• Collaboration

    Burkina Faso
    Collaborating for change

    Burkina Faso prides itself not only on having one of the highest vaccination coverage rates in Africa, but also on successfully using immunisation as a means to deliver other health services. The country’s experience shows what can be done through high-level political support and a willingness on the part of all stakeholders to collaborate across the health sector.

    • Prof. Nicolas Meda,
      Minister of Health, Burkina Faso

    • Delphine Sandwidi
      EPI nurse, Burkina Faso

    Without strong political commitment, immunisation programmes often fail to live up to early expectations. This has, however, not been the story in Burkina Faso. Free access to immunisation was introduced by President Thomas Sankara in 1987, and continues to this day. "The President’s commitment," explains Professor Nicolas Meda, Burkina Faso’s Minister of Health, "is tangible in the fact that healthcare for children under five and for pregnant women has been free since 2015, and in that the 2018 budget will be 5 billion CFA francs [US$ 8.9 million], compared to scarcely 2 billion in 2015.” The Minister of Health intends to continue to increase this budget allocation year-on-year.

    Capitalising on this high-level support for child health, Burkina Faso’s health sector is harnessing immunisation programmes as a platform for other interventions. "Vaccination is a great gateway to healthcare!" says Delphine Sandwidi, the nurse in charge of the Expanded Programme on Immunization (EPI) at the Dassasgho Centre for health and social advancement (Centre de santé et de promotion sociale, or CSPS) in Ougadougou, Burkina Faso. Sandwidi, who has been working at the CSPS for 23 years, speaks enthusiastically about the broader impact that vaccination has had in terms of improving access to healthcare.

    Vaccination clinics provide health workers with the ideal opportunity to identify children, parents and caregivers who are in need of other health services. "Every day, during weighing and measuring, I take advantage of children's visits to refer them to other services if necessary – especially those suffering from malnutrition," Sandwidi explains.

    For many pregnant women, vaccination clinics are their first interaction with health services. When an expectant mother brings her older children to be vaccinated, nurses and doctors can make use of this point of contact to provide advice, medical examinations and any necessary vaccinations, and to encourage her to come back for follow-up visits. "If they like the welcome they get at the health centre, they will feel confident about coming back," says Sandwidi.

    Discussions prior to vaccination sessions also provide an opportunity to inform parents about health issues beyond immunisation. In Burkina Faso, where nearly half of all medical consultations and a quarter of hospital admissions in 2017 were due to malaria, pre-vaccination discussion sessions can be a means of disseminating information on ways to prevent this devastating disease.

    EPI: a platform for health

    While the EPI is by its very nature focused on providing vaccination, it does not operate in isolation. It requires some level of health infrastructure to be in place if it is to be effective and efficient, including a supply system that can transport vaccines from central stores to the most remote villages and trained healthcare staff who can deliver those vaccines. This system can be, and in virtually all countries is, used as a platform to deliver other primary healthcare services.

    The EPI is well established in Burkina Faso. Says Dr Anne Vincent, UNICEF's representative in the country: "By building on the EPI’s maturity, we can achieve success in other parts of the health system. The EPI is instrumental in establishing and strengthening the health system, and it allows other programmes to be bolted onto it."

    The integration of the EPI and the broader health system is particularly evident in rural parts of the country. Here, community nurses or midwives are typically in charge of all aspects of healthcare. "We really encourage health workers to take advantage of every contact opportunity in order to provide maximum health care and to take a holistic view of the child," explains Dr Alimata Jeanne Diarra-Nama, WHO’s representative in Burkina Faso. "We incorporate activities that have proved to be worthwhile, such as vitamin A supplementation, seasonal chemoprophylaxis and other essential interventions. It has to become part of the culture."

    This approach is not restricted to health centres, but is also very much part of the ethos of many small community-based organisations. In Tanghin-Dassouri, a rural area some 50 kilometres outside of Ouagadougou, the nurse in charge of the EPI, Albert Sekoué, works closely with ALAVI, an AIDS association founded in 1995. In addition to their core programmes, which are focused on increasing access to healthcare among the most vulnerable, ALAVI organises awareness sessions on HIV, malaria and immunisation with the help of its community-based health workers.

    Pooling resources to reduce duplication

    Abdoul Karim Ouedraogo is the coordinator of the Programme d'Appui au Développement Sanitaire (PADS), an organisation responsible for ensuring a coherent allocation of international funds to the health sector. According to Ouedraogo, in 2017 the Global Fund to fight AIDS, Tuberculosis and Malaria financed the operation of 263 CBOs and paid part of the salaries of 17,688 community-based health workers.

    The work of these community-based organisations and health workers is by no means restricted to the three diseases covered by the Global Fund. For example, one organisation is helping to identify and register all children who do not yet have a vaccination booklet.

    In the same way, EPI motorbikes, which are financed by Gavi to facilitate immunisation outreach, are being used for a range of other interventions. In isolated rural health clinics, which need to cover large geographical areas, it is important to be mobile enough to reach people who themselves have no means of transportation.

    This pooling of resources is unanimously welcomed. As Abdoul Karim Ouedraogo points out: "It optimises the management of funds provided by our international partners."

    For Dr Issa Ouedraogo, Director of Vaccination Prevention, pooling assets has benefits in terms of greater equity in the allocation of resources. “The duplication we used to come up against is avoided, and it has had an immediate impact in the field. More people are benefiting, access to health facilities is easier and the quality of healthcare has improved."

    Interagency collaboration

    Increasing levels of interagency collaboration is also delivering benefits at the administrative level. The newly-established strategic EPI management exchange committee, chaired by Burkina Faso’s Minister of Health, brings together a wider group of partners with a diverse skillset.

    Says Jean Nouboussi, country portfolio manager for Burkina Faso at the Global Fund: “We have always planned things together with Gavi to avoid duplication of resources, but our collaboration now goes much further. We work closely together to coordinate support, field missions and capacity building.”

