ERG Discussion Paper 07

Tackling inequities in immunization

outcomes in urban contexts

Robin Nandy, Helen Rees, Jeff Bernson,

Peder Digre, Elizabeth Rowley, Breese McIlvaine

December 2018
Tackling inequities in immunization outcomes in urban settings

© 2018 PATH and Equity Reference Group for Immunization

Who we are
The ERG consists of senior experts in global health working with WHO, GAVI, World Bank, BMGF,
and UNICEF; academics in critical topics such as metrics, gender, and health systems development; and
senior leaders from the ministries of health in Indonesia, Ethiopia and Tanzania. Together they work to
ensure that diverse perspectives are shared to identify the best way forward.
What we do
The ERG has identified four priorities of work: urban poor areas, remote rural areas, children affected by
conflict, and gender-related inequities and barriers to immunization. The ERG has also begun exploring
innovative ways to measure and track immunization equity, drawing on successful approaches from such
areas as human rights, behavioral economics, and social policies. The group is working to provide
actionable recommendations for decision makers at the national and global levels and aims to test
innovative approaches through implementation research.
For this work, the ERG, with support from PATH, conducted a literature review and 110 individual
expert interviews (Annex 1. Acknowledgments) to comprehend challenges to reaching equitable
immunization coverage, and to identify the change agents and interventions with the potential to address
those challenges. The Group employed snowball sampling of respondents from three strata: (1) global-
level health stakeholders; (2) country-level health stakeholders; and (3) non-health stakeholders. After
applying a conceptual matrix to synthesize and analyses the interview responses, thematic analysis
identified clusters of interventions. The conceptual clusters were stratified by respondent type to assess
uniformity and variation across respondent groups. The case studies in Annex 2 highlight the specific
challenges of select countries and the recommended approaches to address them.
PATH is a global organization that works to accelerate health equity by bringing together public
institutions, businesses, social enterprises, and investors to solve the world’s most pressing health
challenges. With expertise in science, health, economics, technology, advocacy, and dozens of other
specialties, PATH develops and scales solutions—including vaccines, drugs, devices, diagnostics, and
innovative approaches to strengthening health systems worldwide.

ii
 Gender Conflict Urban Remote rural

This paper is part of a series produced by the Equity Reference Group for Immunization (ERG). The
series focuses on defining key challenges in equitable immunization coverage and highlighting actionable
recommendations that can help countries reach 100 percent coverage for routine immunizations.
This is a working document. It intends to facilitate the exchange of knowledge and to stimulate
discussion. The text has not been edited to official publication standards.
The findings, interpretations, and conclusions expressed in this paper are those of the authors and do not
necessarily reflect the policies or views of the organizations of the ERG members.
The designations in this publication do not imply an opinion on legal status of any country or territory, or
of its authorities, or the delimitation of frontiers.
The authors would like to acknowledge the many people who contributed time and expertise to support
the development of this working paper. Annex 1 includes a complete list of these individuals.
For more information, contact Alyssa Sharkey (asharkey@unicef.org).

Note: Icons used throughout this paper were sourced from the Noun Project.

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Contents
Abbreviations ................................................................................................................................................ v
Executive summary ...................................................................................................................................... vi
Understanding urban contexts....................................................................................................................... 1
Defining the problem and opportunity for impact .................................................................................. 2
What we know today .................................................................................................................................... 7
Gaps in our knowledge ........................................................................................................................... 7
Promising novel approaches ......................................................................................................................... 9
Collecting timely and actionable data .................................................................................................. 11
Increasing community engagement ...................................................................................................... 13
Motivating health workers.................................................................................................................... 15
Offering flexibility in services.............................................................................................................. 16
Building partnerships for greater impact .............................................................................................. 17
A framework for action ............................................................................................................................... 19
Recommendations of the Equity Reference Group for Immunization ........................................................ 20
Annex 1. Acknowledgments ....................................................................................................................... 23
Annex 2. Country case studies .................................................................................................................... 24
Annex 3. Intersections of inequity with gender .......................................................................................... 29
Annex 4. Summary of Urban Immunization Working Group toolkit recommendations............................ 31
Annex 5. References ................................................................................................................................... 32

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Abbreviations
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
CHW community health worker
EIR electronic immunization registry
EPI Expanded Program on Immunization
ERG Equity Reference Group for Immunization
ID identification, identifier
IFRC International Federation of Red Cross and Red Crescent Societies
I-POINTS Indonesia Pediatric Online Immunization Reporting System
LINKAGES Linkages across the Continuum of HIV Services for Key Populations Affected by HIV
NUHM National Urban Health Mission
PAHO Pan American Health Organization
PPIA Private Provider Interface Agency
RED Reaching Every District
SMS short message service
TB tuberculosis
UHRC Urban Health Resource Centre
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization

v
Executive summary
By 2050, 68 percent of the world’s population is expected to live in an urban area. The risk of disease
transmission and outbreak increases in large (and growing), densely populated areas with mobile and
transient populations. We, the global health community, must get ahead of this massive demographic shift
towards urbanization, which requires focus on how to provide equitable services—such as
immunization—to an increasingly dense, diverse, and dynamic urban population. Whilst average
immunization coverage is typically higher in urban areas than rural areas in most countries, deep
inequities in immunization coverage in urban areas are present—in most cases affecting the urban poor.
In some countries, more than half of unimmunized children live in urban areas.
To achieve universal health coverage and ensure all people can get the health care they need, we must
address inequities in urban health systems. Seven key challenges must be addressed:
1. A lack of accurate, disaggregated data creates difficulty in identifying and tracking populations.
2. Cultural differences and discrimination create social distance and disenfranchised communities and
lead to a mistrust of the health system and influence health care–seeking behavior.
3. Quality of services and a lack of information impact access to immunization services, especially
for low-income, working caregivers.
4. A lack of political will to prioritize immunization services for disenfranchised communities.
5. Residents of informal settlements may fear encountering public authorities, and authorities may be
less interested in investing in residents of informal settlements.
6. Multiple stakeholders and a lack of effective partnerships, particularly with private-sector providers,
reduce the ability to improve immunization equity.
7. Insecurity and violent crime restrict access to public services, especially in slums.
The Equity Reference Group for Immunization (ERG) believes that we must try new approaches and
leverage new technologies to make a difference. This paper focuses on community-level policies and
practices that can be employed today, whilst acknowledging that these practices will be impacted by
global and national policies, governance, and financing. The authors have landscaped approaches from
within and beyond immunization and health sectors to learn what others have tried in addressing similar
challenges, with a focus on what will have the most impact at the community level. We need to be
flexible in our implementation—experimenting, iterating on successes, and moving quickly to try new
approaches.
The ERG proposes the following recommendations for immunization program managers and their
partners (including ERG members themselves) to act upon:
• Strengthen community engagement.
• Scale up and provide support for peer networks for health workers.
• Adjust timing of immunization services for caregiver convenience.
• Implement a unique identifier system for patient identification.
• Institute ‘opt-out’ immunization policies.
• Identify missed opportunities.

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• Continue implementation and scale-up of electronic immunization registries, dashboards, and
visualizations.
• Increase coordination with private providers and employers to identify and vaccinate more children in
urban areas.
• Integrate novel data sources and advanced analytics into routine reporting and proactive targeting of
services.
• Improve security for caregivers and health workers to reach communities in insecure areas.
The novel approaches and recommendations here represent some of the most promising of the global
efforts currently underway. Not all approaches will work in all settings—in fact, one of the major
recommendations is an improved tailoring of approaches to context. The recommendations here are
intended to spur innovation and to challenge us to break from the status quo.

vii
Understanding urban contexts
Today, we face the greatest distribution of people in cities in our history. 1 Driven by economic
opportunity or displacement from humanitarian crises, 55 percent of the world’s population lives in urban
areas and this number is projected to rise to 2 68 percent by 2050 (Figure 1). 3 The United Nations
estimates this trend will add 2.5 billion people to urban areas—with the majority (90 percent) in Asia and
Africa. 4 Many of the world’s fastest growing megacities, such as Delhi, Dhaka, Karachi, and Lagos, are
in low- or middle-income countries, where inequities can be stark. The rapid growth of urban areas also
likely spurs an increase in the number of residents of slums and informal settlements. Today, it is
estimated that more than 300 million children live in slums. 5

Figure 1. Urban and rural populations of the world, 1950–2050.

Source: United Nations, Department of Economic and Social Affairs, Population Division. World Immunization Prospects:
The 2014 Revision. New York, NY, USA: United Nations; 2014.

