Overcoming Barriers: Financing and Service Delivery for Vaccination in Fragile and Conflict-Affected States
Overcoming Barriers: Financing and Service Delivery for Vaccination in Fragile and Conflict-Affected States
ต้องการข้อมูลเพิ่มเติม ติดต่อฝ่ายสื่อสารองค์กร HITAP
Vaccination is a critical and cost-effective public health intervention that significantly reduces child mortality. Since the inception of the World Health Organization’s Expanded Program on Immunization (WHO-EPI) in 1974, vaccines have saved millions of lives, with a Lancet study highlighting that global immunization efforts have averted 154 million deaths over the past 50 years, including 101 million infants (1, 2). However, access to vaccination services remains limited in Fragile and Conflict-Affected Settings (FCAS), such as Myanmar, the Central African Republic, South Sudan, Somalia, and Syria, where ongoing conflicts contribute to low DTP3 vaccination rates (3). The WHO’s Immunization Agenda 2030 underscores the necessity of reaching marginalized and displaced populations in these challenging contexts to ensure equitable immunization coverage (4).
Challenges in delivering vaccination services in FCAS include infrastructure damage, with over 700 healthcare facility attacks reported by the Safeguarding Health in Conflict Coalition (SHCC) report in 2022, disrupting vaccine storage and administration (4). Security concerns, including ongoing attacks on healthcare workers, exacerbate the situation. Forced displacement, affecting over 108 million people (5), leaves many without access to healthcare, and refugee camps often lack resources for immunization (6). Additionally, a shortage of trained healthcare professionals and funding constraints further hinder vaccination efforts, with fragile states relying on unpredictable humanitarian support.
Why is this topic important, and why are we talking about this?
This issue is becoming increasingly urgent as the prevalence of conflicts and the displacement of populations continue to rise globally, exacerbating health inequities and leaving millions of children susceptible to preventable diseases (6). Addressing this topic is critical to highlighting the challenges associated with financing and delivering vaccination services in FCAS and underscoring the necessity for sustainable and context-specific solutions.
Key issues
Financing mechanisms suited to FCAS
A review of academic literature and grey literature on health financing and the delivery of primary health care including vaccination in FCAS showed that funding for vaccination often relies on external sources or international donors such as the WHO, the United Nations Children’s Fund (UNICEF), Gavi, the Vaccine Alliance, and other Non-Governmental Organizations (NGOs). In Democratic People’s Republic of Korea, Gavi’s Health System Strengthening (HSS) supported to sustain high and equitable immunization coverage by strengthening institutional capacity, with the collaboration between UNICEF and WHO enhancing its implementation for the benefit of all stakeholders, including the Ministry of Public Health, Gavi, UNICEF, and WHO (7).Two financing mechanisms have been used in FCAS for improving vaccination outcomes, which are Direct Disbursement Mechanisms (DDM) and Results-Based Financing (RBF). DDMs streamline funding by channeling resources directly to implementing partners, local NGOs, or community-based organizations, reducing bureaucratic delays and ensuring timely access to funds. This approach is particularly valuable in unstable environments where traditional government systems may be weak or non-functional (8). RBF links funding to the achievement of specific vaccination targets, such as vaccination coverage rates or the number of children reached, fostering accountability and incentivizing performance. These mechanisms have been found to not only enhance the efficiency of resource allocation but also empower local actors and strengthen health systems by focusing on measurable outcomes (9). The two mechanisms can complement each other, with DDM offering flexibility and RBF ensuring that funding leads to tangible results.
Vaccination delivery services in FCAS
Several common strategies are employed to enhance vaccination coverage among vulnerable populations in conflict-affected settings. Key approaches include partnerships with local non-governmental organizations (NGOs), the use of mobile and outreach services, and the establishment of fixed vaccination points in strategic locations (10-12).
- Partnerships with Local NGOs
Collaboration with NGOs plays a crucial role in delivering immunization services in insecure and hard-to-reach areas. For instance, in Myanmar’s Kalay region, UNICEF partnered with a local NGO to provide vaccinations to internally displaced persons (IDPs). This partnership involved negotiating with various actors and facilitating transportation to nearby health facilities (13). Similarly, in Afghanistan and the Central African Republic (CAR), NGOs have been contracted to deliver vaccination services in conflict-affected areas, ensuring continued immunization access despite instability (11, 12). Chad’s approach to supplementary immunization activities (SIAs) is distinct due to its reliance on NGOs, particularly in refugee-dense areas where governmental health services may be limited (10). SIAs in Chad targeted high-risk populations, ensuring that displaced and marginalized communities received essential vaccinations (10).
- Mobile and Outreach Services
Deploying mobile vaccination teams is an effective strategy for reaching displaced and remote populations. Yemen has expanded its vaccination coverage through mobile outreach initiatives, establishing additional vaccination points and utilizing mobile teams to operate in insecure regions, highlighting the reliance on non-state actors to bridge gaps in service delivery (14).
- Fixed Vaccination Points in Strategic Locations
Some countries have established fixed immunization posts in key areas to improve accessibility for displaced populations. Ethiopia, for example, has set up vaccination posts at cross-border sites to ensure immunization services reach mobile and displaced communities (15). This approach is particularly effective in regions with high population movement, where maintaining routine immunization coverage is challenging. Successful immunization efforts in conflict-affected settings rely on well-designed, context-specific communication strategies. (16).
Challenges and considerations
When it comes to healthcare financing in FCAS, both RBF and DDM come with several challenges. RBF can be expensive to implement, mainly due to the verification and administrative costs, and works best when combined with other payment systems, like salaries (4). Moreover, it requires a clear division of responsibilities between various entities, which can be difficult to coordinate (4, 17). There is also the risk of relying too heavily on donor funding if governments are not fully involved in the financing system (4). On the other hand, DDM struggles with logistical hurdles like high transaction volumes, poor infrastructure, and security risks, particularly in rural areas of FCAS (8). In addition, issues like weak banking networks and low literacy levels can prevent beneficiaries from fully accessing and utilizing funds (8). Both systems need careful planning and execution to overcome these obstacles and ensure their success. A conflict-affected region is a complex landscape where political tensions and security threats intertwine, posing immense challenges for international organizations and NGOs working to provide healthcare, including vaccination (18). In some cases, governments that are unable or unwilling to ensure healthcare within their borders may actively prevent external NGOs from stepping in to fill the gap (19). Meanwhile, armed non-state actors controlling certain territories often obstruct humanitarian aid, leaving countless people without access to healthcare (19). Experiences from Afghanistan, Myanmar, Nigeria, and Pakistan underscore that navigating this environment requires carefully designed and localized communication strategies to ensure the effectiveness of immunization programs in conflict-affected areas (16).
Conclusion
In conflict-affected regions, delivering healthcare comes with a mix of political, logistical, financial, and security challenges. Despite these hurdles, international organizations and NGOs play a vital role in saving lives, particularly from vaccine-preventable diseases (VPDs). Millions of people in these fragile settings remain vulnerable to VDPs, highlighting the critical need for sustainable financing mechanisms, strengthened health systems, and equitable vaccine delivery to improve vaccination coverage in FCAS. Governments, international organizations, and donors must collaborate to implement flexible, context-specific financing and service delivery models that prioritize accessibility, security, and long-term sustainability for fragile societies.
Acknowledgements
The post was reviewed by Saudamini Dabak (Head of International Unit, HITAP).
28 February 2025
