UNICEF: The State of the World’s Children Report 2023

The UNICEF flagship report, The State of the World’s Children 2023: For every child, vaccination, was released in April 2023. This annual report aims to deepen knowledge and raise awareness of key issues affecting children while advocating for solutions to improve their lives. The 2023 edition examines the state of vaccination across different regions of the world. The report emphasises that while vaccines save lives, too many children, especially in poor and remote areas, remain unvaccinated, a problem worsened by the COVID-19 pandemic. It calls for increased investment in primary health care and support for health workers, primarily women. Building confidence in vaccines and using new technologies are also crucial. The report warns that failing to vaccinate children endangers their health and societal development, stressing the need for innovative financing and technological solutions to ensure every child is vaccinated.

Impact of COVID-19 on Childhood Vaccination

• Vaccination coverage dropped to levels last seen in 2008, reversing over a decade of progress. The pandemic resulted in more than a decade’s worth of lost progress in just two years.
• The number of zero-dose children rose from 13 million in 2019 to 18 million in 2021. The number of under-vaccinated children increased by 6 million, reaching 25 million.
• The largest increases in zero-dose children were observed in India, Indonesia, Myanmar, and the Philippines.

Zero-dose refers to children who have not received any vaccinations. These children often live in communities facing multiple deprivations. Under vaccinated describes children who have received some but not all of their recommended vaccinations.

• DTP3 vaccine coverage fell from 86 per cent to 81 per cent. Measles vaccine coverage experienced a similar decline. The number of measles cases doubled in 2022 compared to the previous year.
• Global HPV vaccine coverage dropped by more than a quarter. School closures contributed significantly to this decline.
• The major reason for the decline was the diversion of health systems resources to pandemic response, affecting routine care. Nearly half of 72 countries surveyed by WHO reported disruptions in routine vaccination programs.
• Vaccination campaigns were cancelled or postponed, resulting in the loss of millions of vaccine doses. By the end of 2021, stalled campaigns in African countries resulted in the loss of 382 million doses.
• The pandemic led to a shortage of skilled health workers. Health workers faced increased workload, risk of infection, social discrimination, and burnout.
• Global vaccine sales fell by about a third in April 2020. Supply constraints were relatively short-lived but impacted vaccine availability.
• Other reasons included travel restrictions, budget constraints, and fear of COVID-19, leading families to confusion, and stay-at-home recommendations by governments.      

Role of Social, Cultural, Economic, and Gender-Related Factors in Shaping Immunisation Outcomes

