The burden of middle-income countries

March 6, 2024 by Kateryna (Katya) Gamazina, MD and Nguyen Tuyet Nga, MD, PhD

In a post-pandemic world, raising vaccination rates means myriad challenges amidst decreasing donor resources.

Health care workers conduct a supportive supervision session at a vaccination point in Tuan Giao district, Dien Bien province, Vietnam.

Health care workers conduct a supportive supervision session, an important activity for maintaining routine immunization coverage, at a vaccination point in Tuan Giao district, Dien Bien province, Vietnam. Photo: PATH.

Worldwide, more than 14 million zero dose children have not received an initial dose of the diphtheria, tetanus, pertussis vaccine (DTP), a reflection of the lack of access to immunization and other critical health services. An additional 6.2 million children are partially vaccinated, having received initial, but not all, routine childhood immunizations. Millions of these children live in middle-income countries that are no longer eligible for donor support for immunization.

The World Bank defines a middle-income country as one where the per capita gross national income is between $1,086 and $13,205 (2022). Globally, middle-income countries encompass a diverse set of nations that vary by size, population, and income level. In these countries more than 829 million children are living at or below the poverty line of $3.65 per day.

While some international resources still go to middle-income countries, overall donor support remains limited, placing the responsibility for immunization financing for routine immunization and new vaccine introduction on the shoulders of local policymakers. As governments consider the increasing portfolio of vaccines available for routine immunization they are simultaneously confronted with an increased number of displaced or migrant populations, rapid urbanization, conflict, economic crises, and more extreme weather events. COVID-19 pandemic disruptions to immunization systems persist today, reaching fewer children while millions remain unvaccinated.

The structures to safely deliver vaccines are eroding. Many middle-income country health systems cannot simultaneously handle the increased slate of childhood vaccines while reversing poor coverage trends of existing antigens, particularly in hard to reach areas. Community healthcare providers are burnt out, overwhelmed, and need refresher training on critical functions. Vaccine misinformation and distrust is perpetuated by insufficient healthcare provider capacity and high turnover as communities no longer have rapport and familiarity with local healthcare workers. Local gender barriers continue to restrict access to information and vaccines.

Middle-income countries benefit from localized support

Recognizing these challenges, PATH is working at the sub-national level with governments and civil society organizations in Indonesia, Ukraine, and Vietnam to provide focused technical assistance on building and sustaining capacity of government systems, health care workers, and local partners to overcome pandemic and conflict related immunization challenges. PATH seeks to help governments improve and sustain their routine immunization coverage. We have a long history of local partnership and health programming in Indonesia, Ukraine, and Vietnam. In collaboration with the local governments and civil society partners, PATH can localize health solutions to help overcome local challenges to sustaining equitable vaccine coverage.

After years of significant distrust and the perpetuation of immunization myths, vaccine coverage in Ukraine has dropped precipitously. Now, the health system in Ukraine has been decimated by two years of war, and our work is crucial to identify communities where vaccines are not reaching or being accepted.

“As families move for safety, they often lose their access to a trusted medical provider and are not accounted for in local immunization planning. Children are not receiving the preventative care that they need,” says Dr. Katya Gamazina, Eastern Europe & Central Asia Hub and Ukraine Country Program Director.

In Vietnam, hard-to-reach communities, be it from language or cultural barriers, or geographical challenges, have not regularly accessed routine immunizations for their children. Without systematic, high-quality health services, communities lose trust in the health care system, creating a vicious cycle of distrust and lack of available care.

PATH’s work in Indonesia, Ukraine, and Vietnam represents diverse geographic regions with deeply embedded religious and cultural perspectives, varying trajectories since Gavi graduation, vastly different governing and economic situations, as well as conflict. Despite the differences between these countries, and other middle-income nations, the root of declines in immunization coverage are similar.

Dr. Nga Nguyen Tuyet, Southeast Asia Hub and Vietnam Country Program Director notes that we are working to have universally applicable project deliverables that intentionally allow for specific nuance and tailoring to best meet the needs of the individual countries.

In July 2022, PATH organized field visits to IDP shelters and dormitories by multidisciplinary teams offering offered various vaccinations: COVID-19, polio, measles, mumps, rubella, tetanus, and hepatitis B, among others.

In July 2022, PATH organized field visits by multidisciplinary teams to IDP shelters and dormitories to offer various vaccinations: COVID-19, polio, measles, mumps, rubella, tetanus, and hepatitis B, among others. Photo: PATH.

Focused on equitable access to the health system

For many, the designation to middle-income country is progress; in theory, it signifies increased per capita income, national financial stability, poverty reduction, and more independence from donor funds. However, the reality is that the jump to being designated a middle-income country comes with challenges that are too often overlooked by the international community and national governments. Governments continue to need support to maintain their immunization policies and programs. Our work in Indonesia, Ukraine, and Vietnam aims to support countries as they regain ground from the COVID-19 pandemic and simultaneously manage challenges from climate change, economic inequity, and conflict. We are working to support national and sub-national governments on their pathway to closing the gap in resources to ensure children living in middle-income countries are fully vaccinated with equitable access to the health system.