Rapid urbanization over the next 50 years will

dramatically increase the burden on health What do we mean by “urban”? Urban areas are
services in urban settings. The ongoing massive different in each context, but typical characteristics
demographic shift requires consideration on of urban areas include:
how to provide equitable services—such as • High population density. a
immunization—to an increasingly large, • Perceived higher standard of living. 6
diverse, and dynamic urban population. Whilst • High mobility.
the average immunization coverage in most • Choice of health services.
countries is typically higher in urban areas than • Greater risk of disease spreading. 7,8,9,10,11,12
rural, deep inequities in immunization coverage • Uneven distribution of wealth and services.
in urban areas are present. Economic status is a
key determinant of immunization status, with significantly lower coverage amongst the poor (Figure 2).
In many countries, the disparities between the richest and poorest urban residents are growing. 13
Additionally, not all unimmunized children live in slums; more than half (59 percent) live in non-slum
areas dispersed throughout a city. 14

a. The Organisation for Economic Co-operation and Development (OECD) defines an urban area as a minimum of 50,000 people
and a contiguous population density of at least 1,000 people per square kilometre.

1
Unimmunized residents of urban areas tend to have migrated to the urban area more recently; have fewer
ties to traditional institutions; be more mobile; and may be financially, socially, or otherwise
disadvantaged. 15 They may also settle in new areas that are not officially recognized—or explicitly
illegal—and are therefore not included in service delivery plans and implementation. Evidence supports
the disproportionate urban migration of men in sub-Saharan Africa and South Asia and the subsequent
under-representation of women in urban areas. b,16,17 However, there is also evidence from sub-Saharan
Africa of the “feminization” of rural to urban migration in some settings. 18,19 Promoting community
participation to understand the challenges of accessing immunization services and design more
appropriate services is key to improving immunization coverage and equity in urban areas. Investing in
these underserved communities recognizes a human right to health and contributes to successful universal
health coverage efforts.

Figure 2. Diphtheria-tetanus-pertussis vaccine third dose coverage amongst urban poorest versus richest (%).

100 Q1 (urban poorest) Q5 (urban richest)

90
80
70
60
50
40
30
20
10
0
Nigeria India Pakistan Indonesia Ethiopia DRC Iraq Angola Brazil South
(2013) (2005) (2012) (2012) (2011) (2013) (2011) (2015) (1996) Africa
(1998)

Source: Global health observatory data website. http://apps.who.int/gho/data/view.main.v100210?lang=en. Accessed August 29, 2018.

Defining the problem and opportunity for impact

The Equity Reference Group for Immunization (ERG) identified seven primary challenges to attaining
equitable immunization outcomes in urban settings:
1. Accurate, disaggregated data. A lack of appropriate data makes it difficult to identify and track
populations.
2. Disenfranchised communities. Cultural differences and discrimination lead to mistrust of the health
system and influence health care–seeking behavior.
3. Quality of services and information. Service hours, wait times, and a lack of information impact
access to immunization services, especially for low-income, working caregivers.
4. Political will. Municipalities and local authorities face many issues and may not prioritize
immunization, especially for communities with little political representation.

b. Gender-related barriers in mothers’ access to child vaccination services intersect directly with many other factors leading to
immunization inequities. Please see Annex 3 for further detail.

2
5. Informal settlements. Residents of informal settlements may fear encountering public authorities,
and authorities may not invest in informal settlements.
6. Multiple stakeholders. Few effective partnerships, especially with private providers, reduces the
ability to improve immunization equity.
7. Insecurity. Violent crime restricts access to public
services, especially in slums.
Accurate, disaggregated data
The identification of 100 percent of caregivers c and
unimmunized children is difficult in crowded and highly
mobile areas. Data systems to measure and track
immunization coverage and needs are limited, and data
from private providers are not always captured in routine
data systems.
Accurate, disaggregated data—starting with birth
registries—are often unavailable, making it difficult to
understand the population that has not been immunized. In
sub-Saharan Africa, for example, only 43 percent of births
are registered. 21 Tools to accurately estimate and locate
unimmunized communities are particularly important in
relation to the previous point, as many children in low-
resource settings do not encounter the health system at all
before age five.
The presence of seasonal migrants, 22 and evidence that
transient groups utilize fewer health services, further
complicates identification. 23 Catchment areas and accurate
denominators or targets can be difficult to clearly measure.
Higher average rates of immunization in urban settings and
quickly changing denominators (commonly leading to
coverage rates exceeding 100 percent) reduce the political
urgency to identify unimmunized communities.
Disenfranchised communities
Whilst urban populations may not be physically far from
services, discrimination or stigma may decrease their
motivation to seek out those services. A caregiver’s sex,
socioeconomic status, education, ethnicity, and migrant
status15,24,25 can create a social distance d within the
c. In most cases, caregivers are mothers or female caretakers. We use caregivers to also include fathers and male caretakers,
whilst recognizing that many caregivers face gender-related challenges to accessing immunization.
d. Social distance is the degree of social acceptance or rejection of an individual (or group) and their community, typically in
relation to socioeconomic status, race, ethnicity, sex, or sexual identity.
3
Improving data to track vaccination equity
To measure countries’ progress, data collection
must continuously improve. Generally,
vaccination equity is tracked through surveys,
such as Demographic and Health Surveys and
Multiple Indicator Cluster Surveys, and through
routinely collected administrative data. Cesar
Victora and Tove Ryman have completed a
thorough review of potential data
improvements. 20
Regular surveys are necessary for governments
to monitor and react to trends. More frequent
surveys and over-sampling vulnerable
populations in urban areas ensures recognition
of these groups. Surveys should also collect and
report disaggregated data on all equity
variables: income, sex, geography, and ethnic
group.
Administrative data are less widely available
and less standardized across countries. The
emphasis for administrative data should be on
creating feedback loops, with data reporting
taking a user-centered approach—especially in
urban areas, where faster response times are
possible and necessary. Collection of
disaggregated data on equity dimensions may
also be possible through electronic
immunization registries, though more research
is necessary on feasibility and use.
Good data systems remain the best way to
identify vaccination inequities and require
consistent support and maintenance. High-
quality data should be a focus for countries
seeking to further reduce vaccination inequity.
community and influence demand for immunization. e Cultural norms and language may further isolate
and marginalize caregivers experiencing social distance, as services are typically designed for the
majority population.22 Even caregivers who migrate within the same country may experience social
distance from linguistic and cultural differences. One study in Pakistan found that membership in a
marginalized ethnic group reduced the likelihood that a child would be immunized, especially when
ethnicity was partnered with an insecure residential status. 26
Recent migrants typically have lower coverage than migrants who have resided in the new location for
more than a year. 27 One contributing factor may be the loss of social networks. Caregivers who recently
resettled may lack social networks that would spur conversations on child health. Building new social
networks can take time. In addition, migrant women may lack health literacy if they do not understand
local signage due to language barriers.
Caregivers of unimmunized children in urban areas are typically poor women.b Impoverished caregivers
feel marginalized because of shame, humiliation, and perceptions of inadequacy as a caregiver. 28,29
Addressing patient abuse and disrespect can improve health care–seeking behaviors, especially for
marginalized and low-income communities. 30 Beliefs such as a fear of side effects, distrust of the
government, and suspicion of free services also affect demand for immunization.15,31
Lastly, provision of immunization services often focuses on supply issues and interventions. Interaction
with communities and participatory design are essential for increasing demand.

Quality of services and information

If caregivers overcome the previous two challenges, they likely
face the hurdle of the lack of consumer-friendly health services. Time poverty: Women’s
Taking time off from work during traditional facility operating responsibility for work required for
hours may be difficult or impossible.22 Caregivers of the maintenance of the
unimmunized children may be juggling multiple jobs and household, the care of children
working long hours far from their residence. In many urban and the sick, and livelihood
settings, wait times at health clinics may be hours, making it
activities pose heavier demands
even harder to take time off from work when employment is
on their time and may leave them
unstable or inflexible.23 When faced with inconvenient locations
with little time and opportunity for
and hours and long wait times, mothers prioritize their activities
out of necessity due to time poverty.b This may lead some seeking health care services for
caregivers to not seek or demand care. themselves or their family.

A lack of high-quality, integrated services further reduces

mothers’ ability to seek care in a time-efficient manner. Language differences may be a barrier for women
who migrate to urban areas where services are offered in a different local language. Caregivers are
discerning consumers of health services and will travel farther and pay more to health workers deemed
high quality and effective—often private providers.

e. It is important to consider intersectionality, as these factors do not exist independently. Intersectionality is a framework to
identify how multiple systems of power impact marginalized people, and recognizes that forms of social stratification (e.g.,
socioeconomic status, race, ethnicity, age, gender) do not exist independently, but rather are interwoven together.