• Many vulnerable children remain unimmunised due to certain barriers and socioeconomic determinants such as poverty, location, and marginalisation. These children often reside in remote rural areas, urban slums, crisis-affected zones, and migrant or refugee communities.
• Poverty Children from the poorest households are less likely to be immunised, with 22.6 per cent being zero-dose compared to 4.9 per cent in the wealthiest households.
• Location In low- and middle-income countries, 15.1 per cent of children in rural areas are zero-dose compared to 9.4 per cent in urban areas.
• Marginalisation Ethnic, gender, and educational disparities contribute to lower immunization rates.
• In West and Central Africa Some 48.6 per cent of children from the poorest households are zero-dose, compared to 6.3 per cent from the wealthiest.
• In Eastern Europe and Central Asia, 4.5 per cent of children in the poorest households are zero-dose compared to 8.1 per cent in the wealthiest.
• Ten countries, including Angola, Nigeria, and the Central African Republic, have the largest gaps in zero-dose children between urban and rural areas.
• Mothers’ education level significantly impacts immunization rates. Zero-dose prevalence is 23.5 per cent among mothers without education, 13.1 per cent with primary education, and 6.9 per cent with secondary education.
• In countries like Nigeria, there is a substantial gap in zero-dose children linked to mothers’ empowerment level, with 53.2 per cent prevalence among low-empowerment mothers and 10.8 per cent among highly empowered mothers.
• Instability and conflict severely disrupt health systems, reducing vaccination rates. In 2018, 40 per cent of unimmunised children lived in fragile or conflict-affected settings.
• Displacement due to conflict or crisis complicates vaccination efforts as displaced families may be hard to locate and face additional socioeconomic hardships.
• Children in poor households are less likely to be vaccinated than children in wealthy households. Nigeria, Angola, and Papua New Guinea are among the countries with the largest gap.
• The report mentions the case study of Nigeria’s vaccination efforts focusing on mobile outreach in urban slums like Gengere, Lagos, to reduce zero-dose children, supported by UNICEF and the U.S. Government. Challenges in vaccination include dense population, limited services, and financial constraints, but integrated outreach programs have successfully increased vaccination rates among vulnerable families.
• Gavi, the Vaccine Alliance helped immunise over 981 million children, mobilising over US$ 40 billion.
• The Global Polio Eradication Initiative reduced polio incidence by over 99.9 per cent since 1988.
• Women make up 63.8 per cent of the workforce in low- and middle-income countries, and 75.3 per cent in high-income countries, earning an average of 20 per cent less than men.
• The case study of Yemen reveals that female health workers are essential, particularly in rural areas, providing maternal and newborn care.
• Mobile clinics and targeted outreach campaigns have effectively increased vaccination coverage, particularly for zero-dose children.
• In Kenya and Uganda, house-to-house visits by community health workers have led to increased immunisation coverage and reduced numbers of children missing follow-up doses for vaccines like measles and diphtheria.
• Integration of services, while initially expensive, is crucial and must be sustained to reduce the number of zero-dose and under-vaccinated children.
• Community engagement is vital, as demonstrated by the Immunization Agenda 2030, which emphasises integrating immunisation into primary health care and involving community leaders to ensure culturally appropriate services and combat misinformation.
• Integrated Service Delivery (ISD) initiatives in Pakistan, supported by organisations like the Bill & Melinda Gates Foundation and UNICEF, link polio vaccination with multiple services such as health care, nutrition, and sanitation, leading to a significant drop (72 per cent) in polio vaccine refusals from 2019 to 2022 in Gujro, Karachi. The initiative also includes six dispensaries, water filtration plants, and off-site health camps linked to polio campaigns.

The Immunisation Agenda 2030 (IA2030) is a global strategy endorsed by the WHO, with the support of countries and partners, aimed at ensuring that immunisation reaches everyone over the next decade. It seeks to halve the number of children missing essential vaccines and achieve 90 per cent coverage for key vaccines, potentially saving an estimated 50 million lives. The agenda aims to significantly increase the introduction of new vaccines in individual countries, building on the progress made between 2010 and 2017, when 116 low- and middle-income countries introduced at least one new vaccine. It also aims to strengthening health systems and integrating immunisation into primary health care services emphasising on the central role of national governments.

Role of Vaccine Confidence in Childhood Immunisation

• Vaccine acceptance hinges on trust in governments, healthcare providers, and vaccine producers. Global declines in confidence stem from misinformation and political polarisation.
• The COVID-19 pandemic exacerbated vaccine hesitancy with uncertainties and rapid developments, intensifying online misinformation and reshaping public perceptions of vaccine safety and efficacy.
• Data from the Vaccine Confidence Project underscore widespread declines in perceived vaccine importance globally. While China (95 per cent) and India (98 per cent) saw increased confidence, many African countries experienced declines.
• Post-pandemic, younger adults and women exhibited higher vaccine hesitancy, revealing demographic disparities in vaccine perceptions.
• Case studies from Samoa, the Philippines, and Pakistan highlight severe consequences of vaccine misinformation, leading to outbreaks and reduced immunisation rates.
• Effective strategies include community engagement, social listening, and tailored education to address community-specific concerns and combat misinformation.
• Successful interventions necessitate political commitment, community involvement, and targeted educational campaigns to bolster vaccine acceptance.
• Accessibility, affordability, and availability of vaccines are crucial for sustaining high immunisation coverage globally.
• In Remo North, Nigeria, community-led efforts boosted full immunisation coverage by 30 percentage points.
• Informal training of traditional and religious leaders in Cross River State, Nigeria, significantly improved vaccination rates.
• Community engagement strategies across 61 studies increased full vaccination rates by 14 percentage points at an average cost of US$3.68 per child for each percentage-point increase.
• In Ethiopia, Myanmar, Nigeria, and Pakistan, involving community leaders in monitoring enhanced vaccine acceptance.
• Women’s empowerment correlates positively with childhood immunisation rates, with initiatives in Nigeria and Ethiopia showing improved vaccine uptake.
• Tools like the Vaccination Demand Observatory (VDO) dashboard facilitate real-time monitoring of vaccine acceptance to counter misinformation effectively.
• Pro-vaccine education and culturally appropriate public messaging have successfully increased vaccine acceptance, with examples of improved HPV vaccination rates through social marketing campaigns.
• Community health volunteers in Ecuador and other regions play a pivotal role in increasing vaccine coverage through local engagement and monitoring.
• Innovation in immunisation spans beyond technology, encompassing new ideas and approaches in financing, vaccine research, product development, and delivery systems. This innovation is essential for achieving sustainable and equitable immunisation coverage.

