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Reaching every child: A new regional perspective on immunisation

In international development there is a tendency to think that Sub-Saharan Africa and Southern Asia are the only areas that need attention, and we can be guilty of forgetting that the rest of the world exists.

So it was something a little different for me to be invited to an immunisation conference aimed predominantly at two regions that rarely come onto my radar — the Middle East and North Africa, and Central and Eastern Europe. This part of the world faces its own unique set of health challenges.

Despite a 93% reduction in measles mortality and immunisation rates that are often in the high 80-90% bracket, there are still 250,000 unimmunised children in Central and Eastern Europe. These children are mainly in Russia, Turkey, the Ukraine and Azerbaijan.

The Middle East and North Africa region includes several middle-income countries that contain pockets of unimmunised, hard-to-reach children, making the task of universal immunisation very difficult. Egypt and Morocco fall into this category.

The issues these countries face are not unique, but they take on different dimensions in the context of this region.

Security
In the latter half of the 20th century, conflict in several African countries, such as Ivory Coast and Democratic Republic of Congo, led to the destruction of many health facilities and the infrastructure is still struggling to recover. But conflict, insecurity and political instability have hampered immunisation efforts in the Middle East and North Africa even as recently as last year.

Equity
Equity is an issue in many countries. National coverage rates often conceal huge disparities in terms of wealth, geographical location, gender and the urban/rural divide. This region is no different; but here the groups missing out tend to be immigrant communities or particular cultural groups, such as Roma children or certain tribal groupings.

In Bosnia, less than half of the districts in the country have reached 90% coverage and in Georgia that figure is 57%. According to regional targets, not one single district should be below 90% coverage.

Reverse Equity

Three Eastern European countries demonstrate an unusual trend whereby the poorest children are more likely to be immunised against measles than the richest.

Further investigation is required to uncover the exact reasons why Armenia, Turkmenistan and Belarus are displaying this phenomenon, dubbed ‘reverse inequity’, but one suggestion may be that measles campaigns are targeting the most vulnerable children but at the expense of the richer children, or alternatively that these children are obtaining vaccines outside of the public sector.

Private Sector
In some countries private sector healthcare providers are delivering immunisation services, particularly to the richer sections of society, thus creating a two-tier system. This is more salient in light of the expensive new vaccines coming to the market that can only be afforded by the few.

A parallel service provided by the private sector can create inaccuracies in data and coverage levels as private monitoring systems are not always co-ordinated with central government records.

A global challenge

So the challenge for the Decade of Vaccines is not just on the plains of Africa and in the slums surrounding Asia’s megacities; much work also needs to be done closer to home and in middle-income countries.

If the Decade of Vaccines initiative is to be the game changer it desires to be, every child in every country — rich or poor — must receive the benefits of immunisation.

Sincere thanks go to Dr Mahendra Sheth, from the Unicef Middle East and North Africa Regional office (but formally of Save the Children UK in Ethiopia), for his excellent presentation, upon which much of this blog is based.

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