4
Political will and governance
A lack of political will amongst government leaders to recognize the dire needs of unserved communities
leads to a failure to allocate resources to meet those needs. In many cases, disenfranchised communities
and undocumented migrants are not represented in government and local authorities are more inclined to
served affluent populations. Even if political will exists, adequate resources may be absent. The human
and infrastructure resources needed to provide immunization services may be financially prohibitive. For
example, the price of land, labor, and building supplies may limit construction of new health facilities in
informal settlements.

Informal settlements
Whilst informal settlements and slums f provide the first place of residence for many people migrating to a
city, living in these legally ambiguous informal settlements offers limited tenure security and access to
services. 32 Some governments have created policies to control rural-to-urban migration by regulating
access to government services through systems of civil registration. For example, China provides health
care to individuals based on where they are registered to live; if a family migrates out of their “registered”
rural community, they are unable to obtain government-provided health care in their new urban
community. Such policies may decrease migration, but they also add barriers to immunization for the
children accompanying their parents to urban communities. In addition, these government practices result
in agglomerations of unregistered and uncounted populations, which either are not accessing services or
not being included within population denominators. 33
Residents in informal settlements may fear identification and prosecution through the sharing of health
facility records with a public health department that is restricting or persecuting undocumented residents.
Public administrators may lack adequate information and resources to address rapidly expanding informal
settlements. They may also have a policy that discourages informal settlements by not providing health
services to them, and therefore excluding those communities from service delivery.

Multiple stakeholders
To ensure equity and reach the unreached, the immunization community needs to reach beyond traditional
partners to private providers, employers, and community associations. Patients may never come into
contact with the public health sector, challenging immunization program managers’ efforts to track and
ensure immunization coverage with high-quality services. Urban residents are more likely than rural
residents to seek care from a private provider.34 In one study from Ouagadougou, Burkina Faso,
20.5 percent of residents who sought a formal provider for a severe condition chose a for-profit
provider. 35
This is especially important in urban areas, where caregivers may interact with and obtain non-health
services from many nongovernmental and private-sector organisations on a daily basis. A lack of
coordination between these organisations reduces opportunities for data and information sharing, policy
alignment, and convenient services for caregivers of unimmunized children.

f
The United Nations Educational Scientific and Cultural Organization defines a slum as “a contiguous settlement where the
inhabitants are characterized as having inadequate housing and basic services.”

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Insecurity
Insecurity in slums is an increasing challenge for marginalized communities accessing health services—
especially in Latin America. This challenge is well documented, with gang violence directed at women
and young girls in Honduras and its impact on their ability to seek education. 36 Presumably, this violence
also affects caregivers’ ability to seek care for children. Additionally, health workers are concerned about
working in some communities that experience territorial control by gangs or criminal groups. Incidents of
violence against health workers has been recorded. 37 This is especially important to consider, as
caregivers may feel more comfortable receiving services from a female health worker. Safety is a noted
concern for female health workers in informal urban settlements in Bangladesh and Kenya. One health
worker in Kenya even reported incidents of rape. 38 Vandalism and theft of equipment further deters
establishment of robust health programs in slums where resources are limited.

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What we know today
Since immunization coverage in urban areas is assumed higher than in rural areas, programs to improve
coverage and equity typically focus on reaching rural populations through Reaching Every District
(RED) 39 and Reaching Every Child strategies. This changed when the World Health Organization (WHO)
Regional Office for Africa placed a focus on urban, poor, and marginalized populations as one of the five
important considerations for immunization programs in the 2017 revision of the RED guide. 40 The
increasing rate of urbanization requires a renewed focused on improving urban immunization equity by
addressing the context’s unique challenges.
The Urban Immunization Working Group started in 2017 with the goal of generating evidence and
guidance on the challenges experienced in urban areas to inform programmatic changes. In 2018, the
Working Group published a toolkit—based on the five components of RED—as a complement to already
available guides and handbooks, including WHO’s Urban Heart. 41 The toolkit is one of the most
comprehensive resources for immunization services specific for urban contexts and provides information
on both proven interventions and unproven innovations (see Annex 4 for a summary). Some simple
interventions that have been proven to improve immunization equity include addressing missed
opportunities during antenatal care, curative services, and school; adjusting facility hours to be more
convenient for caregivers; and reframing services to be ‘opt-out.’
Whilst the evidence of RED points to success in improving the delivery of routine immunization services,
the impact of RED on immunization service uptake and immunization coverage has not been evaluated.
There is evidence that points to the potential impact of the RED components individually, but there is no
conclusive evidence on the entire suite of RED services. Novel interventions may strengthen and extend
the implementation of RED components in urban settings.

Gaps in our knowledge

Whilst the Working Group’s toolkit contains a comprehensive set of approaches to address most issues in
urban immunization (see Annex 4), several key gaps exist:
• Accurate, timely, granular data regarding demographic shifts (new residents, new births).
• Collection, timeliness, and reporting of data on variables that identify differences in population health
over time to help policymakers understand the impact of programs and policies. g,h,22,42
• Evidence of what other services are reaching or are sought out by the communities with low
immunization coverage.
• Novel methods to collect data using social media and cell phones, and strategies to use big data in a
cash economy.
• Fast, low-cost, and tested solutions that empower marginalized populations and democratize access to
services.
• Effective policies and approaches to advocate for and enable the provision of health services
regardless of legal status.

g. When collected, these variable types are often not comparable or are collected through disparate data systems.
h. See box on page 3: “Improving data to track vaccination equity.”

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• Knowledge about care-seeking behaviors of missed populations.
• Methods to implement more flexibly designed services and times for services to reach underserved
populations.
• Interventions designed specifically for new migrants. 43
• Effective policies and approaches for mitigating insecurity so that health workers can reach
vulnerable populations.
• Demonstrated private-sector partnership models to improve immunization coverage and equity.

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Promising novel approaches
The ERG investigated novel interventions or approaches, particularly from outside the immunization
sector, that could address these challenges to achieving equity. We focus our work on community-level
policies and practices that can be implemented today, though we acknowledge that national policy,
governance, and financing influences the power communities hold. As a result, the implementation of
these practices and the ability of communities to act will be impacted and shaped by higher-level policies,
governance, and financing. Table 1 maps the alignment of intervention themes and vaccine delivery
challenges. This section identifies multiple potential interventions; the ERG’s recommendations follow
(ideas are categorized as needing to be further strengthened or explored).

indicates ideas that have been tried and need to be further strengthened.
indicates ideas that are new and novel and should be explored further.

Novel approaches also require dedicated implementing individuals—or change agents—to succeed. These
change agents are the persons who make decisions or act to immunize children. The following section
highlights the key change agents necessary to mobilize around these interventions and achieve
immunization equity. Many of the novel approaches presented are also relevant for rural/remote and
conflict settings.

9
Table 1. Alignment between intervention themes and vaccine delivery challenges.

Quality of services and

Disenfranchised information: Service Political will. Informal settlements:
communities: Cultural hours, wait times, and a Municipalities and local Residents of informal Multiple Insecurity:
Accurate, differences and lack of information authorities face many settlements may fear stakeholders: Few Violent crime
disaggregated data: discrimination lead to impact access to issues and may not encountering public effective partnerships, restricts access
Lack of appropriate a mistrust of the health immunization services, prioritize immunization, authorities, and especially with private to public
data creates difficulty system and influence especially for low- especially for authorities may be less providers, reduces the services,
in identifying and health care–seeking income, working communities with little invested in residents of ability to improve especially in
Intervention tracking populations. behavior. caregivers. political representation. illegal settlements. immunization equity. slums.
Collecting Allows improved Demonstrates the
timely and data and targeting of urgency and unmet
actionable eligible children. need.
data…
Increasing Develops a potential Increases demand and Improves uptake of Improves political Improves relationships Facilitates Creates the
community opportunity for facilitates easier current approaches. representation and with government and development of new potential for
engagement… community-based access. empathy. service providers. community-supported community
monitoring. partnerships. ownership of
safety and
developing
creative
solutions.
Motivating Encourages workers to Encourages health Facilitates
health workers… build relationships to workers to provide high- access in
reduce stigma and quality services and insecure areas
improve trust. understand community and increases
concerns. confidence of
workers to
deliver services.
Offering Shows recognition of Provides options for Offers opportunities Offers caregivers more
flexibility in and sensitivity to accessible services that for residents to options to seek
services… community needs. meet caregivers’ needs. independently seek immunization services.
services—increasing
acceptance.
Building Provides more Allows flexible design Harnesses resources for Facilitates sustainable Develops more Addresses
partnerships for sources of data to and service options. a common cause. approaches to address partnerships to reach insecurity from
greater impact… identify and track new residents. previously unreachable a systemic level
eligible children. populations. to reduce the
burden on the
health system.

