Opinion: Rethinking immunization strategies to reach the urban poor

A cooler containing vaccines. Photo by: JC McIlwaine / United Nations / CC BY-NC-ND

Almost one third of the world’s urban population — about 1 billion people — live in poverty. This is likely to increase over the next 40 years, with 90 percent of urban growth occurring in low and middle income African and Asian countries. Rapid urbanization is outpacing the public sector’s ability to build essential infrastructure and systems to provide basic healthcare and social services, leaving these cities with a myriad of interrelated challenges, including over-extended resources, sub-standard services, weak coordination and increased possibility of social unrest.

These global trends are particularly important for national immunization programs, as vaccine preventable diseases have higher potential for transmission in densely populated urban areas, particularly among rural-urban migrant populations living in crowded slums.

The World Health Organization’s Expanded Program on Immunization was designed over 40 years ago, to support vulnerable rural populations in their efforts to overcome geographic barriers to accessing services. This model successfully helped increase immunization coverage rates. However, in 2009, the world’s population officially became more urban than rural. Inequities between communities continue to rise, due to increasing social barriers to access. The traditional rural EPI model requires adaptation if the needs of the growing urban poor are to be met. Five potential immunization program adaptations could address other health-related problems faced by the urban poor.

1. Understand the underlying reasons for inequality.

Although urban populations have more service provision points compared to rural populations, the urban poor have limited access to health care for economic, social and cultural reasons. These include inability to pay, unsuitable location of the facilities, social distance, inconvenient hours of operation, and poor quality of public health services. As a result, the children of rural-urban migrant families are less likely to be fully immunized than urban non-migrants as well as the general population in low-income and middle-income countries.

However, due to a lack of disaggregated data, this equity gap in immunization coverage among the urban poor is often masked by high overall urban coverage. In order to fully understand the immunization situation, a landscape analysis focusing on urban poor areas is needed to identify who the underserved populations are, where they live, the specific reasons why they are underserved and the barriers they face in trying to use services.

2. Strengthen advocacy efforts to achieve high-level political will.

The voice of impoverished urban groups is often not heard, as they may be residing in settlements that are not officially recognized. At the same time, city administrations generally give greater importance to services with greater political visibility, such as curative care, road maintenance, sewerage, waste disposal and mosquito control. Immunization can fall by the wayside, set against other priorities for the growing urban center. Focused advocacy with city planners, civil society and other decision makers is necessary to discuss urbanization and its political, social, and health consequences, particularly relating to immunization.

3. Develop city-specific models with tailored interventions to reach the most vulnerable.

Each city is unique in its size, population, administration, infrastructure and availability of resources and services. Also, parents of urban poor families have competing priorities to bring food to the table for the family, making it harder to bring children in for vaccination during traditional clinic hours for immunization. It is necessary to develop tailored strategies that will meet the needs and specific situations of urban poor families.

4. Develop a multi-sectoral approach.

Multiple parties and providers — public, NGO and private — have varying levels of involvement or responsibility for providing immunization services in urban areas. But they often work without much coordination. It is necessary for cities to form a multi-sectoral committee to coordinate the plan, design and implementation of interventions and activities for urban immunization, particularly in urban poor areas. The committee should include a wide range of stakeholders from different sectors, including interministerial, civil society and community representation, to increase immunization uptake by vulnerable populations. This has the potential to coordinate and deliver multiple health interventions.

5. Develop alternative data collection and monitoring systems for urban poor areas.

Estimating population denominators, demarcating catchment areas and tracking records of vaccinations are much harder to carry out  in urban areas, in part due to migration. Urban poor households, especially informal settlements, are often invisible in population surveys or official statistics, and unrecognized by researchers, analysts, city planners and others. It is necessary to develop an alternative system for periodic assessments and concurrent monitoring of immunization coverage in urban poor areas.

The urban tsunami is already coming, and practical urban immunization programs urgently need to be redesigned to strengthen new health care delivery systems — ones that can adapt to our changing world and reach the most vulnerable for the next 40 years and beyond.

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About the authors

  • Craig Burgess

    Dr. Craig Burgess is a senior technical advisor with JSI Research & Training Institute, Inc. Over the last 25 years, he has worked on a broad range of public health issues related to equity, integration, primary health care, infectious disease control and health sector coordination. He has worked in civil war-torn contexts, chronic crises, emerging economies and high income countries at the community, district, national, regional and global levels with National Health Services, Médecins sans Frontières, MERLIN, UNAIDS, WHO, UNICEF and the Gavi Vaccine Alliance secretariat.
  • Iqbal Hossain

    Iqbal Hossain is a senior technical advisor with JSI Research & Training Institute, Inc. He is a public health physician with over 30 years’ public health experience in immunization, reproductive health and family planning, injection safety and infection prevention and control, and nutrition in Africa, South and Central Asia. He has extensive experience in providing technical assistance to ministries of health in strengthening public health systems and building capacity of health care workers. Iqbal worked with John Snow Inc., World Health Organization, Basic Support for Institutionalizing Child Survival, Save the Children UK, and Pathfinder Fund at global, regional and country-level capacity.