Gender-Responsive Programming to Improve Immunization Services
Data released by the World Health Organization (WHO) and UNICEF on July 15 show that global coverage of routine immunizations, such as the diphtheria-tetanus-pertussis vaccine or measles-containing vaccine, decreased for a second year during the Covid-19 pandemic. The drop in coverage is the largest in nearly three decades, driven by supply chain disruptions, lockdowns, misinformation, and parents’ reluctance to take children to health clinics out of fear of infection with SARS-CoV-2. The coverage gaps leave more children around the world vulnerable to infections and threaten global health security by creating the potential for outbreaks of vaccine-preventable disease.
Increasing global immunization coverage depends both on ensuring children who receive vaccines receive all doses of recommended vaccines and on reaching the 18 million “zero-dose” children, who last year received no vaccines, with immunization services. To improve access to overlooked and hard-to-reach populations, including children living in fragile or conflict-affected settings, the immunization community has intensified its focus on breaking down gender-related barriers to immunizations. Gendered expectations regarding men’s and women’s roles within the family, the community, and the healthcare setting influence who receives vaccines, where and when they receive them, and from whom. If a mother is responsible for her children’s healthcare, but the children’s father controls access to the resources needed to get to the clinic, for example, the children may not receive needed vaccines in a timely manner. Or if male vaccinators make community visits during times when mothers and children are home alone, the women may not be comfortable allowing the men into the house to vaccinate the children. By applying lessons from other health sectors such as HIV/AIDS, family planning, and sexual and reproductive health that have been at the forefront of efforts to improve health outcomes through attention to how gender dynamics can exacerbate vulnerabilities to illness or limit access to care, organizations that support vaccine delivery programs can begin to close gaps in immunization services overall.
The relative parity in global immunization rates among boys and girls, along with a lack of granular data shedding light on gender-related barriers to immunization, have rendered global immunization efforts largely gender-blind historically. But in recent years, the stagnation of global immunization rates even prior to the Covid-19 pandemic, coupled with more intense global attention to reducing immunization inequities, have contributed to a greater recognition of the importance of focusing a gender lens on immunization efforts.
Over the past decade, Gavi, the Vaccine Alliance (Gavi), WHO, UNICEF, major donors, and implementers have all incorporated gender mainstreaming principles into organizational policies, guidance, tools, and activities. Engagement in this area has also built on the work of the Equity Reference Group for Immunization, a high-level panel convened by UNICEF and the Bill & Melinda Gates Foundation to identify ideas to accelerate progress on immunization equity, which in 2018 released a discussion paper calling for greater attention to gender at the highest policy levels.
Since then, global organizations have further bolstered their work on reducing gender-related barriers to immunization. Gavi released an updated gender policy in 2020; the Global Polio Eradication Initiative (GPEI) released a gender equality strategy in 2020, and gender-responsive programming is reflected in its new 2022–2026 organizational strategy. UNICEF has developed resources including a guide for integrating a gender lens into immunization programming, and in 2021, WHO, UNICEF, and Gavi published a guide to gender mainstreaming across the various activities and priorities that underpin Immunization Agenda 2030. Additionally, donor governments, including the United States, program implementers, and other stakeholders have been engaging in efforts to address gender-related barriers in immunization programming.
As the childhood immunization community continues to strengthen gender programming in order to both reverse the declines in coverage seen since the onset of the pandemic and build new momentum for routine immunizations, it can draw lessons from other health sectors, including HIV/AIDS, family planning, and sexual and reproductive health, that have had a longer track record in considering how gender relations influence disease transmission or influence care-seeking behavior. Successful initiatives have included fostering communication among couples and engaging men to increase uptake of family planning and HIV prevention activities; co-locating and integrating HIV and family planning services to increase access for women who are at risk for both unintended pregnancies and sexually transmitted infections, including HIV; using community health workers and other outreach strategies to deliver services where people are, especially women and girls; and addressing gender-based violence (GBV), among many others.
Lessons from this work can inform the more nascent gender-responsive policymaking and programming surrounding childhood immunization. Actions to consider include the following:
- Ensure that gender mainstreaming is not just a “box-checking” exercise. Rather, programs should be clear about the outcomes they hope to achieve in integrating a focus on gender equity into work on immunizations.
- Capture sex-disaggregated and other related data to inform policies, programming, and learning agendas, and build the evidence base about the implications of gender for immunization equity and health outcomes.
- Engage with a wide range of stakeholders (e.g., women, men, adolescents, mothers-in-law, community leaders, non-health entities) in program design and more deliberately incorporate their voices, needs, and realities into programs to strengthen the likelihood of programmatic success.
- Take care to ensure that gender-related barriers impacting service demand (e.g., mobility issues, resource constraints for women) and supply (e.g., lack of accessible and quality health services) are addressed.
- Co-locate and integrate services, and conduct community outreach, to reduce barriers to care, address gender-related barriers in other social realms (e.g., economy, education), and amplify the success of efforts.
To date, global actors have been at the forefront of driving and funding gender-responsive programming. And while they play critical roles, the effort is not without challenges. Investments are relatively small compared with those for biomedical interventions, making it difficult to scale programs to effect more transformative change. Against the backdrop of the rollout of Immunization Agenda 2030, the growing momentum surrounding gender-responsive immunization programming and the spotlight the pandemic has shined on inequities present an opportune moment for stakeholders to apply lessons learned from other sectors in order to move the needle on immunization coverage and, potentially, contribute to the reduction of gender-related barriers to health more broadly over the next decade
Multilateral organizations—Gavi, WHO, and UNICEF—and initiatives, such as GPEI, have a powerful role to play in continuing to develop normative guidance for countries and program implementers, advocating for the collection of sex-disaggregated and other data, setting learning agendas, and building the evidence base for the global community. These organizations have worked in concert to align related policies and frameworks; the collaboration is encouraging and should be continued. Immunization Agenda 2030 also presents an opportunity for multilateral organizations to work with countries and regions to develop new immunization plans that reflect a gender lens and create political will around reducing gender-related barriers to care.
Governments providing bilateral support, such as the United States, can support gender-related programming for immunizations in several ways. They can require organizations they support to collect gender-related data about access to services and quality of care; and they can support integrated programming across accounts or funding streams to ensure parents can access immunization services for their children when they visit clinics for other reasons. Donor organizations can also use interactions with host governments and communities to raise the importance of gender equity as a way of improving immunization coverage and strengthening health security.
The continuing downward trend in immunization coverage revealed in the latest WHO and UNICEF immunization coverage data underscores the need to redouble efforts to prevent additional losses in immunization coverage and make up ground lost during the last two and a half years of the Covid-19 crisis. Addressing gender-related barriers at all levels is essential to these efforts. Improving communications between caregivers; empowering women to make informed decisions about immunizing their family members; integrating immunization services with other family health services to make it more convenient for women to seek healthcare for children; and engaging men in decisionmaking and as end users of immunization services can all help promote equitable access to vaccines and strengthen immunization coverage rates in the future.
Katherine E. Bliss is senior fellow and director, immunizations and health systems resilience, with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Alicia Carbaugh is an independent consultant with the CSIS Global Health Policy Center.
Special thanks to Mackenzie Burke and Maclane Speer for their support in the preparation of this report and to the participants in a CSIS roundtable on gender and immunizations for sharing their experience and perspective.
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