    Joining hands to modernise the supply chain

    Cross-agency collaboration has led to a new initiative to replace old electric fridges with modern, solar-powered ones – an investment that will benefit the wider health system. "For us, the switch to solar energy is a no-brainer," explains Abdou Diallo, nursing officer in charge of the Tanghin Dassouri Medical Centre. "It will lead to greatly improved preservation of vaccines, for one thing, and it will also benefit our entire structure. Although the initial investment is substantial, the savings we will make over the long term are beyond doubt."

    Diallo’s view is shared by the Minister of Health, who stresses that while Burkina Faso has 90% vaccination coverage, it does not yet have 90% vaccine effectiveness. "We have a cold-chain problem, which we are working with Gavi to solve by replacing the whole system.” UNICEF is highly involved in the project, providing technical support and procurement assistance thanks to its expertise in cold chain equipment.

    Meanwhile, collaboration with the Global Fund is at the heart of a project which uses digital tablets to collect data on childhood diseases and immunisation. Ahawo Komi M. Alain, Gavi’s senior country manager for Burkina Faso, describes how the initiative was conceived: “Last February I visited a health centre in Ouahigouya together with my counterpart at the Global Fund to watch a demo of mHealth tool being used to collect data on childhood illness. It targets the same age bracket as immunisation. As we watched, we had the idea that the same tool should be used to collect vaccination data.”

    This collaboration is fundamental to Burkina Faso’s efforts to strengthen its health system. As Diallo points out, the benefits are immediate: "Thanks to vaccination and a more efficient health system, children no longer miss school and parents can maintain their level of income. Together we are fighting poverty."

  •  
    Supply chains

    Modernising supply chains to reach the unreached

    In some parts of the world it is now possible to order goods or groceries online and have them delivered straight to your door within 24 hours. In most low-income countries, however, it is an entirely different story. Poor roads and ageing or non-existent infrastructure can make a delivery of any kind a real challenge.

    The logistics of vaccine deliveries can be especially problematic. This is not only because vaccines need to be kept cold during their journey from depot to clinic, but also because often the people who need them most live in the least accessible places.

    Since 2000, Gavi has supported close to 400 vaccine introductions and seen the number of immunised children rise significantly. Despite this, pockets of low coverage remain, even in countries with seemingly good national coverage. These hotspots of low coverage represent the world’s most vulnerable children. If we are to continue to increase coverage, we need to find ways of immunising these children.

    Vaccines can only do their job if they reach people, and they can only reach people if supply chains are effective and efficient. Strengthening supply systems is thus a central part of Gavi’s efforts to improve immunisation coverage and equity in the countries it supports. In 2017, Gavi worked with a range of private- and public-sector partners to kick start what will likely be the single biggest revamp of vaccine supply chain infrastructure and management in more than four decades of the Expanded Programme for Immunization (EPI).

    Upgrading outdated cold chains

    A key component of the supply chain revamp is Gavi’s cold chain equipment optimisation platform (CCEOP). The platform utilises the same innovative market shaping principles that has enabled Gavi to reduce vaccine prices to accelerate the introduction of affordable and innovative cold chain equipment across the estimated 135,000 supply chain points in Gavi-supported countries.

    In some countries, cold chain equipment has scarcely been upgraded since the EPI was first introduced over 40 years ago. Before the introduction of the CCEOP, one in five facilities that needed cold chain equipment did not have it, and in those that did, one fifth of the installed devices did not function. Where equipment was working, performance was substandard, with 60% of storage units running the risk of exposing vaccines to excessive freezing or unacceptably high temperatures.

    The CCEOP aims to address precisely these kinds of issues by encouraging manufacturers to increase production, stimulate innovation and reduce the cost of state-of-the-art cold chain equipment. With an initial US$ 50 million upfront commitment, it was designed to give manufacturers the confidence to develop and produce innovative cold chain equipment adapted to the needs of developing countries. By helping countries to purchase and maintain this equipment, Gavi removes one of the main barriers standing in the way of cold chain modernisation. The initial commitment has now been increased five-fold to match anticipated demand over the next five years.

    Since the launch of the CCEOP, Gavi has committed to helping countries purchase more than 66,000 pieces of cold chain equipment for more than 55,000 sites. Two thirds of these items will replace outdated or broken equipment, while the remaining third will help expand existing cold chain facilities.

    The first country to take advantage of the CCEOP was Haiti. With help from Alliance partners, Haiti used the platform to overhaul its outdated cold chain infrastructure. In 2017 the first consignment – comprising more than 190 state-of–the-art solar-powered fridges – was deployed to rural and mountainous areas.

    Powered by renewable solar energy, these fridges freeze an ice liner during the day that later keeps the unit cold either overnight or on cloudy days. With no need for a battery or a control unit, these fridges – unlike older models – are not reliant on the kind of components that are prone to failing. This simple innovation also eliminates the need to transport heavy and expensive propane fuel over large distances.

    Most Gavi-supported countries are eligible for CCEOP support. Depending on a country’s gross national income per capita, Gavi will cover between 50% and 80% of the total cost of the purchase, delivery and installation of new equipment. Countries themselves are expected to cover the remaining cost.

    Innovation key to improving vaccine delivery

    The CCEOP is not the only market-based approach that Gavi has rolled out to stimulate supply chain innovation. Innovation for Uptake, Scale and Equity in Immunisation (INFUSE), launched in 2016, also does this by identifying tried-and-tested innovative technologies that have the potential to improve vaccine delivery in developing countries. These are then “infused” with capital to help businesses and innovators take their solutions to scale.

    In January 2017, Gavi and Google.org announced an INFUSE partnership to help tech start-up Nexleaf Analytics develop an analytics platform which monitors cold chain performance in real time. Nexleaf’s cloud-based platform uses its ColdTrace technology, in combination with other temperature monitors, to relay real-time temperature data and other information about vaccines to supply chain managers.

    After initial introductions and scale ups in Kenya, Mozambique, Senegal and the United Republic of Tanzania, it is hoped that this innovation will eventually help all Gavi-supported countries to better manage their cold chain networks and improve efficiency.