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Collecting timely and actionable data
Global-level health workers
highlighted interventions for timely
and actionable data. Current
administrative data and survey
practices do not allow health workers
to adequately track targets and
prioritize services. Administrative data
can be supplemented with other data
sources to equip immunization
program managers with a more
detailed and nuanced picture and
understanding against which to target
resources.
Telecommunication data
At a population level,
telecommunication data can augment
administrative and survey data to provide insight into current population density. 48 The amount of
telecommunication data generated in an urban setting makes this particularly applicable when compared
to other contexts.
Machine learning and artificial intelligence
Big data techniques—such as machine
learning and artificial intelligence—
provide the opportunity to use
predictive algorithms and recurrent
neural networks to identify populations
at risk of being unimmunized and
improve automation of services. Over
time, these algorithms can forecast a
population’s or individual’s risk of a
lapse in coverage due to various
drivers and anticipated trends. The
density of data and diversity of data
sources in urban settings create an
opportunity for these new methods.
Satellite imagery and geographic
information system mapping
Satellite imagery or imagery from
unmanned aerial vehicles or drones
along with geographic information system mapping produce timely estimates of population and
TELECOMMUNICATION DATA
Telecommunication data can identify geographic areas with
new migrants and at-risk population groups.
Telecommunication data accurately estimate the
socioeconomic status of small areas when triangulated with
a small linked survey. 44 This can enable the estimation of an
accurate denominator and population demographics with
limited effort. Just a small segment of anonymized data
collected by mobile phone operators is necessary to produce
accurate population distribution maps. 45 Another study
demonstrated the ability of mobile phone records to detect
internal migration patterns in Rwanda, including circular and
temporary migration. 46 One challenge is aligning incentives
and reaching agreement with the telecommunication
company to access the data. 47
MACHINE LEARNING
As more data are collected and aggregated about people
and the areas where they live, associations previously
hidden quickly become commonplace using deep learning.
New methods and improved computing power predict the
number of unimmunized people residing in a certain area by
assessing the area’s physical characteristics available
through satellite imagery or Google Maps. A recent study
assessed the association between the built environment and
obesity prevalence within a census tract across many cities
in the United States. 49
In another example, macro-eyes is piloting machine learning
techniques to forecast demand and recommend vaccine
delivery to immunization sites in Tanzania. Data collected
from two test sites will train and test algorithms to identify
predictive patterns, with the aim of reducing waste and
maximizing coverage. 50
11
demographic characteristics within a catchment area. Detailed maps in the hands of local health workers
can make existing programs more effective. A recent study in Indonesia and the Philippines demonstrated
health workers’ ability to map disease patterns reliably. 51 OpenStreetMap is one platform used by
organizations such as the Humanitarian OpenStreetMap Team to support health initiatives.

Promoting data use

Whilst new sources of data extend the ability to Figure 3. Example of a Visualize No Malaria dashboard.
estimate population, collecting new data is not
worthwhile unless the data are used and
actionable. User-friendly dashboards and
visualizations are necessary to inform the work
of health workers at all levels of the health
system. Visualize No Malaria has developed and
deployed interactive dashboards that allow
health workers and supervisors to access reliable
data and make informed decisions. For example,
one dashboard for use by district-level
supervisors, health system administrators, and
national policymakers provides a risk overview
at the level of facility and health clinic (Figure 3). Dashboards tied to alerts provide direct feedback to
health workers, reminding them to follow up on issues of data quality or investigate a specific case of
malaria if it appears transmission is rising. In urban settings, proximity of caregivers to facilities and a
wealth of information spurs action based on nearly real-time data. In another example, the city of Bogotá,
Colombia has used an online information system since 2005, which monitors new residents and has led to
an increase in immunization coverage. 52

Unique identifiers and electronic immunization registries

The identification of pregnant women and the capture of key socio-demographic data during antenatal
care allows the health system to assign a unique identifier (ID) to each child. i The ID2020 Alliance is
one group working to support and scale up the use of digital identities. A unique ID enables accurate
lifetime tracking of the child through an electronic immunization registry (EIR). EIRs provide more
efficient, accurate, and timely data and insights to patients about their immunization status. However,
registries are limited in their ability to address equity because children who have never been to the facility
will never be in the system, and therefore not highlighted as missed/defaulting.
New technologies provide opportunities to improve unique IDs with enhanced privacy and easier tracking
across facilities. Biometric tools create unique, secure IDs and blockchainj improves data security by
storing information in anonymized ledgers. Aadhar is one example of a biometric-linked ID available to
residents of India. Blockchain is particularly of interest for refugee populations, who often lack official
identification or institutional affiliation.53 As mobile phones become ubiquitous, short message service

i. A unique ID could be used across sectors (e.g., birth registries, education system, food distribution) and enable access to
services of interest for caregivers. As an example of impact, this would easily allow schools to check for vaccination status upon
entry.
j. Blockchain is a digital decentralized public ledger of transactions.

12
(SMS, or text) reminders of vaccination due dates, such as mTika, 54 combined with EIRs, result in
improved outcomes. 55,56

Increasing community engagement

Community engagement is critical for demand generation and to improve quality of services. In addition
to quantitative data, a common theme presented by interviewees was the need for more qualitative data.
Unimmunized people may not seek appropriate, accessible, or affordable health services even when
identified, in part because of mistrust of the system or discrimination. Behavior change interventions and
strengthening of social networks in urban areas are effective in promoting care-seeking. k
The increasing prevalence of mobile phones, Internet access, and social media provide opportunity for
community engagement in urban areas. 57 However, it should be noted that over-reliance on these
technologies can widen inequity based on gender, as women own mobile phones at a lower rate than
men. 58

Qualitative information
Qualitative information gained through focus groups or surveys provides insight into where and when
people seek immunization services and the challenges they face in accessing those services. This insight
is essential to making health centers more welcoming and effective (e.g., improved lighting and better
signage). One strategy undertaken in urban development of slums is to encourage local community
members—sometimes even children—to draw on a map the services needed by the community.
Community organizations, such as SDI (formerly Shack/Slum Dwellers International), work to surface
community issues and requirements and can be valuable partners in providing better services.

Incentives
In addition to improving services, more tools are needed for demand generation to ensure caregivers
return for services. Incentives were a common method identified to increase demand. Some possible
incentives include a transit pass to support travel to a health facility, or free mobile phone airtime—in
addition to traditional incentive structures like conditional cash transfers, vouchers, or free meals. Bolsa
Família in Brazil and maternity packages (also known as “baby boxes”) in Finland are examples of
effective incentive programs. 59,60 Incentives could also be used to identify unimmunized children or
provide a bonus to caregivers for fully immunizing children. Monetary incentives can be costly to sustain
and can cause unintended negative consequences.61,62 Further research and testing of effective
nonmonetary incentives could have significant impact in immunization services.

Easily accessible information and media campaigns

Lack of information about the location and time of immunization is a challenge for caregivers.
MomConnect, a program provided by the South African Department of Health, provides a mechanism to
electronically register pregnancies, send health promotion messages, and provide pregnant women with a
feedback mechanism on services received. A similar program could be developed for immunization, with

k. For more information on behavior change interventions for caregivers and health workers, see: Chopra M, Weis J. Closing
equity gaps in immunization: Relevance of human rights-based and behavioral economics approaches. New York, NY, USA:
Equity Reference Group for Immunization; 2018.

