WHO to support African countries to achieve universal immunisation coverage

Jun 01, 2018

Every year, more than 30 million children under-five fall sick due to vaccine-preventable diseases, and of these, over half a million die

The World Health Organization (WHO) recently launched the Business Case for WHO Immunisation Activities on the African Continent 2018-2030, which outlines how WHO will support African member states to achieve universal immunization coverage.

The launch took place at the 71st World Health Assembly in Geneva, Switzerland. The term ‘business case' refers to a justification for a proposed project or undertaking on the basis of its expected commercial benefit.

WHO acknowledges that while Africa has made tremendous progress in improving access to immunization, most countries are off track to achieving the Global Vaccine Action Plan (GVAP) target of 90% national immunization coverage by 2020. This is because one in five African children still lack access to all the WHO recommended life-saving vaccines, which is a threat not only to the health of fa­milies, but also to the strength of economies and equity in African societies.

According to WHO, every year, more than 30 million children under-five fall sick due to vaccine-preventable diseases, and of these, over half a million die. Deaths due to vaccine-preventable diseases account for 58% of global deaths. Such diseases also impose an economic burden of $13b every year - funding that could be used to fuel the economy and drive development. 

Economic benefits

Data from the business case shows that curbing four major vaccine-preventable diseases - measles, rubella, rotavirus and pneumococcal diseases - could save more than 1.9 million lives in Africa, avert 167 million cases of vaccine-preventable diseases and generate $58 billion in economic benefits by 2030. Data from WHO shows that the return on this investment has been estimated to be $37 for every dollar invested, with returns going up to $93 for measles elimination. 

"The benefits of immunization are far reaching. When children survive and stay healthy, entire families, communities and countries thrive. In short, immunization is a cornerstone of sustainable development," Pr. Samba Ousmane Sow, the minister of health and public hygiene for Mali was quoted in a press release from WHO.

Sow added: "We must ramp up our efforts immediately to ensure universal access to immunization for all children in Africa, no matter who they are or where they live."

To scale up progress against vaccine-preventable diseases, the business case adopts a comprehensive approach to immunization, shifting focus from a disease-specific to an integrated, multi-sectoral life-course approach from infancy through to old age. In addition, the business case recognizes and addresses one of the toughest challenges to meeting immunization targets in Africa - a changing funding landscape.

"As Africa nears polio eradication, critical funding for immunisation through the Global Polio Eradication Initiative is expected to ramp down and end. Additionally, as more countries in Africa approach middle-income status, they will transition away from GAVI, the Vaccine Alliance funding. As of 2018, Angola and Congo have transitioned from GAVI support and several other African countries will enter an accelerated transition process, after which they will be expected to finance 100% of the cost of their vaccines and other immunization costs," a statement from WHO noted.

Models from the WHO business case indicate that if current vaccination efforts are not maintained, reversed progress could lead to more than 2.4 million deaths in Africa and a negative impact of $59 billion over the next decade.

"The World Health Organization has played a critical role to ensure stead­fast support of countries' immunization programmes for 70 years. We are committed to continue to strengthen our support for years to come," Dr Jaouad Mahjour, the acting WHO regional director for the Eastern Mediterranean, was quoted in a statement. "We know that business as usual will no longer work, which is why we have developed this business case to better understand how we can support member states in strengthening national immunization programmes." 

Immunization maturity grid

To implement the business case, the WHO regional offices for the African and Eastern Mediterranean Regions have differentiated all African countries into four categories based on an immunization maturity grid. The categories highlight the level of effort needed to achieve robust immunization systems all over the continent.

Going forward, WHO will provide targeted support to each group of countries to optimize resource management and increase impact. The four categories, which range from 1 (low maturity) to 4 (high maturity), were selected based on various immunization components such as vaccine financing, immunization service delivery and data analytics.

Category One refers to countries with a very weak immunization system with major gaps.

Category Two refers to countries with significant deficiencies in immunization service delivery. These countries have deficiencies in several immunization components, including the immunization service delivery.