    Innovative technologies are also being used in India, a country which has struggled in the past to reliably monitor its vaccine stocks. Through its health system strengthening support, Gavi is supporting the Government of India to roll out the Electronic Vaccine Intelligence Network (eVIN) nationwide. The system will help track the movement of vaccines across India’s vast network of 27,000 cold chain points. Public health officials use a mobile phone app to record the temperature of cold chain equipment in real time and to log vaccine transactions. The data is uploaded to the system and then used to create and audit vaccine inventories.

    Through INFUSE, Gavi is working with companies such as Logistimo to extend the reach of such electronic logistics management systems to other countries.

    2017 also saw the launch – quite literally – of the world’s first nationwide autonomous drone delivery service for medical supplies such as blood and blood products in Rwanda. This unique project, which is led by the Rwandan Government, was brokered by Gavi – bringing together the US drone company Zipline and the UPS Foundation.

    Fixed-winged drones are launched into the air by catapult-like devices and fly autonomously to a specified GPS coordinate. Just before the drone reaches its destination, the clinician who ordered the blood or plasma receives a text message notifying them that their delivery is about to arrive. On arrival, the drone descends to a lower altitude, releases its cargo, which falls to the ground by parachute, and then returns to base.

    Currently half of all blood supplies in Rwanda are delivered this way. This service allows the Government to centralise supplies in its capital Kigali, reducing waste to almost zero. For people in remote, rural districts in need of an emergency blood transfusion the benefits are obvious, as average waiting times have been reduced from 4 hours to just 20 minutes. Gavi is now working with Zipline and other drone delivery companies to see how this remarkable technology can used to deliver vaccines.

    The right training for the right people

    Innovative technologies and the right infrastructure can only achieve so much, and by themselves are not enough. Supply chains also have to be well run. To help countries improve their supply management capabilities, Gavi launched its Strategic Training Executive Programme (STEP) in Rwanda’s capital, Kigali, in 2015 – an innovative programme aimed at improving the skill set of supply chain managers.

    Drawing on expertise from the public and private sector, including partners such as UPS and the International Federation of Pharmaceutical Wholesalers, in 2017 STEP was delivered by the East African Community Regional Centre of Excellence, based in the University of Rwanda, and the LOGIVAC Centre in Benin. STEP uses both remote and in-person training to enhance the skills of senior immunisation supply chain managers. Mentorship provided by private sector leaders forms a crucial part of the course. Since its launch, the programme has expanded to 15 countries.

    STEP has proved such a success that the Alliance is now looking at ways to emulate it as part of a broader strategy to strengthen leadership, management and coordination across all Gavi-supported countries.

    The EPI Leadership and Management Programme, a similar initiative developed in partnership with Yale’s Global Health Leadership Initiative, the University of Global Health Equity and PATH, will provide medically-trained professionals with the management skills they need to run effective EPI programmes.

  •  
    Data

    Good immunisation needs good data

    How Nigeria is overcoming the challenges of acquiring accurate vaccine coverage information.

    How can we reach the huge number of children who are still missing out on basic vaccinations when we do not even know how many there are or where they live?

    That is the challenge facing Nigeria, Africa’s most populous nation. A large country of outstanding beauty and diverse landscapes, Nigeria embodies some of the most significant challenges that Gavi and its partners face when trying to ensure that all vulnerable children are vaccinated against infectious disease.

    It is estimated that Nigeria is home to over 3.9 million underimmunised children – more than any other country in the world. Many of these children live in hard-to-reach places, far from towns and cities, and are largely unknown to healthcare providers.

    The country also has some of the greatest inequities in immunisation coverage. For example, there is a huge disparity in routine vaccination coverage between the southwest city of Lagos, which has 80% coverage, and the northwest city of Sokoto, where just 3% of children receive basic vaccines.1 Inequities based on income levels are also very much in evidence, with a 73 percentage point difference in coverage between the wealthiest and poorest sections of society.2 

    However, these figures are at best educated guesses. That is because in the past Nigeria has lacked the capacity to acquire and report reliable population and health statistics, and has yet to provide correct information on the number of children it immunises each year. There is an urgent need to accurately report the health and immunisation status of the whole population, so that health services can be designed and planned to meet their true needs.

    Identifying the known unknowns

    Population estimates for Nigeria vary from 170 million up to 198 million – a difference of 28 million. There are also large differences in reported vaccine coverage rates. “Historically, the administrative reporting of routine immunisation coverage in Nigeria has been high," says Dr Dorothy Nwodo, Director of Disease Control and Immunization at Nigeria’s National Primary Health Care Development Agency, based in Abuja. “But survey reports would indicate very poor routine immunisation coverage.”

    In 2017, matters came to a head. Administrative reports suggested that during the previous year, Nigeria had achieved 98% coverage with the third dose of pentavalent vaccine, which protects against diphtheria, tetanus, pertussis (DTP), hepatitis B and Haemophilus influenzae type b. That would have meant that Nigeria was far exceeding WHO’s region-wide target for third-dose DTP vaccine coverage, which is 90% by 2020.

    Alternative estimates of immunisation coverage, based on multiple indicator cluster surveys and national immunisation surveys, were much lower – just 33%. The disparity is thought to have been caused by some regions falsifying data in a bid to meet strategic targets.

    The lack of reliable data in the country is not surprising. “Nigeria has a poor health system with poor services,” says Dr Nwodo. The country lacks the infrastructure required to provide primary healthcare, including immunisation, she says, and has struggled to coordinate services. This lack of front-line services makes it difficult for Nigeria to consistently acquire information about the health of its people.

    “The health centres and delivery points often lack properly trained personnel, funding and equipment to capture data,” adds Dr Omotayo Bolu, Director for Immunization Programs at the Nigeria Country Office of the Centers for Disease Control and Prevention (CDC) in Abuja. "Healthcare workers often do not understand the importance of collecting data while, in some parts of the country, a lack of security prevents any data from being captured at all.”

    Not knowing the size of the total population does not help. “The current projected national census figure is unrealistic, and not ideal for accurate planning,” says Dr Nwodo. “There is also poor data reporting from rural areas compared to urban areas.”

    2017: a turning point

    Although 2017 marked the end of a recession caused by a collapse in oil prices, Nigeria’s economic growth remains modest. Relative to other countries, the majority of the population has poor health outcomes and continues to suffer the consequences of outbreaks of diseases like yellow fever, meningitis and cholera.