Current Funding Landscape

• From 2000 to 2017, US$ 112.4 billion was spent on immunization in low- and middle-income countries.
• In 2017, approximately US$ 40 was spent per surviving infant in low-income countries and US$ 42 in lower-middle-income countries.
• Governments are the largest contributors to immunisation funding, with donor assistance playing a significant role, especially in low-income countries.
• Challenges in funding and spending include economic instability and fiscal constraints post-COVID-19, which have hindered government spending on immunisation. Many countries underspend allocated budgets due to procurement and coordination issues, leading to vaccine shortages and lower coverage rates.
• Countries can waste 20–40 per cent of their health resources due to inefficiencies. Improving budget transparency and execution, along with enhancing procurement and service delivery efficiency, are critical.
• Meeting immunisation goals, especially reaching zero-dose and under-vaccinated children, requires significant investment. This investment should not only focus on financial resources but also on partnerships, political will, and effective planning.
• Recent years have seen advancements in vaccine technologies such as mRNA vaccines, which were accelerated due to the COVID-19 pandemic.
• New vaccines for diseases like malaria, RSV, and polio are in development, alongside innovations in vaccine delivery methods and formulation to improve accessibility and effectiveness.
• Innovations like vaccine vial monitors, freeze-preventive carriers, drones for delivery, and solar direct drive refrigeration systems are improving vaccine delivery to remote and underserved areas.
• Electronic immunisation registries (EIRs) and geographic information systems (GIS) are enhancing data accuracy, monitoring vaccine coverage in real-time, and improving program efficiency.

India’s Scenario

Vaccine perception and immunisation About 99 per cent of the Indian population perceive vaccines as important for children, a significant increase post-pandemic. Eighteen percent of children in India are zero-dose, equating to around 2.5 million children. There was a notable rise in zero-dose and under-vaccinated children between 2019 and 2021. Fully vaccinated children aged 8 to 11 show a 6–12 per cent improvement in basic reading, writing, and math skills. Initiatives in Uttar Pradesh and Bihar increased vaccination rates through community engagement and health education. Systems like TeCHO+ and eVIN have improved vaccination coverage and data management in India.

Demographics (2021) India’s population is 1.4 billion, with 438 million under 18 and 115 million under 5. The annual population growth rate is 1.3 per cent (2000–20) and expected 0.7 per cent (2020–30). The urban population growth rate is 2.4 per cent (2000–20) and expected 2.0 per cent (2020–30). Life expectancy has increased from 48 years in 1970 to 67 years in 2021.

Child mortality (2021) The under-five mortality rate has decreased from 127 (1997) to 31 (2021), with an annual reduction rate of 5.2 per cent. The infant mortality rate has reduced from 89 to 25, and the neonatal mortality rate has decreased from 57 to 19.

Maternal and newborn health (2021) The female life expectancy is 69 years. Universal health coverage for reproductive, maternal, newborn, and child health is at 61 per cent. Seventy-three percent of the demand for family planning is satisfied with modern methods. Antenatal care is at 85 per cent for at least one visit and 59 per cent for four visits. Delivery care includes 89 per cent skilled birth attendants and institutional delivery, and 22 per cent C-section. There were 24,000 maternal deaths, with a maternal mortality ratio of 103.

