to identify what was not necessarily helpful or impactful so that these activities would not be replicated in other contexts.
The RISP LC was organized into two complementary workstreams: One evaluated the effectiveness and drivers of outcomes in country-specific models, and the other conducted cross-country analysis to identify shared patterns and lessons across fragile and humanitarian settings. While no two settings are exactly alike, the challenges and barriers to health care and immunization are often similar. By gathering and synthesizing key insights and lessons, the RISP LC focused on the most replicable and shareable lessons learned.
Implementation insights
Overall, the RISP LC identified four crosscutting topics across ten project countries, which emerged as the most transferable to future investments in fragile, humanitarian, and conflict-affected settings: governance and cofinancing, adapted service delivery, data systems and use, and multipartner ecosystems.
To document and share the results of the analysis, the RISP LC developed a suite of materials to provide pragmatic implementation evidence on how and why these approaches worked. The resources aim to share actionable guidance for future program design rather than simply demonstrate success.
Female caregivers in Pakistan gather to learn about the importance of vaccines. Photo: PHC Global.
As the focus of global resources shift, policymakers and program implementers are increasingly being asked to make health gains with fewer resources. For fragile and humanitarian contexts, these demands stretch already constrained systems to the brink.
By synthesizing learning across countries and contexts, policymakers and partners can identify common challenges and seek solutions that may be adaptable to their context. Shared learning provides a framework from which to build, taking what has been done before, and growing and evolving, rather than starting from scratch.
The nature of work in fragile, humanitarian, and conflict settings can feel isolated from mainstream implementation efforts. Through program-specific exchanges and public webinars, the LC successfully shared key findings from fragile, humanitarian, and conflict settings to country actors, implementing partners, and the donor community.
