MOMENTUM Routine Immunization Transformation and Equity Project

The MOMENTUM Routine Immunization Transformation and Equity project aims to reduce the number of zero-dose and under-immunised children in its national and sub-national project areas by identifying root causes of entrenched obstacles. The project does so by helping countries engage new partners from within and beyond the health sector who bring different expertise and approaches to addressing obstacles to equitable immunisation coverage. The project mobilises a diverse set of stakeholders at the sub-national level (such as local non-governmental organisations (NGOs) and non-health government agencies) and facilitates deeper engagement with community-level actors to improve immunisation quality and utilisation. These strategies are compatible with the project's active use of human-centred design (HCD) and co-creation methods that focus on the perceptions, needs, and circumstances of a range of stakeholders. The project works with partners to strengthen capacity to implement solutions.

The MOMENTUM Routine Immunization Transformation and Equity achieves its objectives through specific technical priorities:

• Identify and analyse the root causes for inequitable immunisation and co-create context-specific solutions to reach zero-dose and under-immunised populations.
  • Example: The project's initial assessment of barriers in the Democratic Republic of the Congo (DRC), Mozambique, and Nigeria found that power dynamics play an important role in how immunisation services are delivered. In some of these settings, health workers held relative privilege and wielded power over clients; however, their managerial and institutional superiors simultaneously made them feel disempowered and undervalued. The findings also showed that while caregiver reports of service quality varied across those interviewed, mothers of under-vaccinated children were likely to report poor service experience as a reason for not returning.
• Build health personnel capacity to plan and provide high-quality immunisation services to all populations.
  • Example: In Nigeria, the project helped review the National Community Engagement Strategy and, at the state level, provides technical assistance for the updated communication and demand generation strategy and builds capacity to address social and gender norms through engagement with community mobilisers. In addition, the project works with local immunisation officers to introduce a gender equity lens into their supportive supervision activities.
• Strengthen community partnerships and integrate behaviour change, gender,  and equity considerations to improve uptake and build trust and confidence in vaccination.
  • Example: The multi-country research cited above informed co-creation workshops that brought health workers and community members together using tools from HCD and the Journey to Health and Immunization Framework. During these workshops, participants used vignettes - short stories developed by the research team using synthesised, non-identifiable data that centred around caregivers' experiences - to illustrate common immunisation challenges. Vignettes included "caregiver facing multiple intersecting and interacting barriers based on her context" and "immunisation services not aligned with a caregiver's needs". The co-creation workshops were described as effective in using identified barriers and drivers of vaccination and in creating the space for community and health system participants to come together as equals to propose solutions to those problems. Many solutions reflected ideas on people-centred care and improved service experience, like integrating delivery of all child health services at facilities and reducing wait times.
• Expand partnerships with other health and non-health stakeholders to improve immunisation access, quality, and utilisation.
  • Example: In DRC, the project collaborates with a local women's rights organisation, Femmes Mains dans la Main pour le Développement Intégrale (FMMDI), in Kasaï-Central Province to improve the use of vaccination services. With project support, FMMDI engages members of the health department, civil society groups including women's and youth organisations, political and administrative authorities, and local businesspeople to co-create local solutions through the use of HCD methods. Solutions include raising awareness among grassroots women's organisations on the importance of vaccinating children and women of childbearing age and mobilising resources to increase demand for vaccination. FMMDI has incorporated information on vaccination into the instructional materials it uses with women who are learning to read and write. These women have themselves become peer educators for other women in the community, creating a multiplier effect focused on awareness-raising and referrals to the health centre. The focus on facilitating women's use of vaccination services has reportedly led to substantial increases in the numbers of doses of vaccines administered to both children and women of childbearing age.
• Strengthen adaptive management, use of data, and leadership capacity for immunisation.
• Improve capability in immunisation financial management and domestic resource mobilisation.

As suggested by several of the examples above, the MOMENTUM Routine Immunization Transformation and Equity project works to mainstream gender into its global and country-level work, incorporating gender considerations into all phases of the programme cycle, from assessment to activity design, strategic communications, monitoring, evaluation, and continuous learning. Its gender mainstreaming efforts focus on five areas of improvement for immunisation: service access and convenience; service quality and experience; communication and demand generation for immunisation among caregivers (both women and men) and families; making services more responsive to agency and autonomy constraints of female caregivers; and the conditions and circumstances of health workers, who are mostly women. Here are two further illustrations, which also speak to the capacity-building technical areas listed above:

• Around the world, women are generally held responsible for their children's health, including RI. In Mozambique, the project works to improve men's and boys' understanding of RI and what they can do to support their families' well-being. M-RITE used gender-sensitive assessment methods to identify entrenched obstacles to RI and underlying causes in districts in Nampula and Zambezia provinces. These findings were used to develop activities that include working closely with community health committees, community health workers, and religious leaders. One aim is to increase their recognition of the importance of male engagement in RI, reduce the imbalance of power between mothers and fathers, and build capability to negotiate ways to meet their children's immunisation and health needs. The project conducts capacity building for health workers and community dialogues with community members to discuss practical actions that men and boys can take to help increase child immunisation. The vaccination calendar is used as a key instrument for equipping community focal points and female and male caregivers with information on when to come for vaccination and the vaccines to be provided. Project efforts are tailored to the specific social norms and educational levels of different communities. This work is amplified through working with local-language community radio stations to discuss community support for and male engagement in RI without distracting attention from women's needs and agency in this area.
• The MOMENTUM Routine Immunization Transformation and Equity project also works to grow a cadre of capable practitioners for gender and immunisation. In 2022, it conducted a four-session, month-long online short course titled Gender in Immunization: Opportunities for Action, offered through The Sabin Vaccine Institute's BOOST platform. Initially offered in English and focused on national and subnational participants from lower- and middle-income countries (LMICs), the interactive programme drew approximately 130 professionals from over 30 countries. Course facilitators prioritised peer exchanges, featuring country-level implementers who presented on their work and lessons learned. In response to demand for a French version, the project updated the course for francophone LMICs with adapted materials and content. For this effort, the project worked closely with a civil society organisation active in West and Central Africa, the Organisation d'Afrique Francophone pour le Renforcement des Systèmes de Santé et de la Vaccination (OAFRESS). Over 100 participants from 14 countries earned certificates.

Immunisation and Vaccines, Equity, Gender

In 2019, an estimated 14 million children were identified as zero-dose, meaning they had not received even a single dose of the vaccines that prevent diphtheria, tetanus, pertussis, and other diseases. An additional six million children were under-immunised, having started but not completed the vaccination schedule, and therefore, only partially protected against diphtheria, tetanus, pertussis, and six other diseases. In 2021, global immunisation coverage for infants dropped to 81%, the lowest in more than a decade, largely due to the COVID-19 pandemic, conflict, and various health systems challenges. While immunisation coverage began to recover in 2022, an estimated 20.5 million have not received life-saving vaccines.