13
the added benefit of improving health literacy, or vaccine messages could be integrated into programs that
are already reaching caregivers. Media campaigns that include community voices were suggested as
methods to address hesitancy and misinformation and encourage behavior change to increase demand.
Traditional routes (e.g., radio, television) or new formats like community-produced resources (e.g.,
Digital Green) and social media make for effective campaigns. Peers are powerful advocates to address
vaccine hesitancy and mistrust and improve health literacy. Communication campaigns and resources
should target both mothers and fathers to build awareness on behaviors related to early childhood
development. Whilst applicable to many contexts, easily accessible information is especially important
for urban settings with many choices for caregivers. However, some studies note that information is not
enough in informal settlements. Unless the caregiver has internalized the information on immunization
through robust discussion, often reinforced by social networks, health care–seeking behavior is unlikely
to change. 63

Feedback mechanisms
Interviewees noted that an essential precursor of
improving equity is listening to the community and LINKAGES – SMS SERVICE QUALITY
empowering them to hold health providers
MONITORING SYSTEM (SMS2)
accountable for quality of services. Often caregivers,
especially those who face discrimination, do not An SMS-based feedback system was developed
have a channel for complaints or suggestions for to monitor the quality of health services
improvement. Caregivers who are more educated provided to key populations impacted by
and those of a higher socioeconomic status have stigma and discrimination (e.g., men who have
greater power to lodge complaints, and often have sex with men, people who inject drugs, sex
the choice of facility for service, whereas caregivers workers, and transgender people) as part of
who face discrimination may cease seeking health the LINKAGES project funded by the United
services if their complaints go unanswered. One States Agency for International Development in
survey suggestion was to develop an SMS-based Burundi, Côte d’Ivoire, Haiti, and Malawi in
anonymous feedback system on the quality of health 2017. 64 The system sends text messages to
services for patients and caregivers to report patients after health services and asks them
unsatisfactory services, like the one developed for about satisfaction levels with the care
the LINKAGES (Linkages across the Continuum of received. Health workers also receive SMS
HIV Services for Key Populations Affected by HIV) surveys to assess their own performance and
project. This type of mechanism is especially the performance of the facility in which they
important for urban settings, where caregivers are work.
more likely to feel social distance and
discrimination.
Community forums increase community monitoring and advocacy for health systems quality. Through
collective action, communities can hold health systems accountable for service delivery, improving
engagement and quality. Providing communities with consistent, timely, and reliable services that meet
their stated needs proves to citizens that health systems are honoring the social contract and motivates use
of health services. For example, Advocacy for Better Health in Uganda organizes forums between citizens
and duty-bearers where citizens dialogue with policymakers on needed changes. Uganda also has Health
Unit Management Committees, which are comprised of citizens and health system representatives and
help monitor and elevate quality concerns about health facilities. In Pakistan, polio campaigns have
organized forums for discussion with female doctors, religious figures, female vaccinators, and women

14
who have recently vaccinated their children. These
forums allow women to receive answers to their
questions from trusted community sources and alleviate
fears about vaccination.
Motivating health workers
Country stakeholders identified motivating health
workers as a key intervention. Whilst health workers are
the frontline change agents, they often experience poor
working conditions and limited resources that hinder
motivation and retention. The most commonly cited
interventions for motivating health workers were
incentives (monetary and nonmonetary) and improved
peer networks to promote the role of community health
workers (CHWs) as change agents. Another intervention
is to provide a smartphone application, such as the
Community Health Toolkit, which integrates data
collection and standard process instructions. 65 Lastly,
providing security for health workers whilst visiting
slums was a suggestion unique to informal settlements.
One example is to enlist help from local emergency
services.52 An alternative is to establish mobile
immunization clinics near areas deemed too insecure for
a facility to operate.
Incentives for health workers
Whilst there are many types of incentives for health
workers, reliable salary payments for CHWs, who are
often volunteers, and recognition for all types of health
workers were most commonly identified as the most
effective incentives for health workers; both have strong
support in the literature. 66 Paying CHWs should be
examined through a gender lens in order to understand
the implications of payment on recruiting women, and
potential impact on women’s financial status. Coupons
for health workers who meet coverage targets,
gamification of performance metrics, and nice
uniforms are also potential nonmonetary incentives.
One suggestion is to increase recognition of health
workers by engaging them in the testing and
implementation of program changes through quality
improvement teams. This model results in greater
ownership of the process, empowers staff to make
further changes, and enables task-shifting from over-
15
CHANGE AGENTS
To tackle immunization inequity in urban
contexts, important known change agents
include the following.
• Mothers/caregivers are, of course, the
ultimate change agents. No one knows
better the barriers to getting children
vaccinated.
• Community health workers, who are, in
many countries, the first point of
contact with the health system.
• National policymakers who develop
rules and guidelines that prioritize the
needs of disadvantaged populations in
urban areas.
• Traditional practitioners, including
healers and midwives, can help identify
missed opportunities.
• Private providers, including
pharmacists, service significant portions
of urban populations, including the
poorest.
• Civil society and community
organizations that already have
established outreach and trust with
underserved communities, including
migrant community leaders.
• Civic groups and religious organisations
provide channels of communication and
influence to reach marginalised
populations.
Potential non-traditional change agents
identified in urban settings:
• Employers offer a vital connection to
working caregivers.
• Teachers and school-aged children can
help identify younger siblings who may
be unimmunized.
• Transit companies can be a source of
information and behaviour change
communication (e.g., bus plaques, signs
at waiting areas).
burdened nurses to lower-level workers—allowing those workers to feel more useful and gain new
skills. 67
In Brazil, CHWs are valued members of a family health team, which also includes nurses and physicians.
CHWs provide important contributions to monthly team meetings, as CHWs meet regularly with each
family in their assigned district. Pay and benefits for CHWs are set locally and turnover is low. The
CHWs are respected as a stable and enduring presence in the community, and their social standing has
been noted to protect them from violence. 68

Virtual community of practice

In addition to incentives and supportive supervision, ideas to improve motivation included developing a
virtual community of practice through social media or SMS. For example, health workers in Tanzania
established a WhatsApp peer support group as part of the Better Immunization Data Initiative. As an
example of impact, this resource enabled the group to communicate about an excess of syringes for use
with bacillus Calmette-Guérin vaccine (for tuberculosis [TB]) at one facility to avoid a potential stockout
at another facility. 69 The high density of health workers in urban settings could make this particularly
productive.

Offering flexibility in services

An emergent theme from interviewees was the necessity of flexible service offerings in urban areas.
Whilst immunization services are available in urban areas, they may be incompatible with the needs of
urban caregivers. With greater choice and demanding schedules, caregivers in an urban setting demand
flexibility.

Flexible services
To accommodate the time and resource constraints urban caregivers face, service delivery must be
flexible and leverage alternative delivery mechanisms (e.g., vaccine centers at markets, extended
facility hours). This flexibility is essential to improving access to vaccine services.

Integrated services
In many places, immunization is handled separately from primary care and regular visits. More
integration of immunization and other health services would allow health workers to address missed
opportunities during antenatal care and curative services. Caregivers may also feel more satisfied with a
holistic approach. For example, the Urban Health Resource Centre (UHRC) in India is a nonprofit
organization “that works towards socio-economic empowerment, improving quality of life, health,
nutrition, wellbeing and empowered social organizations amongst disadvantaged urban populations.” 70
The UHRC illustrates the effectiveness of a holistic community-based approach. In part to build demand
for immunization, the UHRC supports the creation of women’s groups and offers them training sessions
not only on health issues but also on how to advocate for solutions to everyday challenges (e.g., lack of
safe water). 71 In addition to women’s groups, outreach campaigns in slums and Urban Accredited Social
Health Activists (ASHAs) play a key role in encouraging health care–seeking. Men may also have social
support needs, especially in challenging settings such as slums. Engaging men in questions about their
children’s immunization may encourage them to participate in conversations about health.

16
Partnership with the private health providers
Improved collaboration with private
providers is an effective strategy to PRIVATE PROVIDER INTERFACE AGENCY
improve equity by sharing data,
PPIA works in Mumbai to increase the private sector’s
developing better methods to track
role in achieving universal access to TB services. PPIA
patients between facilities, and contracting
strengthens the capacity of private practitioners serving
private facilities to offer free
people in slum areas to ensure early, accurate diagnosis
immunization in some cases. One of TB, effective case management, and successful
example of private-sector collaboration in treatment.
TB services is the Private Provider
Interface Agency (PPIA) in Mumbai. During development, this project employed 40 field
PPIA successfully linked private workers to map the locations of more than 11,000 private
providers to the public system to identify health workers in the slums of Mumbai over a two-month
and treat previously missed cases of TB. period. These workers collected the geolocation, opening
Another example comes from Indonesia hours, and services provided by each provider, as well as
with the Ikatan Dokter Anak Indonesia a photo of the location.
Pediatric Online Immunization Reporting PPIA also established a technology-based patient
System (I-POINTS). I-POINTS collects registration and management platform for
immunization data from all pediatricians, reimbursement of service providers. This platform
regardless of whether they work for a enables patient subsidies for diagnosis and treatment. 72
public or private facility. This has allowed
There is an opportunity to collaborate with entities (in
for improved estimates of immunization
this case, private providers) that are already serving
coverage for the vaccines of the Expanded
marginalized populations, to tackle inequities in
Program on Immunization and
immunization coverage. This is also an example of how
nonprogram vaccines (e.g., influenza,
triangulation of data sources not only enabled better
rotavirus).
services to reach the people who needed them but the
Partnership with private drug vendors government to gain greater visibility amongst its
could be impactful. They are often the population’s health.
main access point for health care products
and services in underserved communities. Drug vendors could be contracted to provide immunization
information or incentives to neighborhood caregivers. Incentives for these drug vendors could include
free or discounted courses that lead to certifications, cash commissions on the utilization of tracked
vaccination e-vouchers originating from their shop, or free tools to increase customer traffic at their shop.