Category Three refers to countries with targeted areas for improvement. These countries have deficiencies in some dimensions and intermediary capabilities on immunization service delivery.

Category Four refers to countries with strong and robust immunization systems across most dimensions. These have the ability to plan, implement, monitor and evaluate immunization programmes autonomously, with continuous improvement plans.

A total of 21 African countries have been classified as having weak immunization systems (categories 1 and 2), while Uganda has been placed in category 3. 

Uganda's situation 

Table showing WHO/Unicef estimates for vaccine coverage

 

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

BCG

83

87

86

90

86

97

96

96

95

96

96

89

DPT1

85

93

87

96

87

91

92

92

93

95

95

95

DPT3

64

73

71

79

80

82

83

84

85

85

85

85

OPV3

62

70

69

78

79

79

79

78

78

80

80

80

IPV

 

 

 

 

 

 

 

 

 

 

44

61

PCV3

 

 

 

 

 

 

 

 

60

64

77

81

MCV

75

75

70

77

73

75

83

84

85

80

80

80

The GVAP recommends countries to achieve at least 90% coverage for each antigen. However, according to the above table, for Uganda it is only BCG (the vaccine against tuberculosis which is usually given at birth) and DPT1 (a combination vaccine against diphtheria, whooping cough and tetanus) which are above 90% since 2011. It is noted that a good number of children are started on the journey of vaccination as exhibited by a good coverage of (BCG) but drop off along the way

For example, since 2006, there is a big drop from DPT1 to DPT3 every year of more than 10%. This means children are not continuing to receive the next antigens according to the schedule.

In addition, since 2006, Uganda has not achieved a more than 90% coverage for measles. Therefore, this accounts for the ongoing rampart measles outbreak in country as its only when we achieve more than 95% coverage that we can be sure that we can protect the children from contracting measles.

Information from WHO also shows that the Polio 3 coverage through the years has been poor and Uganda has failed to achieve more than 90% coverage despite the availability of the vaccine nationally. 

Uganda's strengths

Uganda has been commended for promoting immunization and its strengths include the fact that the immunisation program (UNEPI) has political support as the President has put vaccination among the priority program of work and on his manifesto.

Other strengths include:

  • Uganda has a dedicated EPI team comprised of UNEPI and Technical Partners that are there to plan and coordinate the EPI (Expanded Programme on Immunisation) activities
  • There is an established EPI system from national to district, with EPI focal persons at district, HSD, sub-county and health facility level
  • The EPI program has grown from six antigens to 11 antigens following introduction of new vaccines like Pneumococcal conjugate vaccine (PCV), human papilloma virus (HPV), inactivated poliovirus vaccine (IPV) and ROTA. There are now plans to introduce Rubella vaccine
  • Uganda has an Immunization Act 2016. This mandates compulsory immunization of children, women of reproductive age and other target groups. It also promotes the funding of activities to promote immunisation. 

Weaknesses

In regards to achieving immunization coverage in Uganda, the EPI program is faced with issues of inadequate funding at subnational level to ensure activity implementation. In addition, Information from WHO also shows that there is low routine immunization demand because of lack of social mobilization. It is acknowledged that the immunization program is a people-centred one and that it requires community engagement to own it for its sustainability.

Other challenges that hinder the achievement of GVAP targets in Africa include:

  • Inequalities in the access of immunization
  • Increasing numbers of outbreaks and humanitarian emergencies which strain the health systems and ultimately immunization systems
  • Data quality and use remain limited at national and local levels 

WHO plan

It was also noted that over time, WHO will decrease efforts and focus in countries as they move up the maturity scale, to ensure country ownership and sustainability.

"The WHO business case is strongly anchored in a broader vision to improve accountability and transparency within WHO, in line with the broader WHO Transformation Agenda," Dr Matshidiso Moeti, the WHO regional director for Africa, was quoted in a statement.

WHO aims to bring all Afri­can countries to a satisfactory level of immunization maturity by 2030.

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