    In September, a major outbreak of yellow fever, centred around Ifelodun in western Nigeria, proved to be a decisive event. Following the outbreak, the Nigerian Government announced its plans to vaccinate 25 million people against yellow fever in the largest vaccination drive the country has ever seen.

    This ambitious campaign is a testament to Nigeria’s intention to take ownership of its immunisation programmes, a move triggered both by the scale of recent disease outbreaks and the debate sparked by the discrepancies in reported coverage rates for pentavalent vaccine. “In the past, the Government always seemed to align with the high administrative coverage. The acceptance of the 2016 survey results by the current leadership of the National Primary Health Care Development and the Federal Ministry of Health is a demonstration of the commitment of the current Government to address outstanding routine immunisation-related issues,” says Dr Nwodo.

    This acceptance of the survey data led to direct action. On 17 June 2017, Nigeria’s Government declared a state of public health concern due to the numbers of people lacking protection against infectious disease. “The country had to declare immunisation as an emergency to review the process of service delivery and vaccine logistics and improve routine data quality,” explains Dr Bolu.

    Then on 4 July, the Government established the new National Emergency Routine Immunization Coordination Centre (NERICC). “This was done to rapidly revamp the routine immunisation performance of the country,” says Dr Nwodo.

    Harnessing mobile technology to plug data gaps

    Improving the data management systems that collate information on how many people have been vaccinated has become a high priority. In December 2017, Nigeria piloted an innovative way to track immunisation statistics in two regions in Nasarawa State in the north of the country.

    The pilot scheme takes full advantage of mobile phone technology. Each of the 55 participating health centres was given a simple-to-use, durable mobile phone with a long battery life and a mobile SIM data card. The card carries a phone number which identifies the health centre to a central computer server.

    When a child or adult attends an immunisation session, health workers select the appropriate symbol on the mobile device that corresponds to the vaccine and dose given. They then relay that information via text message, using basic cell phones, to the central server – allowing all vaccinations to be accurately logged and recorded in real time. Gavi and its partners are playing a key role in working with phone companies to upgrade the basic mobile phones to smartphones, and to introduce an app to send the messages.

    The SMS-based system has revolutionised the reporting of immunisation data in Nigeria. Within the first month of its introduction, 72% of health facilities offering routine immunisation were sending in information. Preliminary results have made it possible to track each conducted session and the vaccines used relative to the children immunised on a weekly basis. This has allowed immediate decision-making to improve programmes.

    National immunisation data is centrally stored in Nigeria’s District Health Information System (DHIS2), which is used by the Expanded Programme on Immunization to measure progress towards its overall goals. The immediate transmission of accurate data allows the DHIS2 to display real-time charts and graphs, and to conduct a daily analysis of the data. This means that health professionals working at state and district levels are able to quickly monitor and adjust their immunisation programmes to real-time needs. The data is shared monthly with NERICC, which helps guide the project’s implementation.

    “The SMS component complements the DHIS2. Having data entered in real time significantly reduces the risk of falsification and errors,” says Dr Bolu. “SMS reporting also ensures data from service delivery points is received promptly and can guide quick decision-making. However, it should not detract from the more in-depth national DHIS2 data, which is delivered monthly.”

    “The pilot is already showing the gaps in the current reporting system and contributing to improved data quality from the health facilities,” adds Dr Nwodo. The scheme, initially funded by the CDC across 18 states, has proved so successful that Nigeria will now extend the approach to more than 26,000 health facilities nationally.

    Looking to the future

    By the end of 2017, Nigeria had rolled out the DHIS2 nationwide with support from the Bill & Melinda Gates Foundation and the CDC. The system now encourages all data to be electronically recorded and transmitted directly to the DHIS2 platform, rather than through the previous data management tool. Steps were also taken to implement quarterly vaccination surveys, known as routine immunisation lot quality assurance surveys, in 36 states. These surveys are helping to establish accurate baseline data, so that Nigeria can measure improvements in the quality of its routine immunisation programme over time.

    Following this progress, by the end of 2017 the Alliance had begun a process of intensive engagement with authorities in Nigeria – notably with the Nigeria Primary Health Care Development Agency – to develop a 10-year National Strategy for Immunisation and Primary Health Care System Strengthening, which will run from 2018 until 2028.

    In the wake of these recent achievements, and given the unique challenges the country faces, the Gavi Board will consider extending support to Nigeria for another 10 years.

    By taking action to make drastic improvements to the quality and reliability of its immunisation data, Nigeria is working hard to meet its targets for vaccine coverage. If it meets them, it will be able to prevent an estimated 1 million or more deaths by 2028. That, in turn, will help to radically reduce the size of the world’s largest remaining national cohort of underimmunised children in the world.

    1 – 2016 multiple indicator cluster survey and national immunisation survey results.
    2 – Successfully transitioning Nigeria from Gavi support. Report to the Gavi Board. 6-7 June 2018, page 3.

  • Fragile states

    Fragile settings call for special measures

    A fast, flexible and coordinated approach is required to reach people living in, or fleeing, fragile communities.

    Imagine being a child and seeing your world crumble, either reduced to rubble by bombs, laid bare by a natural disaster or eroded by political and social instability. Imagine leaving the only world you’ve ever known because of events beyond your comprehension or control for an unknown future someplace else.

    In 2017, that is what happened to millions of children living in fragile countries in Africa, the Middle East, Asia and beyond. Not only were they forced to cope with the direct consequences of conflict and other humanitarian crises, they also had to contend with unsafe and unsanitary living conditions that dramatically reduced their chances of staying healthy. Large numbers of already vulnerable people have become increasingly exposed to outbreaks of debilitating, and potentially fatal, infectious diseases.

    Sadly, their experiences are becoming the norm. It is estimated that in 2017 over 1.6 billion people, or 22% of the global population, were living in fragile settings.1 Furthermore, in 2017 fragile countries were collectively home to nearly 50% of all underimmunised children in Gavi-supported countries. Approximately half of these children lived in Nigeria and the rest in 17 other fragile countries.

