A Practical Guide to Identifying, Addressing and Tracking Inequities in Immunization

"Resolving inequities in immunization will improve uptake and reduce the risk of future outbreaks and preventable cases in those who are often at higher risk of infections and severe outcomes."

The reasons for inequitable vaccine coverage are multiple and complex. Immunisation inequities can be related to the capability of groups or individuals within a group to access vaccination services, the motivation to access vaccination, or the opportunity to access vaccination services. Immunisation inequities can exist even in programmes with high national immunisation coverage and may not be apparent until they are looked for. Published by the World Health Organization (WHO) Regional Office for Europe, this document provides practical guidance for those working in immunisation programmes to help advocate for immunisation equity, embed equity as an aim in delivery of immunisation programmes, and understand existing inequities by considering: who is left behind; why they were left behind; how we can intervene to resolve and avoid this; and whether intervention has made a difference.

The guide aims to:

• improve understanding of immunisation equity, and help those managing, overseeing, or working within vaccination programmes to advocate for it;
• provide practical and pragmatic advice rather than theoretical recommendations;
• engage and be relevant for individuals at all levels from local health facilities up to the health ministry;
• build on existing guidance and give examples of how to operationalise it;
• offer a range of approaches considering the diversity in health systems across the WHO European Region, while acknowledging that countries are at different stages of identifying and addressing immunisation inequities; and
• encourage an intersectoral approach with other programmes, functions, organisations, and agencies.

The resource comprises three main sections:

1. Immunisation equity and its importance: This section seeks to improve understanding of immunisation equity for decision-makers and policy-developers, as well as those managing programmes and services, who will need to advocate for equity, support it, and make it a policy priority.
2. Embedding equity in delivery and monitoring of immunisation programmes: This section is primarily for immunisation programme managers at the national, subnational, and local levels who are implementing an equity strategy. It contains examples of how immunisation equity can be embedded into roles and responsibilities at different levels of the national programme.
3. Frameworks, examples, and practical guidance: This section contains a series of frameworks and concise examples of how to identify, address, and monitor immunisation inequities. This is the most technical section of the document and is aimed at programme managers and those on the ground. It focuses on these steps:
   • Step 1. Identify vaccine inequities and under-vaccinated populations.
   • Step 2. Characterise root causes of immunisation inequities and under-vaccination.
   • Step 3. Develop interventions - e.g., using information (increasing knowledge or understanding); persuasion (using communication to induce positive or negative feelings or stimulate action); incentivisation (creating an expectation of reward); coercion (creating an expectation of a cost or other negative outcome); training (imparting skills); restriction (using rules to reduce the opportunity to engage in the target behaviour); environmental restructuring (changing the physical or social context); and modelling (providing an example for people to aspire to or imitate). Key messages:
     • The most effective interventions to reduce inequity are likely to be multi-component and can be context specific.
     • There are no "off the shelf", ready-made interventions likely to be entirely suited to specific contexts, and even evidence-based interventions successful elsewhere may require tailoring.
     • National and subnational teams should consider whether it is possible to adapt existing evidence-based interventions to their context and situations, or whether the situation demands a completely new approach.
     • Interventions should address barriers identified through research, not assumptions.
     • Early planning and identification of relevant stakeholders, potential risks, and performance indicators before implementing are key to success.
   • Step 4. Monitor, evaluate, and disseminate the impact of the interventions.

Annex 1 includes documents addressing inequities in immunisation.

All in all, the resource makes the point that "Identifying and addressing immunization inequities is core to the success of immunization programmes and will require a collective effort from all parts of the immunization programme, working in partnership with governments and other areas of health."