Child health (2021) Immunisation coverage rates are as follows: BCG (84 per cent), DTP1 (88 per cent), DTP3 (85 per cent), Polio3 (85 per cent), MCV1 (89 per cent), MCV2 (82 per cent), HepB3 (85 per cent), Hib3 (85 per cent), Rota (83 per cent), PCV3 (25 per cent), and Tetanus (90 per cent). Intervention coverage rates are 56 per cent for acute respiratory infection, 61 per cent for diarrhoea treatment with ORS, and 80 per cent for malaria care.

Nutrition Among children aged 0–4 years, 31 per cent are stunted, 19 per cent are wasted (with severe cases at 8 per cent), and 2 per cent are overweight. Among school-aged children (5–19 years), 27 per cent are thin and 7 per cent are overweight. Among women, 24 per cent are underweight and 53 per cent are anaemic. Ninety-four percent of households consumed iodised salt between 2015–21.

Education Early childhood education attendance is at 14 per cent. Completion rates for primary education are 92 per cent for males and 91 per cent for females, for lower secondary education 82 per cent for males and 79 per cent for females, and for upper secondary education 46 per cent for males and 40 per cent for females. Youth literacy rates are 93 per cent for males and 90 per cent for females.

WASH (water, sanitation, and hygiene) As of 2020, 90 per cent of households have basic drinking water services, 71 per cent have basic sanitation, and 68 per cent have basic hygiene. In 2021, 74 per cent of schools had basic water services, 86 per cent had basic sanitation, and 53 per cent had basic hygiene.

Social and gender index (2019) Labour force participation rates are 76 per cent for males and 21 per cent for females. The unemployment rate is 5 per cent for both males and females.

Economic indicators GDP per capita is US$ 2,100.

Migration and displacement The international migrant stock in 2020 was 4,879. In 2021, there were 527,873 internally displaced persons, with 1.5 million children affected by internal displacements due to disasters.

Social protection 42 per cent of mothers received cash benefits between 2010–2019. Twenty-four per cent of children were covered by social protection between 2010–2019.

Action Agenda: Four Key Recommendations

Enhance digital platforms for vaccination campaigns Utilise real-time tracking for vaccination progress and daily reporting to improve coverage, especially in areas with vaccine hesitancy (e.g., Indonesia’s RapidPro Platform).

Implement digital health platforms for efficient case management, data entry, and vaccine supply chain monitoring (e.g., India’s eVIN for cold-chain equipment monitoring).

Expand effectiveness of mobile health (mHealth) interventions Deploy mHealth strategies such as text message reminders to enhance vaccine coverage, particularly in low- and middle-income countries.

Evidence shows significant increases in immunisation rates among pregnant women receiving tetanus shots through mobile interventions.

Promote local vaccine manufacturing Develop local vaccine production capacity to reduce dependency on foreign supplies, ensuring equitable access during pandemics.

The African Union’s goal to produce over 60 per cent of vaccine doses locally by 2040 is pivotal for enhancing regional vaccine security.

Strengthen financial investment and health systems Address challenges in reaching remote communities by supporting mobile clinics and community health workers (CHWs).

Invest in a robust health workforce and sustainable financial support to maintain outreach activities effectively.

Some other recommendations include

• Increase the health workforce in low- and middle-income countries to bolster successful vaccination programs.
• Provide integrated management training for health workers to improve skills in immunisation and childhood illness management.
• Improve compensation, employment opportunities, and career pathways for women in the health workforce to address gender disparities.
• Recognise and properly training CHWs to optimise their role in connecting immunisation services with communities, particularly in underserved areas.
• Ensure immunisation services are integral to primary health care systems to achieve global vaccination goals effectively.
• Increase government revenue, utilise debt relief, implement health-related taxes, and expand health insurance schemes to augment immunisation funding.
• Forge stronger collaborations between governments, donors, and international organisations to sustain immunisation programmes globally.

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