Building partnerships for greater impact

A common issue underlying most challenges is a lack of collaboration amongst involved stakeholders.
Global, national, regional, and local partnerships are necessary to meet the goal of eliminating
immunization inequity. Partnerships are critical ways to improve service provision and community
engagement. Creating nontraditional partnerships with new sectors and organizations can extend the reach
of existing programs.52 Partnerships with community organizations that represent disenfranchised
communities, such as SDI, 73 are essential.
Collaboration with the community, including migrant communities, is essential to improving
immunization equity. In Peru and Tanzania, a community mobilization initiative reduced incidents of TB
using a rights-based approach. With the help of micro-loans, residents of underserved urban areas

17
engaged in participatory planning to address issues of sanitation, waste management, and housing. This
approach was successful because it addressed health from a multisectoral approach and engaged
marginalized communities, promoting equity and human rights of urban slum dwellers. 74 Overall,
evidence demonstrates that the most effective tool in changing behavior towards improved immunization
coverage is community-led information sessions and discussion. It is critical that the sessions allow for
vigorous information exchange with caregivers, rather than short lectures at the facility level. 75
Community participation can also be a powerful tool when it comes to data collection. In Cali, Colombia,
city officials compensate citizen scientists with micro-payments to maintain mosquito traps, report data
on mosquito densities, and identify mosquito breeding sites along a regular route, all via a mobile
application to improve vector surveillance and control.76 Another example is HarassMap, which,
“[encourages] users to flag up incidences of sexual harassment against women on the streets … to a
shortcode [short messaging service] number, following which the report is stored in an online database
and illustrated … in the form of a hotspot map.” 77 Mapping was also completed in Kenya’s two largest
informal settlements, Kibera and Mathare, which helped expose the lack of many services, such as water,
electricity, trash collection, and health care.78
Community members can be effective change agents to spur behavior change. To improve safety,
community leaders in Kiberia, a slum near Nairobi, organized a community response team composed of
residents. The team serves as a neighborhood watch and an emergency response team for fires, floods,
and other local crises. Reportedly, crime has decreased by nearly 30 percent since the team’s initiation,
due in part to slum residents’ trust of other community members as opposed to official police or
emergency responders.
Political leaders are also essential collaborators, especially when addressing the legal status of recent
migrants living in informal settlements. Lawmakers and country officials can advocate for resources and
permission to prioritize and reach unserved communities. One approach could be to enact a policy that
stipulates legal status is not collected for treatment and that sensitive data are not shared with other
government entities. Another approach is to incentivize immunization by requiring children to be
immunized in order to receive other services, such as enrolment in school. When coupled with policies
that remove barriers, this policy enforces a culture of immunization coverage.
Collaboration with employers is an opportunity to provide immunization behavior change
communication or the social protections (e.g., approved time off) caregivers need to seek immunization
services.

18
A framework for action
There are many ways to explore and address the problem of inequity in immunization coverage. To
identify actionable recommendations, the ERG developed a guiding framework (Figure 4) focused on
balancing three critical elements that form the basis for the recommendations. The elements include:
1. The challenges to achieving equity (the problem).
2. The interventions change agents need to address immunization inequities, including innovative
approaches and/or technologies.
3. The change agents—the persons who makes decisions resulting in the immunization of a child—and
the necessary information and incentives.
Recommendations reflect the framework. They seek to identify (1) the problem (challenges) being
addressed; (2) the innovative interventions necessary to reduce inequity; and (3) the change agents that
can act. The ERG’s goal is to identify recommendations for key actors that can directly reach
marginalized populations and act.

Figure 4. Equity Reference Group for Immunization framework.

19
Recommendations of the Equity Reference Group for
Immunization
To improve equity in immunization coverage, the global immunization community must boldly act and
innovate. We must advance in new directions and bring new partners along with us. In reflecting on past
progress and novel interventions from within and beyond the immunization and global health sectors, the
ERG prioritized a set of actionable recommendations that we believe will tackle the key challenges
contributing to inequity.
Recognizing that an enabling environment is vital to the implementation of new interventions, the
recommendations outlined require broader health system reforms in governance, financing, and policy,
such as higher budgetary allocation to these communities. Therefore, the work of the Group focuses on
novel practices that can be adopted immediately by lower-level change agents, and leaves
recommendations on structural changes to other authors.
The ERG recommendations are categorized in three ways:
1. Act now. Evidence exists to support the idea, but with minimal implementation.
2. Continue doing. Interventions that are working well and should persist.
3. Test before acting. Interventions that require further study to assess and test value.

20
 Intervention
Act now Strengthen community engagement. Develop
standardized methods to connect with
caregivers and understand opportunities to
increase demand in the local context.
Scale up and provide support for peer
support networks, which enhance the impact
and implementation of other recommendations.
These networks enable health workers to
quickly raise and resolve issues that arise and
support learning from each other.
Improve security for caregivers and health
workers to allow children in the most
vulnerable and dangerous urban contexts to
receive vaccinations.
Continue Adjust timing of immunization services to
doing allow busy caregivers more convenient access
on weekends and evenings.
Implement unique identifier system for
patient identification to more effectively track
patients and the care they need.
Institute opt-out policies for immunization.
Identify missed opportunities and provide
immunization services when unimmunized
children interact with the health system.
Continue implementation of EIRs,
dashboards, and visualizations that allow
current data to be collected and aggregated for
the appropriate level of use and to influence
decision-making.
Test Increase coordination with the private
before sector and employers to identify more
doing unimmunized children. Develop policy that
enables private providers to administer
vaccines or more effectively refer patients to
the public system.
Integrate novel data sources into routine
reporting (e.g., telecommunication data,
satellite imagery) to better locate unimmunized
children in urban areas.
Change agents required
• National governments.
• District health officials.
• CHWs.
• District health officials.
• CHWs.
• National governments.
• District health officials.
• District health officials.
• Ministry of Health.
• CHWs.
• National governments.
• District health officials.
• District health officials.
• Schools.
• Ministries of health.
• Donors.
• Ministries of health.
• District health officials.
• Local economic
associations.
• Employers.
• Information and
communication technology
companies.
• National governments.
• Donors.
21
Challenge(s) addressed
• Disenfranchised communities: Improves understanding of a
community’s challenges to access.
• Quality of services and information: Incorporates community-led
design to increase demand.
• Informal settlements: Increases trust and reduces stigma of providing
services for residents of illegal settlements.
• Quality of services and information: Facilitates knowledge sharing
across districts to improve services.
• Multiple stakeholders: Increases coordination across partners.
• Insecurity: Allows health workers to immunize children in areas that are
currently inaccessible.
• Disenfranchised communities and quality of services and
information: Increases opportunities for communities to access services
when they are convenient.
• Quality of services and information: Facilitates tracking and follow-up
of un/underimmunized children, regardless of other sensitive
political/societal information about the patient (e.g., immigration status).
• Quality of services and information: Reduces the burden of receiving
immunization services and addresses vaccine hesitancy.
• Quality of services and information: Reduces the number of
interactions caregivers need to facilitate with the health system.
• Accurate, disaggregated data: Results in more timely and actionable
data.
• A lack of political will: Provides evidence to policymakers of the unmet
need.
• Multiple stakeholders: Better highlights where partners can contribute.
• Accurate, disaggregated data: Identifies children vaccinated through
private facilities and unimmunized children with the help of employers.
• Quality of services and information: Offers an opportunity for working
parents to have children vaccinated at a convenient location.
• Multiple stakeholders: Increases awareness of immunization equity as a
key issue amongst partners.
• Accurate, disaggregated data: Provides a data source to identify recent
migrants.
Intervention Change agents required Challenge(s) addressed
Use machine learning to predict the locations • Donors. • Accurate, disaggregated data: Enhances the ability to identify
of unimmunized children, even in areas where • National governments. geographic areas with unimmunized children.
routine data are not available.

22
Annex 1. Acknowledgments
We acknowledge interviewees and participants of the private-sector roundtable held on September 6,
2018, at the Bill & Melinda Gates Foundation in Seattle, WA, USA. Interviews covered a wide variety of
topics and the views expressed in this paper do not necessarily match the views of all individuals
interviewed. Some experts were consulted only on particular contexts or particular countries, depending
on their area of expertise. Some issues proved controversial, and whilst the Equity Reference Group for
Immunization tried to build consensus, differences of opinion remain on certain topics.

