Routine Immunization Strengthening Program Learning Consortium: shared learning for impact

Immunization prevents an estimated 3.5 million to 5 million deaths each year, and every dollar spent on immunization in countries supported by Gavi, the Vaccine Alliance, returns approximately US$21 in health and productivity gains. Yet reaching children in humanitarian and conflict-affected settings remains a defining challenge. In 2025, 13.5 million children received no routine vaccines, and wild and vaccine-derived polio continued to circulate where coverage was lowest.

The Routine Immunization Strengthening Program (RISP), launched by the Gates Foundation in 2019, works in subnational areas with low routine immunization (RI) coverage and high polio risk. RISP is a portfolio of country-led and tailored efforts to strengthen RI systems across diverse contexts. Although countries differ in priorities and activities, RISP investments fall within three models that define how support is delivered and institutionalized: direct service delivery through partners, memorandum of understanding (MoU)–based support through government systems, and hybrid approaches. Across these frameworks, investments span service delivery, governance and accountability mechanisms, community engagement, data systems and performance management, access negotiation, capacity strengthening, microplanning, coverage surveys, financial management, and transition planning.

The diversity of RISP investments created a unique opportunity to generate learning across countries, implementation approaches, and operating environments. From 2023 to 2026, the Gates Foundation partnered with PATH to lead the RISP Learning Consortium (LC), bringing together evidence and learning across program countries to understand what worked, why, and under what conditions. The LC identified lessons that could be applied across contexts and generated practical insights to support governments, donors, and implementing partners to strengthen immunization programs in resource-constrained settings.

The results highlight four domains, outlined below, that offer the most transferable lessons for future investments in fragile, humanitarian, and conflict-affected settings. The corresponding resources provide practical evidence on how and why certain approaches worked and offer actionable guidance for future program design. 

Governance and cofinancing
Governance and cofinancing mechanisms can secure government commitments to RI. In RISP countries that implemented MoUs, the agreements signed between governments and donors addressed critical funding gaps and strengthened governance, accountability, and service delivery. The MoUs increased resources to extend RI coverage to populations consistently missed by the routine systems and reinforced the coordination structures within national systems. Subnational fiscal capacity, political stability, and local advocacy affected the fulfillment and effectiveness of these approaches.

Service delivery adapted to fragile contexts
Service delivery platforms are most effective when tailored to the needs of the community. In humanitarian settings, where the demand for standalone immunization services can be very low, integrating immunization with basic health services can help to increase acceptance and uptake of vaccination. The RISP LC findings show that in communities where distance, insecurity, or seasonal disruptions blocked access to a fixed health post, mobile delivery models helped extend access to and deliver RI services alongside other basic primary health care services.

Data systems and use
Data systems that collect granular, timely, and actionable operational data facilitate efficient performance management with support from specialized data system partners and donor funding. In humanitarian settings, where national health data are often incomplete or unavailable, program management and decision-making based on timely monitoring are difficult. In RISP countries, gathering information on vaccine stocks, cold chain functionality, and other factors allowed for the development of accessible dashboards and performance scorecards that governments and local partners discussed during routine data review meetings. With this information at hand, immunization programs could identify root causes of coverage trends and adjust implementation accordingly.

Multipartner ecosystem
Partnership models enable service delivery in hard-to-reach and previously inaccessible communities. Interorganizational partnerships assemble organizations with complementary strengths so that efforts reinforce, rather than duplicate, each other. In RISP countries, local partners provided access and trust, international nongovernmental organizations had operational agility, and specialist partners supplied data and community engagement expertise. However, partnerships proved difficult to maintain as funding declined.

The following country briefs provide additional details on the RISP LC findings in each country and the key lessons learned.

Chad
The government of Chad signed an MoU with donors to provide upfront capital investments in the early years of the program. In later years, MoU spending progressively transitioned to operational and supervisory functions at the health facility, with increasing government financial responsibility. This arrangement contributed to meaningful improvements in accountability, governance, and vaccine service delivery.

Democratic Republic of the Congo
Monitoring and accountability, strengthened by performance data, drove gains in immunization coverage and facility-level performance in the Democratic Republic of the Congo. RISP faced challenges with provincial instability and fiscal constraints, which ultimately limited implementation quality and longer-term sustainability.

​Niger
Despite challenges that emerged from an unexpected government transition, donor partnerships in Niger helped to address critical funding gaps and improve service delivery. Mobile service delivery strategies likely contributed to reductions in zero-dose children in the most remote project communities.

Pakistan
Focused on closing service delivery gaps in areas with limited access to fixed and outreach services, RISP activities in Pakistan drove important coverage gains. Structured monitoring and frontline accountability routines helped to resolve many immunization-related bottlenecks, and one province further reduced pentavalent vaccination dropout rates by offering paracetamol alongside immunization services.

Somalia
Partnerships proved critical in Somalia, helping overcome barriers in unstable and previously inaccessible communities, ultimately contributing to increased uptake of vaccines and integrated services. The Far-Reaching Integrated Delivery model monitored demand-side constraints and responded to community preferences to improve vaccine coverage.