If you’re going to try to make the world a better place, it’s important to think big and aim high. Combating climate change, protecting the world’s fish stocks or ending extreme poverty, hunger and gender inequality by 2030 are global goals that do precisely this. But while achievable, the ability of governments to meet these targets, and all 17 Sustainable Development Goals promised by all world leaders, is dependent not just on the goals and their targets themselves, but on how ambitiously we measure our progress toward reaching them.
For the global health targets of ending preventable deaths of under 5 and achieving universal health coverage with access to affordable and essential vaccines for all, which are all part of SDG 3, that could be a problem. In fact, we may already be in danger of setting ourselves up to fail even before we’ve barely begun. A lack of ambition in how we measure progress toward these SDG 3 targets will not only give us a false assessment of how well we’re doing, but could also hamper our chances of success, putting the lives of millions of the most vulnerable children at risk in the process.
Keeping track of how many children receive two doses of a measles-containing vaccine is currently the SDG 3 progress indicator being considered for these two targets. At first glance this may seem like a sensible choice; an immunization indicator is a great idea because it is universal and has such a direct impact on reducing childhood mortality. Also, measles, is an important vaccine that has been saving lives for more than half a century, and is already used as a tracer vaccine to gauge how many children have access to routine immunization, so a reporting system is already in place. The problem is MCV2 alone simply doesn’t go far enough.
It’s the equivalent of assessing the health of the oceans only on acidity samples taken from around our coastlines, or measuring poverty by only counting those people living in households that already have access to basic services. If we did this, then we’d end up with a very incomplete picture. It is the same with our immunization health indicators.
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While measles is a certainly a big killer, claiming more than 130,000 lives every year — mainly children — there are new vaccines that can have a potentially even bigger impact on reducing childhood mortality, vaccines such as pneumococcal conjugate vaccine and rotavirus. Yet, despite protecting against the two biggest killers of under 5, pneumonia and diarrhea, they are relatively recently introduced vaccines and so coverage is still relatively low, at 42 percent and 25 percent, respectively. Other vaccines protect against cancer, meningitis and birth defects. Our worry now is that if we base progress purely on MCV2, then we could end up in a situation where we think we are doing better than we actually are, and in doing so miss the opportunity to save more lives.
The World Health Organization currently recommends that all children are vaccinated to protect them against 11 different infectious diseases. Confining our measurement to just one of those antigens will not capture how many children are fully immunized. Today, global coverage of children receiving MCV2 stands at 64 percent, suggesting that one-third of all children are missing out. But if you instead look at how many children are receiving all of the 11 antigens, then a very different picture emerges. Based on Gavi’s best analysis just 7 percent of the children living in the 73 world’s poorest countries — those we need to be focusing on to decrease child mortality — are fully immunized. This means we have considerably further to go to meet our targets than MCV2 alone would suggest, with more than nine out of 10 children not getting the minimum protection against infectious diseases.
So why isn’t the global health community considering using the proportion of fully immunized children to track progress instead? One reason is that it’s a lot more difficult, both to measure and to achieve. Today immunization coverage data is based on how many vaccine doses are given, rather than counting the number vaccines each child has received. Given that one-in-three children don’t officially exist, because their birth was not formally registered, it’s easy to see why. And even though more children have vaccination cards than birth certificates, the systems that would be needed to monitor these generally do not exist.
But with a little help from technology they could. The technology sector is already striving to achieve global penetration, reaching everyone. So, it’s quite conceivable that we could have new and affordable digital ID systems capable of working in poorly resourced settings, even where there is no reliable electricity. By leapfrogging existing and often archaic paper-based methods used to certify births we will improve our ability to reach everyone and keep track of those that are missing out, whether they are living in remote village or urban slums. This is not just wishful thinking; SDG 16 already demands it, with everyone on this planet required to have a legal form of identity by 2030.
Ultimately, MCV2 alone will simply not cut it. We need to be more ambitious. Even choosing one of the powerful new vaccines that are making a difference in child mortality would make more of a difference. But going even further and making the child the focal point of immunization monitoring would be nothing short of revolutionary. Not only will it help radically reduce childhood mortality, but it will represent a significant step toward the WHO’s goal of achieving universal health coverage, which aims to ensure that everyone has access to affordable, quality health care — no matter who they are or where they live — and that includes ensuring every child has access to the most cost-effective health intervention and is fully immunized.
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