Addressing Determinants of Immunization Inequities Requires Objective Tools to Devise Local Solutions

"Only through developing and implementing robust local-level interventions will countries in the Region be able to achieve EIA2030's strategic priority on immunization equity: namely, ensuring that routine immunization coverage is high in every community and that all individuals have equitable access to and adequately utilize all vaccines in national immunization schedules."

The European Immunization Agenda 2030 (EIA2030) seeks to build better health in the World Health Organization (WHO) European Region by ensuring equity in immunisation and providing immunisation across the life course. Relatively high immunisation coverage in the Region has allowed it to sustain polio-free status since 2002 and to reduce the burden of other vaccine-preventable diseases. However, routine immunisation coverage still varies considerably among the Region's 53 countries, and among different populations and districts within them. Aligned to the core principle of EIA2030 to devise local solutions to local challenges, this commentary outlines what can be done to empower especially the subnational immunisation managers and functionaries of a health system to address immunisation inequities and thereby contribute to the ethos of the Sustainable Development Goals (SDGs): Leave no one behind.

As reported here, the factors that influence routine immunisation uptake are context specific and multifactorial; addressing immunisation inequities will require overcoming or removing barriers to vaccination for underserved individuals or populations. Local-level immunisation stakeholders must first identify the underlying causes of inequities. For example, formative research and behavioural analysis of a Charedi Orthodox Jewish community of the London, United Kingdom (UK) borough Hackney showed that critical issues related to sub-optimal immunisation uptake were linked to access to and convenience of immunisation services, both for the service providers and the population, while the assumption before the study was that under-vaccination was linked to cultural or religious anti-vaccination sentiment. More broadly, careful consideration of factors such as area of residence, living conditions and characteristics including age, gender, economic status, ethnicity, religion, migration status, education, and/or disability will help in the development of immunisation delivery strategies that yield more equitable uptake.

Based on this information, immunisation stakeholders are urged to tailor resources or service provision to the local context, as per the organisation and characteristics of the healthcare system in their countries. To do this, in addition to using the tools already available to broadly identify immunisation inequities at the national and regional levels (e.g., WHO's Tailoring immunization Programmes (TIP), they will need new pragmatic guidance and tools to address the identified local challenges. As argued here, the operational frameworks undergirding these efforts should be relevant to:

• Decision- and policymakers who can advocate for equity within immunisation programmes, to ensure the required political support is maintained to tackle immunisation inequity as part of the broader heath policy agenda;
• Immunisation programme managers at the national and subnational levels who are developing and implementing immunisation strategies, to embed equity in planning, delivery, and monitoring of the immunisation programmes; and
• Immunisation programme managers and their staff who are tasked with identifying, addressing, and monitoring health inequities, to gather and use information on local determinants of inequities and make informed decisions on interventions.

An operational guide that contains pragmatic, cohesive, and implementable operational frameworks relevant to these immunisation stakeholders and relevant, simple, and action-oriented tools to address immunisation inequity at the local health facility level is being developed by the WHO Regional Office for Europe in consultation with the countries in the Region. In addition, the WHO Regional Office for Europe will support capacity building of the national and subnational immunisation programme managers on the use of these tools.

In conclusion: "Achieving the health-related SDGs requires urgent attention to close the health inequity gap through collection and use of data and information at the local health facility level. Reducing inequity should be embedded as a core aim of national immunization programmes; accordingly, reducing local level inequalities in immunization service delivery and utilization must be a critical cornerstone of every national immunization strategy. Identifying, addressing and monitoring inequity within immunization programmes should become a systematic and ongoing process, with solutions tailored to the context of each country and population."