    The plight of vulnerable children in fragile settings demands a fluid, innovative response – one that is fast and flexible, maximises collaboration and coordination between the Alliance and its partners, and directs support to precisely where and when it is needed most. With the approval of its fragility, emergencies and refugees policy, that is what the Gavi Board delivered in June 2017. This new policy aims to protect the most vulnerable living in an increasingly fragile and fractured world.

    It means that when unexpected crises occur, vaccines as well as financial and operational help can be quickly mobilised, and if necessary, health system and immunisation strengthening funding can be reallocated to improve the delivery of vital vaccines. Countries that host large numbers of refugees can get additional funding to immunise them, and Gavi can grant exceptional support for vaccines that are outside of its regular portfolio.

    Working to protect refugees

    Since September 2017, more than 650,000 Rohingya refugees have crossed into Bangladesh, fleeing violence and persecution in Rakhine State in neighbouring Myanmar. They have taken shelter in refugee camps in the Cox’s Bazar region close to the border, where a lack of safe drinking water and hygiene facilities, crowded living and poor nutrition quickly provided conditions ripe for the spread of contagious disease.

    Recognising the threat, in late September 2017, the Bangladeshi Government started to work with development partners to improve immunisation rates among refugees in the camp, including by requesting additional vaccine support from Gavi.

    An emergency cholera vaccination campaign, financed by Gavi through the global stockpile, prevented a large-scale outbreak of the disease. Gavi also funded additional vaccines for all 150,000 refugee children, aiming to prevent a range of diseases such as polio, measles, rubella, pneumonia, diphtheria, whooping cough and hepatitis B.

    Yet despite the extensive efforts by the Ministry of Health and Family Welfare and aid workers, a diphtheria outbreak spread throughout the camp, infecting thousands of refugees – a result of the low level of vaccination among the Rohingya people in Myanmar – as well as members of the host community.

    Health agencies again carried out an emergency vaccination campaign, this time to contain the diphtheria outbreak. This situation demonstrates how poor routine immunisation significantly raises the risk of outbreaks of epidemics, and the importance of a rapid, coordinated response when they emerge.

    In Africa, Uganda has become home to the continent’s largest refugee population, hosting some 1.5 million people that used to live outside its borders. A huge proportion arrived from South Sudan, the world’s youngest country, and one of its most fragile, beset by protracted conflict.

    Under the new fragility, emergencies and refugees policy, the Alliance has been able to support Uganda in a number of ways, providing additional doses of vital vaccines for refugees, and helping UNICEF and the national government to conduct large-scale catch-up immunisation campaigns, targeting all refugee children under the age of five. Crucially, these campaigns, scheduled for early 2018, will deliver pneumococcal, pentavalent and measles vaccines simultaneously as part of a coordinated effort to immunise vulnerable refugee populations against a series of diseases.

    The support has extended back into South Sudan itself, where national coverage of the third dose of diphtheria-tetanus-pertussis vaccine (DTP3) dropped to just 26% in 2017.

    A Gavi health system strengthening (HSS) grant provided vital support to maintain immunisation and other basic healthcare services in conflict areas and to rebuild them in areas that became stable. During 2017, this grant was used to support the formation of community partnerships and platforms, involving more than 700 schools and 32 radio stations. It also enabled around 2,500 community mobilisers to make house-to-house visits, bringing routine immunisation to more than 700,000 people.

    Large movements of people, such as those witnessed in Myanmar and Uganda in 2017, pose a particular challenge to global health security. According to the UN Refugee Agency, at the start of 2017 there were more than 65 million displaced people worldwide, 22.5 million of them refugees.2 Most refugees leave their native countries with very few possessions and often without documentation. As a result, many are unable to access basic, preventative healthcare in their host countries. Huge crowds living and moving together also create conditions for infectious disease to quickly spread.

    Delivering immunisation in conflict zones

    The conflict in Syria has had a devastating impact on its health system. Although Syria is not eligible for Gavi-support, in 2017 the Gavi Board – recognising the acute humanitarian crisis occurring within its borders – approved an annual amount of up to US$ 25 million for the 2017–2018 period to strengthen the cold chain and the delivery of pentavalent, inactivated polio and measles-mumps-rubella vaccines.

    The support has helped to improve the stability of Syria’s immunisation programme and contributed to increased coverage and uninterrupted supply across all vaccines. Nevertheless, coverage remains low and in 2017, Syria experienced outbreaks of both measles and vaccine-derived polio in areas where immunisation services had been interrupted for a long time.

    As further demonstration of the challenges of providing healthcare services within conflict zones, the UN's Humanitarian Response Plan (HRP) for Syria, which finances the operational costs of immunisation activities for WHO, UNICEF and other partners, is short of funds. By the end of 2017, only 50% of the HRP’s estimated funding needs had been met.

    Yemen has also been destabilised by armed conflict. In a stark reminder that war provides the perfect environment for disease to spread, in 2017 nearly one million Yemenis were infected with cholera. Over 2,000 people lost their lives to this preventable disease. Gavi’s response was, in collaboration with its partners, to release 1 million doses of cholera vaccine from the global stockpile. However, despite the urgent need for the campaign it was not able to start in 2017.

    Acknowledging the country as a fragile state, Gavi continued to work through partners to provide support to Yemen throughout 2017. The Alliance approved a request to fund 2.1 million additional doses of pentavalent vaccine and exceptional support for 7.7 million doses of tetanus-diphtheria vaccine. Yemen also applied for support for a measles-rubella follow-up campaign.

    Fighting cholera in fragile settings

    In addition to the flexible support provided under the new policy, Gavi funds emergency vaccination campaigns in some of the most fragile countries in the world. For instance, prompt action on the part of Gavi and its partners helped to contain several outbreaks of cholera in 2017.

    Floods and landslides devastated parts of Sierra Leone in August, leaving millions vulnerable to waterborne diseases, including cholera. Within weeks of the appearance of the first cases, the International Coordinating Group for Vaccine Provision released enough oral cholera vaccine doses from the Gavi-funded global stockpile to protect half a million people in the country, which was still recovering from the impact of the 2014 Ebola epidemic.

