Zero-dose children: Reaching the unreached

May 2, 2022 by PATH

Worldwide, more than 17 million children went unvaccinated in 2020. As Gavi and others work to close gaps in vaccine access, here’s how PATH can help.

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Health workers in rural Malawi delivering vaccines—doses kept cold in a PATH-designed vaccine carrier. Photo: PATH.

Making progress toward health equity requires a granular understanding of where there are gaps in access or uptake, why those gaps exist, and what can be done to address them. Though vaccination represents only one pillar or part of the primary health care system, it is an especially important one for protecting the health of children.

According to WHO/UNICEF estimates, in 2020, more than 17 million children worldwide were unvaccinated or zero-dose: defined as not receiving the first dose of diphtheria-tetanus-pertussis vaccine (DTP1). According to those same estimates, another 6 million children were under-vaccinated (did not receive the third dose, DTP3).

“In general, it would be fair to see zero-dose and under-immunized children as indicators of gaps in the immunization system and health care inequity,” says Deborah Atherly, PhD, BScPharm, Global Head of Policy, Access, and Introduction at PATH’s Center for Vaccine Innovation and Access. “Ultimately, what we do to reach those children should also contribute to strengthening of the primary health care system as part of a country’s universal health coverage goals.” 

Among the estimated 17 million zero-dose children, about half (8.8 million) live in 12 countries—Afghanistan, Ethiopia, India, Kenya, Nigeria, Madagascar, Mali, Pakistan, Somalia, South Sudan, Uganda, and Zambia. These countries encompass a diversity of settings with anticipated variability in the drivers of zero-dose and under-immunized children, which are complex, interrelated, and highly contextualized. 

Reaching zero-dose children and missed communities—defined by higher rates of zero-dose and under-vaccinated children—will require tailored approaches that address multiple and intersecting sociocultural barriers and economic vulnerabilities, as well as health system challenges to delivering immunization services through the primary health care system and WHO’s Expanded Program on Immunization.

Partnering to accelerate progress

PATH leverages it extensive experience strengthening immunization systems and introducing vaccines as a core partner in the USAID-funded MOMENTUM—Routine Immunization Transformation and Equity, a global consortium that aims to reduce the number of zero-dose children.

MOMENTUM Routine Immunization Transformation and Equity and its members work with national and local health systems to diagnose obstacles to equitable coverage and respond in a variety of ways, depending on the needs, including:

  • Identifying and mitigating gender-related barriers that limit caregivers’ knowledge of when, where, and why to seek immunization services and improving the timing and location of services to better meet their needs.
  • Strengthening immunization supply chains to reduce stockouts of vaccines and increase their availability to all communities through improved forecasting and better vaccine stock management.
  • Forging community and health system partnerships to identify why some children are not vaccinated and jointly plan and monitor the services provided to them.
  • Engaging local leaders to promote the importance of immunization and help find local solutions to immunization service barriers.
  • Supporting national and subnational planning and budgeting and mobilizing local resources to reach zero-dose children.

For example, MOMENTUM Routine Immunization Transformation and Equity has been working in the Democratic Republic of the Congo and Mozambique to understand the unique barriers faced by families of zero-dose children. Using a human-centered design approach, we engaged community members and clients in solution development. By centering the experiences of the communities we seek to support, these workshops helped the project, local communities, and immunization partners to develop tailored strategies for reaching zero-dose children and their families.

At PATH, we’re proud to be a part of the MOMENTUM global partnership and to do our part to realize a world where all people receive high-quality vaccination services to protect their children and themselves against vaccine-preventable diseases.

Other ways PATH is helping

PATH leverages decades of hands-on experience developing, introducing, and improving vaccines and immunization technologies to advance and sustain country goals for immunization equity and vaccine coverage and global goals outlined by multilaterals like Gavi, WHO, and UNICEF.

Over the years, we’ve helped advance vaccine access in many different ways: helping decision-makers determine the best use of limited resources with cost-effectiveness and return-on-investment assessments before and after vaccine introduction; supporting the development and rollout of digital systems to help manage routine immunizations, better direct resources to underserved areas, and deliver more targeted patient care; facilitating knowledge sharing between countries and health departments to speed the digital transformation of entire regions; and more.

PATH’s relevant capacities fall into four functions or areas:

  1. Increasing vaccine coverage and equity
    From awareness campaigns and multisector collaborations to better data and innovative technology, at PATH we use every technique at our disposal to ensure that children everywhere have equitable and sustainable access to the vaccines they need.

    For example, in Vietnam, PATH spent the last decade working side by side with the Ministry of Health to design, develop, and launch ImmReg, the country’s first national digital immunization system. PATH provided support in numerous ways: engaging mobile network operators and private-sector providers, supporting scale-up from a district level to a national pilot, supporting full-scale deployment of the ImmReg system, overcoming barriers to adoption among users, and providing virtual supportive supervision as a means of strengthening implementation during the COVID-19 crisis.

  2. Strengthening immunization as part of primary health care and integrated service delivery
    Our global team specializes in strengthening primary health care systems—and the capacities, policies, markets, and supply chains that make them possible. By increasing the resilience and reach of health systems, we can help countries drive down the number of zero-dose children.

    For example, to support decision-making around advancing maternal immunization in low- and middle-income countries, PATH coordinated the Advancing Maternal Immunization collaboration, which harnesses expertise and forges connections between health care programs often siloed in many countries—immunization and maternal, newborn, and child health. The prospect of routinely and equitably offering vaccines to pregnant women to protect them and/or their babies from certain diseases through maternal immunization, however, requires venturing into uncharted territory. We’re doing so by engaging stakeholders across programs to explore what it will take to advance maternal immunization in a way that adds value—not burden—to existing health care services for mothers and their babies.

  3. Protecting communities from deadly and disabling diseases
    PATH leverages partnerships to accelerate the development and introduction of lifesaving vaccines. And we have decades of experience working in some of the world’s hardest-to-reach places—essential experience for reaching zero-dose children and missed communities.

    For example, PATH is on the front lines of tackling the world’s top two infectious killers of children under age five—pneumonia and diarrheal disease. We’re doing so by supporting a suite of prevention and treatment tools that includes vaccines. These illnesses can also lead to long-term health and economic effects that fuel the cycle of poverty. We’re helping to develop, optimize, raise the profile of, and introduce vaccines against major causes of severe childhood diarrheal disease and pneumonia, such as rotavirus, Enterotoxigenic Escherichia coli, Shigella, pneumococcus, and respiratory syncytial virus. By complementing other crosscutting interventions (e.g., good nutrition, sanitation, drugs, clean air, etc.), we’re giving more children a chance to survive and thrive.

  4. Leveraging a country-centered approach
    PATH engages immunization program managers, ministries of health, the private sector, health workers, and the communities they serve to better understand their needs and priorities and develop appropriate, affordable solutions. Our experience in these areas will be key for developing the context-specific solutions required to reach zero-dose children.

    For example, in Zambia, with funding from the Hewlett Foundation, and in close partnership with the Ministry of Health and other provincial and district leaders, PATH is supporting the country’s integration of family planning services with routine childhood immunization. The project employs our Living Labs 5D (discover, define, dream, design, deploy) human-centered design process, including interactive sprint cycles to engage health workers and postpartum women and their partners to develop prototype concepts. At project midpoint, PATH has completed sprint cycles in one district, engaging ten health facilities and 53 users to generate 35 ideas and test three concepts. The project is currently planning pilot implementation and engaging with government partners to assess opportunities for scale-up.