Fayiz Abakar London School of Mercy Karanja John Snow, Inc Jane Soepardi
Institut de Recherche en Hygiene and Tropical Bill & Melinda Gates Ministry of Health,
Elevage pour le Medicine Foundation Blair Palmer Indonesia
Développement UNICEF
Aguide Soumouk
Haley Kawaja
Molly Abbruzzese Wendy Colebank Justin Pendarvis IFRC
One Acre Fund
Bill & Melinda Gates PATH USAID
Foundation Brian Taliesin
Marcela Contreras Jessica Kiessel Abhishek Pratap PATH
Mark Adams PAHO Omidyar Network Sage Bionetworks
Independent consultant Heather Tallis
Tim Crocker-Buque Katharine Kreis Rhiannan Price The Nature Conservancy
Adinoyi Adeiza London School of PATH DigitalGlobal
IFRC Hygiene and Tropical Pham Quang Thai
Debra Kristensen Praveen Raja National Institute of
Medicine
Siddharth Agarwal PATH PATH Hygiene and
Urban Health Resource KK Das Epidemiology, Vietnam
Kate Kuo Seema Ramchandani
Centre Ministry of Health, India
Bill & Melinda Gates Amazon David Townes
Philippe Duclos Foundation University of Washington
Fazil Ahmad
Syed Raza
UNICEF Caitlin Tulloch
Kevin Etter Feyrouz Kurji Digital Impact Alliance
UPS Foundation Bill & Melinda Gates International Rescue
Anup Akkihal
Logistimo Foundation (Consultant) Scott Reid Committee
Benjamin Fels iRespond
macro-eyes Carol Levin Caroline Vassighi
Miriam Alia
University of Washington Satyabrata Routray Heifer International
Médecins Sans Frontières
David Fleming PATH
PATH Orin Levine Martha Velandia
Brock Anderson
PATH (Consultant) Bill & Melinda Gates Barbara Saitta PAHO
Craig Friderichs Foundation Médecins Sans Frontières
PATH Linda Venczel
Jon Andrus
George Washington Michael Lindenmayer Edda Salvatori PATH
University Sue Gerber Tata Trusts World Health
Bill & Melinda Gates Organization Cesar Victora
Foundation David Lubinksi Federal University of
Gilbert Asiimwe
Infectious Diseases Bill & Melinda Gates Pelotas, Brazil
Meghan Scanlon
Research Collaboration Jan Grevendonk Foundation Bill & Melinda Gates Shibu Vijayan
World Health Foundation PATH
Fazal Ather Frank Mahoney
Organization
UNICEF IFRC Jenny Sequeria Russ Vogel
Dakota Gruene Bill & Melinda Gates Independent consultant
Brian Atuhaire Yuta Masuda Foundation
ID2020
PATH The Nature Conservancy
Brady Walkinshaw
Benjamin Hickler Alyssa Sharkey Grist
Amie Batson Birara Melese UNICEF
UNICEF
PATH Ministry of Health,
Ethiopia Sonia Walia
Bill Donnelly Jessica Shearer USAID
Rafael Baltrons iRespond PATH
Epidemiologo Hospital Karen Lowry Miller
Panorama Global Chris Watson
Amatepec Skye Gilbert Lora Shimp Premise
PATH John Snow, Inc.
Ben Bellows Godwin Mindra
UNICEF Laurie Werner
Nivi Kathleen Goodman Mozammil Siddiqui PATH
Bill & Melinda Gates Gavi, the Vaccine
Foundation Robin Mowson Alliance
Rachel Belt David Wilkie
PAHO
Gavi, the Vaccine Wildlife Conservation
Alliance Laura Harwig Evan Simpson Society
Fintrac Francis Mwansa PATH
Ministry of Health,
Himanshu Bhusha Ante-Liesbeth Wind
Trad Hatton Zambia Moses Simuyemba
National Health Systems Médecins Sans Frontières
Resource Centre, India PATH University of Zambia
Neal Myrick
Tableau Foundation Liya Wondwossen
Craig Burgess Lea Hegg NK Sinha Ministry of Health,
John Snow, Inc. Bill & Melinda Gates Ministry of Health, India Ethiopia
Steve New
Foundation
Fintrac Chuck Slaughter
Boubacar Camara Tim Wood
Agence Nationale de William Kabore Living Goods Bill & Melinda Gates
Directorate of Comfort Olorunsaiye
Télésanté et International Rescue Foundation
Immunization Prevention, Peter Small
d'Informatique Médicale Committee
Burkina Faso The Rockefeller William Wu
Francesco Checchi Foundation QED
Robert Kaufman Saad Omer
IFRC Emory University
Ahmadu Yakubu
Lisa Oot UNICEF

23
Annex 2. Country case studies
In 2017, 59 percent of Haiti’s population lived in urban areas and more than 70 percent of those people lived in slums. 81 Current diphtheria-
tetanus-pertussis third dose vaccination coverage is estimated to be 72 percent. 82 A slum called Cité Soleil experiences especially low coverage.
Accurate, disaggregated data: A lack of
appropriate data creates difficulty in identifying After a period of coverage stagnation in Haiti, the Expanded Program on Immunization
and tracking populations.
Disenfranchised communities: Cultural
differences and discrimination lead to mistrust
of the health system and influence health care–
seeking behavior.
Quality of services and information: Service
hours, wait times, and a lack of information
impact access to immunization services,
especially for low-income, working caregivers.
Political will: Municipalities and local
authorities face many issues and may not
prioritize immunization, especially for
communities with little political representation.
Informal settlements: Residents of informal
settlements may fear encountering public
authorities, and authorities may be less invested
in residents of informal settlements.
Multiple stakeholders: Few effective
partnerships, especially with private providers,
reduces the ability to improve immunization
equity.
Insecurity: Violent crime restricts access to
public services, especially in slums.
Haiti 79,80
Intervention:
manager requested analysis on coverage and equity in urban slums, such as Cité Soleil, with
the assistance of Gavi, the Vaccine Alliance and partners. John Snow, Inc. worked to
diagnose barriers to improving coverage and equity and develop solutions. Accurate baseline
data on the target population were established using micro-census and coverage surveys.
Monthly reports generated by data forms completed by staff were analyzed for decision-
making at the institutional, municipal, and departmental levels. Early pilots indicate:
• Regular dialogue with community and group leaders was essential to increase
community trust. These leaders disseminated information and promoted vaccination to
the community.
• Capacity-building and mentoring on interpersonal communication and customer service
for health workers were identified as short-term priorities.
• Extending service hours and guaranteeing vaccine availability by carefully monitoring
stock were key strategies to improve quality.
Immunization coverage rates were on average 10 percent higher in the first half of 2017
compared to 2016. These pilots will inform similar interventions in targeted districts with
high numbers of unimmunized children.
Cité Soleil has been relatively calm for the past two years, but heavily armed rival gangs
have been known to have shootouts daily. Ensuring security of caregivers and health workers
is a topic that needs further investigation.
Change agents:
In this case, global stakeholders, such as Gavi and John Snow, Inc., were key actors in
sponsoring and informing improvements in urban immunization interventions. However,
engagement of the local community, participation of district health officials, and support of
health workers were essential.
24
 India 83
In 2017, 33.6 percent of India’s population lived in urban areas and 24 percent of those people lived in slums.81 The number of people living in
slums is expected to reach 202 million by 2020. Current diphtheria-tetanus-pertussis third dose vaccine coverage is estimated to be 88 percent. 84
Data suggest slums have a much higher prevalence of unimmunized children than non-slum areas.14 India has about 9.6 million unimmunized
children, which is roughly equivalent to one-third of the world’s unimmunized children. 85
Accurate, disaggregated data: A lack of Intervention:
appropriate data creates difficulty in identifying The National Urban Health Mission (NUHM) was initiated in 2013 and focuses on cities
and tracking populations. with a population greater than 50,000—specifically on urban slums and marginalized
populations. 86 The NUHM recognizes a lack of disaggregated data as a key challenge of
Disenfranchised communities: Cultural
addressing issues in urban areas. 87 To improve data quality, India has stressed the need for
differences and discrimination lead to mistrust
spatial mapping and listing of slums. Each area was mapped to ensure an Auxiliary Nurse
of the health system and influence health care–
Midwife (ANM) was assigned to provide outreach for immunization services. Accredited
seeking behavior.
Social Health Activists (ASHAs) were also identified for each area to mobilize caregivers to
Quality of services and information: Service receive immunization services.
hours, wait times, and a lack of information
To ensure activities were occurring as planned, Urban Routine Immunization Nodal Officers
impact access to immunization services,
were identified for each area and an Urban Task Force on Immunization coordinated with
especially for low-income, working caregivers.
other local authorities and departments. In addition to official departments and health system
Political will: Municipalities and local stakeholders, women’s groups and youth organizations played a key role in increasing
authorities face many issues and may not community awareness of immunization, especially in areas with no ASHA.
prioritize immunization, especially for
Key interventions that contributed to improved coverage included flexible immunization
communities with little political representation.
times, shifting of vaccinators to urban areas from rural areas, and coordination with elected
Informal settlements: Residents of informal representatives and religious leaders. Special immunization campaigns were conducted to
settlements may fear encountering public cover missed children and children who had dropped out.
authorities, and authorities may be less invested
Recognition of informal urban settlements, such as in a report on eight Indian cities, 88 is an
in residents of informal settlements.
important first step in addressing illegal settlements. Slow, deliberative discussions with
Multiple stakeholders: Few effective census investigators have led to progress in identifying unimmunized children.
partnerships, especially with private providers,
Intersectoral coordination has been identified as a key method to improve the quality of
reduces the ability to improve immunization
services. By addressing environmental, sanitation, water, and infrastructure challenges in
equity.
slums, health is improved and demand for services increases.
Insecurity: Violent crime restricts access to
Change agents:
public services, especially in slums.
In India, national-level policymakers played a key role by endorsing an urban health strategy.
The Urban Task Force was an essential body to coordinate partnerships between
stakeholders. ASHAs, ANMs, and other health workers were important to operationalize the
NUHM. Community engagement, especially through women’s groups, youth organizations,