    In September, Gavi, WHO and partners delivered more than 900,000 doses of oral cholera vaccine, enough to vaccinate everyone over the age of one year, in a bid to halt the spread of cholera in Nigeria’s Borno state.

    Post-Ebola recovery

    While humanitarian crises in fragile settings often lead to disease outbreaks, epidemics themselves can tip communities into a state of fragility. That is what happened in west Africa during the 2013–2015 Ebola outbreak, which claimed more than 11,000 lives. The three most severely affected countries in the region – Guinea, Liberia and Sierra Leone – have since relied on Gavi support to help recover their health and immunisation services.

    In Liberia, Gavi helped to quickly rebuild essential health services, preventing outbreaks of other vaccine-preventable diseases. Basic immunisation coverage has now surpassed pre-Ebola rates of 76% in 2013 to reach 86% in 2017, having collapsed to 50% during the height of the Ebola epidemic in 2014.

    In both Liberia and Sierra Leone, we collaborated with the Global Fund to ensure complete alignment of our health system strengthening investments.

    Gavi was among the first development partners to respond to Guinea’s urgent post-Ebola need for immunisation and health system strengthening (HSS) assistance. Support was in place by mid-2015, six months before the country was declared Ebola-free, and continued through 2017. Our HSS support enabled the recruitment of health staff, the provision of technical assistance and the procurement of cold chain equipment, trucks and motorcycles to transport vaccines and conduct outreach and supervision activities, helping Guinea to recover a virtually collapsed immunisation and health system.

    The Democratic Republic of the Congo (DRC) experienced another flare up of Ebola in May 2017, and the emergency supply of 300,000 doses of experimental Ebola vaccine that Gavi has been instrumental in making available was nearly called upon. However, other measures were able to bring the outbreak under control in this case. Once the vaccine has been licensed, the Alliance has committed US$ 300 million for future Ebola vaccine procurement to protect against future outbreaks of this deadly disease.

    Gavi’s work in fragile settings serves to underscore the value of working together with partners. It is only through close collaboration, and by adopting flexible approaches, that we are able to support immunisation programmes in some of the most difficult and trying of circumstances. In these fragile settings, where health needs are often acute, Gavi support needs to be delivered quickly and effectively to ensure that as many vulnerable people as possible get the vaccines they need.

  • Transition

    Secrets to sustainability
    Transition and twinning

    Timor-Leste, one of the world's youngest countries, has been twinned with Sri Lanka, which has an excellent track record in immunisation, as part of a new initiative to help countries transition successfully from Gavi support.

    In a small village outside Suai, near Timor-Leste’s border with Indonesia, a health worker explains the benefits of immunisation to a group of young women, many of whom have a baby resting on their hips. Flipping through a chart showing the impact of each vaccine-preventable disease, he urges them to bring their children to the clinic for immunisation. It is a passionate performance and his audience swells as he works his way through the chart.

    Afterwards, amid the usual backdrop of cries and tears, the women bring forward the children who are due their vaccinations. Watching all of this is someone who, while not Timorese, is a true friend of the country – a Sri Lankan doctor and WHO immunisation expert, Dr Sudath Peiris. Dr Peiris is one of the driving forces behind a Vaccine Alliance-sponsored programme that twins doctors and health workers in Timor-Leste with their counterparts in Sri Lanka. He is in Timor-Leste to offer advice and suggestions to his Timorese peers on how to improve immunisation services.

    “It is very important that health workers go out to the community,” Dr Peiris says. “We have been able to make a little bit of progress and now health workers start going out to the community, finding kids and starting them on immunisation.”

    Twinning for transition

    Timor-Leste (formerly known as the Indonesian province of East Timor), has been twinned with Sri Lanka, which has an excellent track record of sustained high immunisation coverage, as part of a new initiative to help countries transition successfully from Gavi support. This process sometimes requires a degree of flexibility and some lateral thinking.

    Timor-Leste rapidly reached the level of gross national income per capita that triggers the start of the transitioning process. For some countries this can cause problems, especially if the fledgling transitioning country has not had sufficient time to build up a strong immunisation system.

    In this instance, the solution proposed was to build a system of twinning and support that would link Timor-Leste with another country that had recently transitioned and which has successfully maintained high rates of immunisation coverage. A detailed memorandum of understanding between the two governments was agreed and duly signed in September 2017, and the programme has been actively supported by WHO with Gavi funding.

    Twinning in action

    The twinning programme works like this: a group of senior health officials from Timor-Leste travelled to Sri Lanka to see how various parts of the healthcare system, including logistics and supply centres, were organised and managed. A few weeks later, Sri Lankan officials went to Dili to see if some of their practices could be employed to improve services in Timor-Leste. The reciprocal visits laid the foundation for further collaborative work, including exchanges at the grassroots level and detailed planning of activities aimed at strengthening immunisation systems in five key areas: policy development; procurement and supply chain management; data management; vaccine supplies quality and safety; and disease surveillance.

    Within South-East Asia and beyond, Sri Lanka is seen as an immunisation success story, with basic immunisation coverage rates consistently touching 99%. It is also a country that has recently transitioned from Gavi support, despite a recent period of civil unrest. While the parallels with Timor-Leste are not exact, they are close enough for the twinning arrangement to be seen as a win for both sides.

    Getting the logistics right

    In countries like Timor-Leste, getting the right vaccines to the right places is all about planning. Dr Maria Odete Belo knows this more than most – her job is to manage the central logistics and distribution warehouse for health supplies in Dili. From her warehouse, medicines and vaccines are sent throughout Timor-Leste.

    On her visit to Sri Lanka, Dr Belo saw first-hand how the country manages its health supply system and is now thinking about how some of these approaches could work in Timor-Leste. She takes up the story: “Here in Timor-Leste, we use a pull system – we distribute based on the needs of the health facilities. So we just sit and wait and when they submit their requisition, we make a distribution. Also, we don’t bring the items directly to the health facility. They are the ones who collect the items.”

    “In Sri Lanka they use a push system. They know what the health facility needs, they have their schedule and they don’t need another requisition, they know already the numbers of vaccines and other commodities that will be needed.”

