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Rationale

With over 235 million people in need of humanitarian assistance in 2021, vaccine-preventable diseases (VPDs) in crisis-affected settings remain a pressing health concern. Worldwide, of 23 million children who did not complete their vaccinations in 2020, 17 million (75%) did not receive their first dose of the diphtheria, tetanus and pertussis vaccine.

About 9.6 million (42%) of these so-called ‘zero-dose’ children and communities are in conflict-affected settings. Typically characterised by displacement, violence, food insecurity, insufficient water and sanitation and overcrowding, crises largely affect populations with high baseline risk of infectious diseases resulting from inaccessible or underperforming health services, and high burden of malnutrition. This increases both transmission and case-fatality, and the risk of VPD outbreaks or setbacks to long-term vaccination programmes. The COVID-19 pandemic has led to worrisome declines in vaccination coverage and stretched capacity to deliver routine health services. 

Governance of vaccination services in humanitarian responses is often unstructured and not evidence-based. Despite calls for a systematic, evidence-based and accountable approach to vaccine provision in humanitarian crises, in practice it is left to ‘decision-makers’ within each humanitarian crisis, who rarely, if ever, follow the aforementioned approach to select which vaccines to use, when and how. There is also a strong recognition of the need to improve financing mechanisms for vaccination in humanitarian settings, as affordable access to vaccines is a key challenge for both governments and humanitarian actors, though one that has been partially mitigated by the establishment of the Humanitarian Mechanism. Furthermore, there is a need to generate evidence on novel or underutilised delivery strategies to identify and reach under-immunised and zero-dose communities for routine vaccine delivery across different crisis typologies.

Understanding and strengthening vaccination governance, financing and delivery strategies is key to enabling the equitable delivery of vaccines to zero-dose and under-immunised communities in crisis settings.

Aims and Objectives

In RAISE, we aim to map and assess governance practices (including decision-making and financing) for vaccination services in a range of humanitarian responses; and to identify and formulate recommendations for practices for equitable vaccination delivery in these settings, with a specific focus on zero-dose communities. Which we will do by meeting the following three objectives:

Objective 1: Conduct a scoping review of existing guidance on vaccination in crisis settings to characterise and assess the normative landscape for vaccination in these settings

We will conduct a comprehensive scoping review of existing guidance on vaccination in humanitarian crisis settings, ensuring that we are drawing on a wide variety of approaches. We will also assess the quality of these guidance documents.

Objective 2: Conduct mixed methods research to explore current vaccination governance and financing practices and formulate concrete recommendations to improve them by determining what drives decision-making and current barriers, incentives and modalities of financing for vaccines in humanitarian settings

We will collect data on governance, decision-making and financing to map and describe current practices, and assess barriers and facilitators for design and funding of timely, equitable vaccination services across currently activated United Nations Office for the Coordination of Humanitarian Affairs (OCHA) responses. These include protracted crises, areas governed by non-state actors and internal and refugee displacement. We will also explore potential synergies between COVID-19 vaccination and programming for catch up vaccinations for children in zero-dose and under-immunised communities.

Objective 3: Map and assess current delivery practices to reach zero-dose and under-vaccinated communities in different crisis typologies, with a view to documenting best practices, and formulating actionable recommendations for equitable, higher-coverage vaccine delivery

This third objective will be co-designed and led by our country partners SIDRA in Somalia and Adeela for Culture and Art and PHTRU, Ahfad University for Women in Sudan.

Broadly, we will conduct mixed methods case studies in Sudan and Somalia to document current vaccination delivery practices and to identify novel approaches across all the different components of vaccination microplanning (including community engagement), and successful examples of integration with other health service areas and/or other sectors of humanitarian response and civil society. These case studies will support developing actionable recommendations for equitable delivery practices to reach zero-dose and under-immunised communities in varied humanitarian crisis settings. To encourage change-making, we will disseminate and promote the research findings with all relevant stakeholders from local to national and regional/global levels.