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Twenty years ago, the global effort to ensure every child has access to vaccines was stuck in a rut. Since 1990 immunisation coverage in lower-income countries had started to stagnate, and had even declined, and the poorest countries had to wait an average of seven years after the richest before getting access to new vaccines. Ultimately, it was the children left unprotected against deadly diseases like measles, polio and pneumonia that suffered the consequences.

Nearly 50% of zero-dose children live in three key geographic contexts: urban areas, remote communities and populations in conflict settings.

Two decades later we have a lot to celebrate. Ten years of decline has turned into twenty years of growth. In lower-income countries 81% of children now receive routine vaccines, up from 59% in 2000, and more than 500 new vaccine programmes have been introduced and scaled up. The number of children dying from vaccine-preventable diseases in these countries has dropped by 70%. Millions more children are now growing up protected.

One of the key factors in this extraordinary progress was the creation of Gavi, the Vaccine Alliance. Created in 2000 and bringing together a range of organisations working to improve access to immunisation in lower-income countries, from governments and UN agencies, to vaccine industry and civil society organisations, the Vaccine Alliance now helps to immunise almost half the world’s children.

However, despite this progress, millions of children are still being left behind. Every year, nearly 10 million of the 72.5 million children that Gavi aims to reach in lower-income countries do not receive a single vaccine shot, leaving them vulnerable to some of the world’s deadliest diseases.

Gavi is now launching a global movement to bring an end to this inequity, making reaching zero-dose children – defined as children who don’t receive a single dose of diphtheria, tetanus and pertussis-containing vaccine – with immunisation its key priority for the next five years. The goal: to reduce the number of zero-dose children by 25% by 2025, and by 50% by 2030, which will also mark the closing of the Sustainable Development Goals.

Missed communities

Reaching these children means reaching the missed communities they are a part of. These unprotected communities are not only potential epicentres of disease outbreaks, they are also often deprived of other basic services and suffer from entrenched gender inequality.

Two-thirds of zero-dose children live in households surviving on less than US$ 1.90 per day – the international poverty line. Their mothers are twice as likely to miss out on antenatal care or skilled birth attendance. The homes they live in are less likely to have access to clean water or sanitation. A lack of immunisation is just one of a range of problems.

This means that collaboration across governments, international agencies and civil society could bring benefits far beyond immunisation alone. By working together, we have a chance to leverage all our strengths to reach these communities with everything they need for a healthy, successful life – from nutrition and education to clean water to immunisation.

The impact of COVID-19

The COVID-19 pandemic is making things worse. With immunisation, it threatens to unravel two decades of progress. COVID-19 will also make the challenge of reaching these zero-dose children even harder, as fiscal space contracts, already-limited health system capacity is diverted to COVID-19, populations move and trust in health authorities, as well as demand for vaccines, is impacted. Reaching the communities that these children are part of is more urgent and more important than ever.

However, the pandemic also provides opportunities. Governments are now working hard to stamp out COVID-19 wherever it’s circulating, meaning many of the missed communities in which zero-dose children live will be forming new contact points with the health system.

Using these new contacts to reach missed communities will improve our ability to tackle the next pandemic: the contact with the health system provided by immunisation not only improves the chances of a child living a healthy, successful life, it also means health professionals can be on the look-out for new outbreaks and new emerging diseases. This early warning system is our first line of defence against the next COVID-19.

Where do zero-dose children live?

Nearly 50% of zero-dose children live in three key geographic contexts: urban areas, remote communities and populations in conflict settings.

While these missed communities exist in the majority of countries in which the Vaccine Alliance works, two-thirds of zero-dose children live in just five countries: Nigeria, India, the Democratic Republic of the Congo, Pakistan and Ethiopia. A further 18% live in 16 fragile countries. There are substantial variations between and within countries, for example DRC and Ethiopia have the largest number of zero-dose children in remote rural areas, while Nigeria has the largest number of zero-dose children impacted by conflict.

What is Gavi doing about it?

There is no one way of reaching these missed communities. Approaches will vary from country to country and within countries, contexts and settings. It will require flexibility, innovation and the expertise of organisations working in a range of fields.

It will mean working with new partners and new ways of working, particularly in fragile, conflict and cross-border settings outside government reach. Over the past year Gavi has announced new partnerships with humanitarian organisations, including the International Federation of Red Cross and Red Crescent Societies (IFRC), the International Rescue Committee (IRC), Save the Children, the International Organization of Migration (IOM), the UN Office for Project Services (UNOPS) and UNHCR – the UN Refugee Agency. These will be crucial to reach zero-dose children in humanitarian and conflict areas.

It will also mean new funding. In December 2020, the Gavi Board approved US$ 600 million over the next five years to help reach the millions of children still not receiving routine vaccines in Gavi-supported countries.

It will also require a renewed focus on gender – one key barrier stopping children from receiving vaccines is entrenched gender inequalities. Only through dedicated funding, new partnerships and collaboration across the Vaccine Alliance on equity with gender as an integral part will we make the progress we need on reaching the unreached.

Above all, it will mean doing things differently, trying new approaches and learning from past ones, with a central mission to leave no one behind.

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