25
 India 83
elected representatives, and religious leaders, was crucial to reach unimmunized children in
urban areas.
For a specific example of improving immunization coverage, see “Expanding and improving
urban outreach immunization in Patna, India” by Pradhan et al. in Tropical Medicine &
International Health from March 2012.

26

In 2017, more than 26 percent of Kenya’s population lived in urban areas and 56 percent of those people lived in slums.81 Current diphtheria-
tetanus-pertussis third dose vaccination coverage is estimated to be 71 percent. 90 Data suggest that the prevalence of unimmunized children is
similar in slum and non-slum areas.14 About 100 slums exist in the area surrounding Nairobi.
Accurate, disaggregated data: A lack of
appropriate data creates difficulty in
identifying and tracking populations.
Disenfranchised communities: Cultural
differences and discrimination lead to mistrust
of the health system and influence health care–
seeking behavior.
Quality of services and information: Service movement, and a lack of community awareness about available services. For residents who
hours, wait times, and a lack of information
impact access to immunization services,
especially for low-income, working caregivers.
Political will: Municipalities and local
authorities face many issues and may not
prioritize immunization, especially for
communities with little political representation.
Informal settlements: Residents of informal
settlements may fear encountering public
authorities, and authorities may be less
invested in residents of informal settlements.
Multiple stakeholders: Few effective
partnerships, especially with private providers,
reduces the ability to improve immunization
equity.
Insecurity: Violent crime restricts access to
public services, especially in slums.
Kenya 89
Intervention:
To improve immunization coverage in Mathare Subcounty, which consistently had coverage
rates less of than 55 percent, local immunization authorities strengthened existing
interventions and introduced new ones. First, a situational analysis was conducted using
District Health Information System data, a landscape assessment, coverage surveys,
household surveys, and facility microplanning. Data analysis was completed to the lowest
administrative level. The situational analysis found many access and utilization issues,
including wards without a facility offering immunization services, constant population
knew about immunization services, the travel distance to facilities, insecurity, wait times, and
clinic opening times were inconvenient.
As a result of the situational analysis, the number of community health volunteers working in
the area increased, facilities offered flexible times for immunization, and staff were offered
continuous quality improvement awards.
After the situational analysis, targets were set using microplanning at the facility level. An
impact team was created to analyses data monthly, with the help of visualizations and
dashboards to identify gaps and actionable next steps with specific timelines. Immunization
coverage rates have improved to 70 to 80 percent.
In addition to a situational analysis and microplanning, data quality checklists, intensified
supervision, and regular mapping were noted as important tools to aid in coverage
improvement.
Local immunization authorities reported that a population movement or national missed
children tracking system, a multisectoral approach, partnerships with community
organizations for resource mobilization, and private provider engagement could increase
coverage rates further.
Change agents:
The efforts in Mathare Subcounty illustrate the importance of engaging the community to
understand barriers to accessing services. The alignment of district health officials, facility
managers, and community health workers was essential in the effort to improve coverage.
27
Lastly, partnerships with community organizations and private providers increased the reach
of existing interventions.
For an example of a situational analysis, see “Situation of Routine Immunization in Urban
Poor Areas of Kisumu City, Kenya,” authored by Iqbal Hossain, Evans Mokaya, and Isaac
Mugoya in 2017.

28
Annex 3. Intersections of inequity with gender
Gender challenge Description
Health literacy Recognizing that in many parts of the world, access to education
is gendered, women lacking health literacy have a lower
understanding of immunization.
Women’s participation Women’s participatory voice in communities—including
and decision-making regarding many community health initiatives—is often limited by
power socioeconomically and culturally defined gender roles. At the
family level, women’s input on decisions related to child health
can be constrained by gender norms that emphasize the dominant
rights of men in household decision-making, whilst at the same
time placing the bulk of responsibilities for childcare on women
(i.e., limited male engagement in child immunization or other
health issues).
Time poverty and Women’s responsibility for “reproductive” work (i.e., work
mental stress required for the maintenance of the household—including
cooking, cleaning, and fetching water and firewood—and the
care of children and the sick) and livelihood activities impose
heavy demands on their time and may leave little time and
opportunity for health care–seeking.
Service provider Women’s experience of quality of service—encompassing
sensitivity responsiveness of services; range of services available; provider
attitudes, skills, and behavior; and in some settings, the
availability of female providers—may deter them from seeking
health services.
Sex of service provider Women in more traditional areas may not seek care for
themselves or even for their children unless they have access to a
female provider.
29
Intersection with urban contexts
Migrant women may lack health literacy if they do not
understand local signage due to language barriers.
Traditional community structures that may provide channels
for women’s participatory voice in rural communities are
less likely to be intact in urban areas. At the same time, in
some cases, traditional gender norms may be less rigid in
urban areas and potentially offer women opportunities for
more direct participation in community initiatives and
household decision-making.
Mothers in urban areas may work hours or multiple jobs that
conflict with hours of service provision. Additionally, long
wait times discourage busy mothers from seeking
immunization.
Mothers may experience shame or humiliation due to lack of
sensitivity from health workers regarding social status and
caregiving abilities.
Evidence is lacking on the availability of female health
workers in urban areas, where the cultural setting requires
women to interact first and foremost with female health
workers.
Gender challenge Description
Social support Other women may be more authoritative and reliable sources of
systems/connectivity knowledge and information than health professionals.
Furthermore, key authority figures, religious institutions, civil
society organizations, and local media outlets may formulate
conflicting positions on vaccination.
Women’s freedom of Women may experience lack of mobility due to gender norms
movement that restrict female mobility in public and/or difficulties
accessing transportation due to cost.
Financial cost to In low-resource settings, mothers face challenges in finding the
mothers necessary financial resources to secure transportation for
accessing facility-based child vaccination services.
30
Intersection with urban contexts
Recent migrants to urban areas may lack social capital and
support to access services.
Insecurity in some urban areas can dissuade health workers
and mothers from moving outside the home to access or
provide services.
Mothers in urban areas who are employed outside the
household may have more direct access to cash but may also
be employed in services and sectors in which earnings are
directly dependent on the number of hours worked. Work-
related economic opportunity costs may be a barrier to
services in urban areas if these are not offered in an efficient
manner, at times and in locations that are convenient to
women who are typically primary child caregivers.
Annex 4. Summary of Urban Immunization Working Group
toolkit recommendations
The Urban Immunization Working Group toolkit is organized using the five components of the Reaching
Every District strategy and can be adapted for urban areas. Topics include:
• Planning, coordination, and management of resources. Conducting situational analyses helps
immunization program managers understand and prioritize equity issues in their programs.
• Engaging the community and social mobilization. To address issues of high mobility and lack of
awareness about immunization, local health authorities should improve signage at intersections and
along major transportation routes, publish schedules on the Internet, and standardize immunization
schedules in the area.
• Conducting supportive supervision. Approaches to enhance supportive supervision for health
workers, especially those in challenging contexts, are widely acknowledged to improve health worker
motivation, performance, and retention.
• Monitoring and using data for action. The poorest communities are often under-sampled, with
sample sizes not large enough to detect intra-urban disparities. The use of periodic surveys,
convenience monitoring, and electronic registries are key strategies to address these challenges.

31
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