Closing the Immunization Gap: Bringing Vaccines to Doorsteps of Families and Households

As World Immunization Week comes to a close today, it is an opportune time to reflect on the progress made to date with vaccine preventable illnesses. Smallpox is eradicated. There are some diseases on the verge of elimination. Rubella has been eradicated from two continents. Polio lingers in only two countries. Maternal and neonatal tetanus has been eliminated in India. Immunization of more than 230 million people has led to the control and near elimination of meningitis A in Africa's meningitis belt. And the continent has now been polio-free for 19 consecutive months.

Yet inequalities in access persist. We must be vigilant to curb reversal of gains in immunization coverage. A staggering 1 in 5 children are missing routine, lifesaving immunizations. The Global Vaccine Action Plan (GVAP)--a framework that sets the ambitious yet achievable goal of preventing millions of deaths by 2020 through more equitable access to vaccines--will only be achieved through a process of constant review and scaling of best practices.

The expansion of immunization requires innovative thinking. In this regard, Ethiopia's unique experience of expanding access to primary health care offers lessons for advancing immunization. Our Heath Extension Program (HEP), launched by the Ministry of Health in 2002, has dramatically reduced maternal and child deaths. The now 39,000 Health Extension Workers (HEWs) cover 16,000 health posts across the country and provide an outreach service to families. This approach has successfully brought critical services right into communities and to people's doorsteps. The HEWs provide much needed door-to-door immunization services in previously inaccessible areas due to poor infrastructure.

Ethiopia's experience with HEP holds another important lesson in identifying dropouts. Building upon the HEW model, the Health Development Army (HDA) was initiated in 2012 to bring together women volunteers from model households. These women are trained by the HEWs and play a critical role in disseminating health information and promoting positive health behaviours. The HDA conduct routine surveillance of children's participation in vaccination programs. In doing so, they are able to identify barriers to expanded immunization coverage, including substandard vaccine storage and cold chain equipment and poor interpersonal communication among providers and parents on the need to immunize children. This process of deploying the HDA helped us in dramatically reducing the number of defaulting children and improving the follow-up for multi-step vaccinations.

Through Ethiopia's Extended Program on Immunization (EPI), coverage across the country is improving, with 82.9% of children under one-year-old who are fully vaccinated. A key challenge identified was reaching pastoralist areas. The HEP program provided important lessons in ensuring equity between immunization programs in urban and rural areas. This approach mainly focused on incentivizing local champions and supporting them in encouraging immunization within their communities. This community-based approach greatly reduced challenges emanating from religious taboos by confronting local reluctance from within, thereby leading to a quadrupling in access to immunization. One of the local incentives we have used is the idea of model kebeles or "model households" to publicly recognize those within the community for health behaviors, including vaccination for all family members.

Ethiopia's HEP's door-to-door services, the effectiveness of the defaulters tracing system and our community-based champion approach hold important keys for closing the immunization gap. In line with theme of World Immunization Week, Ethiopia's game-changer - bringing health services to the doorstep as opposed to a classic health post approach - has become our norm. It is my belief that this approach can serve as a model to achieve universal access to immunization and other essential preventative services.