    Thanks to the twinning partnership, Timor-Leste is now considering a similar push system to the one used in Sri Lanka.

    Making the transition

    Gavi support has helped Timor-Leste improve its immunisation services and introduce new vaccines, including pentavalent in 2012 and inactivated polio vaccine in 2015. At the end of 2017, the country transitioned out of Gavi support.

    Every Gavi-supported country will one day fund its own immunisation programme. The challenge is to ensure that countries prepare for their transition early and in a sustainable manner, so that immunisation can continue to protect children from infectious diseases after Gavi support ends.

    While twinning may be the right approach in some countries such as Timor-Leste, others may benefit from different strategies as they get ready to take on full funding of their vaccination programmes.

    I

  • Global coverage & equity

    Immunisation in Pakistan’s urban slums: a tale of two megacities

    Lahore and Karachi are two of Pakistan’s biggest and fastest-growing cities, together home to tens of millions of people. Yet in Lahore, significantly more children have been vaccinated against infectious diseases. The reasons why are salutary.

    Lahore

    Since 1998, Lahore’s population has almost doubled. Despite this, coverage with three doses of diphtheria-tetanus-pertussis- containing vaccine (DTP3) has soared from 24% in 2014 to 76% in 2016. Uniquely in Pakistan, tetanus has been eliminated in the surrounding province of Punjab. The last measles outbreak occurred in 2013.

    These successes are due to a combination of strong leadership, collaboration and a concerted effort to locate unvaccinated children. “We’ve done nothing revolutionary, just improved monitoring and surveillance,” says Dr Munir Ahmed, the Expanded Programme on Immunization (EPI)’s Project Director for Punjab Province and the man held responsible by many for the impressive improvement in vaccine coverage.

    “We had full support from the highest level. The chief minister gave his full ownership. We brought in IT solutions and built a surveillance dashboard which is available to all the districts and all the partners.”

    In another ground-breaking step, the EPI’s efforts to reach unregistered families living in Lahore’s urban slums are now supported by community-based vaccinators and communications staff hired by the Global Polio Eradication Initiative (GPEI). Importantly, the EPI and the GPEI have been brought together under one management team. “That is our strength. No other province has been able to do this,” says Dr Ahmed.

    Together, the EPI and GPEI are plotting maps of Lahore’s urban slums, helping to reveal where unvaccinated children may be living. They are also staffing community vaccination centres, and convincing hesitant parents of the benefits of routine immunisation.

    Karachi

    The population of Karachi, 1,000 km south-west of Lahore, has also grown rapidly, swelled by migrants attracted to the city’s bustling port and vibrant economy. The majority have ended up in the city’s slum areas, which have doubled in size since 2000. Plagued by violence and criminality, many have become no-go areas for health workers and international non-governmental organisations (NGOs).

    In Karachi, the precarious security situation and a lack of accurate population figures have conspired to limit the DTP3 coverage rate to less than 50%. Local vaccinators work in only 125 of Karachi’s 986 slums.

    “Anyone can survive in Karachi, this city feeds everyone,” said Dr Muhammad Amjad Ansari, UNICEF’s provincial immunisation officer. “But there is no check on how many people are coming to Karachi. Nobody knows the exact population or the situation these people are in. If you don’t know the population, how can you plan services like vaccination?”

    However, things are beginning to change and the Karachi EPI team is starting to feel more optimistic. Difficulties local authorities face in tracking unvaccinated children may be overcome by a slum mapping project jointly run by CHIP, a local civil society organisation, and UNICEF, with support from Gavi and the EPI. The approval of a new, long-term funding stream from Gavi has also enabled the Sindh provincial government to double their investment in routine immunisation. Nearly 200 extra staff have already been hired and another 1,000 vaccinators have been requested.

    Above all, the appointment of a new, committed EPI project director, Dr Agha Muhammad Ashfaq, is building momentum for improvements to the province’s routine immunisation programme. “We have done a lot over the past two years,” said Dr Ashfaq. “I believe the next survey will show that DTP3 coverage has risen to between 60% and 65%.” That’s up from 45% in 2015.

    “There is much improvement. There were big gaps for so many years, with training, with surveillance activities. Now, thanks to Gavi and the great UNICEF team out here, we cannot only stand. We can start to run.”

  • Global health security

    The rising risk of epidemics

    Events of 2016 underline the need for international action to combat new and emerging infectious disease risks.

    In February 2016, the world faced a new global health crisis. The Zika virus, already established in Brazil, was showing signs of spreading to new continents. More worryingly, the virus, which had previously been thought to cause only mild or no symptoms, was implicated in thousands of cases of congenital defects or nerve damage in babies.

    This unexpected public health emergency followed the devastating outbreak of the Ebola virus in west Africa, the largest in recorded history. Between 2014 and 2016, this latest epidemic killed more than 11,000 people and infected more than 28,000.

    With each disease demonstrating novel behaviours, either in the way the virus spread or in how it affected people, the global health community was caught off-guard.

    Traditionally, Zika was viewed as a cause of relatively benign asymptomatic or mild flu-like disease. The outbreak in Brazil changed this perception as evidence mounted of a link between more widespread infection and a sudden spike in the number of babies born with abnormally small heads, a condition known as microcephaly. Spread by Aedes aegypti mosquitoes, scientists feared the virus may be also sexually transmitted.

    Likewise, for decades Ebola has been a relatively low-impact disease, confined to small outbreaks in remote and relatively sparsely populated rural regions in Africa. Previous outbreaks were so aggressive that they usually immobilised and killed their victims before the virus had the opportunity to infect others. But in late 2014, Ebola reached densely- populated urban areas, where it was able to spread extremely rapidly.

    As both the Ebola and Zika outbreaks posed a threat to other nations, WHO declared each to be a public health emergency of international concern and called for international responses.

    Even by themselves, such outbreaks are a major concern. But when one considers that these recent events may become more common – and potentially have even greater catastrophic consequences – then those concerns become much more acute.

    There is a very real danger that climate change and the increasing mass movement of people and animals will spread diseases and their hosts to new parts of the world. The combination of population increases, land degradation, conflict and poverty, all of which fuel urban migration, means that viruses will have many more opportunities to proliferate in the world’s megacities. This could lead to a resurgence of large-scale urban epidemics of deadly infectious diseases.

    The potential for sudden shifts in viral behaviour or transmission makes future public health threats very difficult to predict. This coupled with the predicted increase in the number and scale of urban outbreaks will challenge our ability to respond, placing unprecedented stresses on our lines of defence and stocks of critical vaccine supplies.

    Millions at risk

    The summer of 2016 provided another serious wake-up call for the global health community, when the worst yellow fever epidemic in 30 years unfolded in Angola. For years, relatively small outbreaks of this mosquito-borne disease had been confined to rural areas of Africa and South America. However, in 2016 an outbreak spread to the Angolan capital, Luanda, where yellow fever vaccine coverage rates were low.

    Despite the distribution of more than 13 million doses of yellow fever vaccine, the virus also spread to Kinshasa in the neighbouring Democratic Republic of the Congo (DRC). It took a further 15 million doses to contain the epidemic.

    Approximately 90 million doses of yellow fever vaccine are produced globally each year. Emergency stockpiles stand at 6 million doses.

    To contain the epidemic in Angola and DRC, doses had to be diverted from preventive campaigns, risking outbreaks elsewhere and leaving emergency stocks severely depleted. To make existing supplies go further, in some regions WHO and UNICEF resorted to fractional dosing, administering just one fifth of the normal dose to each person.

    Yellow fever already kills up to 60,000 people a year. To date, it has not spread to Asia where more than 1.8 billion unvaccinated people live and any significant outbreak could spell disaster. No one knows why yellow fever has failed to establish in Asia, as the Aedes aegypti mosquito – which transmits yellow fever as well as Zika – is highly endemic in the region. In 2016, 11 cases did reach China, but they were contained.

    Prevention is everything

    The current levels of yellow fever vaccine stocks are not designed to cope with large-scale urban epidemics. But the world is changing. In 1950, two thirds of the world’s population lived in rural areas, and one third in urban settings. By 2050, this rural–urban split will likely have reversed. And as the number of megacities increases, each home to 10 million or more people, our emergency stockpiles of vaccines may no longer be adequate.

    These new realities have forced a reassessment both of the risks posed by infectious, transmissible diseases and the existing approach to preventing outbreaks. In December 2015, WHO brought together scientific experts to draw up a list of 11 diseases for which no drugs or vaccines currently exist. The list includes Ebola and other haemorrhagic fevers such as Marburg and Lassa fever, and Zika.

    In order to assist the accelerated development of vaccines which protect against the 11 diseases on WHO’s list, Gavi has been engaged in the establishment of the Coalition for Epidemic Preparedness and Innovation (CEPI). Founding partners include the Governments of India and Norway, the Bill & Melinda Gates Foundation, Wellcome Trust and the World Economic Forum.

    In addition, at the end of 2015, Gavi’s Executive Committee approved an Advanced Purchase Commitment, providing US$ 5 million towards the costs of the development of a candidate Ebola vaccine. In return, the Committee asked that 300,000 doses be made available and for the vaccine to be submitted for licensure by the end of 2017. Once approved, a stockpile will be created. However, increasing emergency stockpiles, including for new vaccines once they have been developed, is only part of the solution. The best way to prevent major disease outbreaks is to stop them happening in the first place by investing in public health infrastructure.

    Strong health systems help prevent future outbreaks via pre-emptive vaccination campaigns and supporting high levels of childhood immunisation.

    They also improve surveillance and the ability of fragile countries to identify and respond to outbreaks quickly.

    The experiences of 2016 have provided some salutary lessons. In Brazil, efficient surveillance by public health workers rapidly established the link between rising numbers of babies born with microcephaly and the spread of the Zika virus. In contrast, in west Africa, where health systems are less well equipped and disease surveillance is more limited, at least three months passed between the first person being infected with Ebola and a laboratory confirming the spread of the virus.

    The case is clear. Strengthening routine immunisation systems in the poorest countries not only helps save vulnerable lives, it also makes the world safer by mitigating the growing threats to global health security.

  • Global health security

    A new kind of fragility

    From a global health perspective, Syria’s humanitarian crisis has revealed a new kind of fragility that has required a new kind of response.

    Since the start of the current conflict in 2011, Syria’s immunisation coverage has plummeted to just 42%; it is now the third lowest among 84% vaccine coverage, pre-conflict coverage falls, the risk of infectious disease outbreaks rises. Cases of polio, measles and meningitis are also likely to become more common.

    In December 2016, the Gavi Board responded to the humanitarian crisis in Syria by pledging up to US$ 25 million a year for two years to support emergency vaccination campaigns and to provide cold chain equipment. The aim is to help UNICEF and partners immunise 3 million Syrian children under the age of five.

    The challenge will be reaching those 3 million children when more than a third of Syria’s remaining population has been uprooted from their homes. Seven years of conflict have displaced more than 11.1 milliona people. Many have reached humanitarian camps, but an additional 4.9 million are trapped in besieged cities and hard-to-reach areas.

    People caught up in conflict are often invisible to humanitarian agencies yet highly vulnerable to infectious disease. Large numbers of unvaccinated people living in close proximity, with limited access to water and sanitation, represent a fertile breeding ground for outbreaks.

    This situation is not unique to Syria. In 2008, roughly 60% of all internally displaced persons (IDPs) were located in rural areas with the majority residing in humanitarian camps. Now, nearly 10 years on, roughly the same percentage of IDPs seek refuge in urban areas while just 1% shelter in camps. Far from fleeing cities, most of the world’s 65 million displaced appear to be hiding in them.

    For global health organisations, this new type of fragility has serious implications. New solutions are needed to reach displaced persons, be they fleeing conflict, persecution, climate change or poverty. To begin to address such issues, Gavi has introduced a new fragile state policy, which provides the Alliance with the flexibility to tailor support to a country’s individual needs.

    a – Source: United Nations Office for the Coordination of Humanitarian Affairs report, December 2016

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