The forum aimed to:

• Provide a reflection on the current state of immunization within fragile and humanitarian contexts.
• Identify and discuss barriers to effective immunization delivery and coverage.
• Propose actionable strategies and recommendations for Gavi 6.0 strategy to address these challenges.

1. The meeting focused on the challenges of immunization in humanitarian and fragile settings. The speakers highlighted the barriers to vaccine access, including supply and importation issues, limited stocks for reactive vaccination, and restrictive policies. They also discussed the complexities of delivering immunizations in fragile situations, citing the gradual deterioration of health systems and the difficulties in reaching remote communities due to insecurity and economic instability. The speakers emphasized the importance of community engagement and the need to extend immunization efforts beyond government reach to reach humanitarian settings. Participants vividly shared on-the-ground experiences, shedding light on multifaceted barriers. These included:

   • Supply Chain Complexities: Detailed examples highlighted the struggles with vaccine importation, especially in settings where government policies restrict supply channels to specific providers, complicating emergency and reactive vaccination efforts. Sometimes the issue is not that organizations can’t buy vaccines, but the restrictions on importation of vaccines in certain countries. Some ministries of health insist that they can’t have different supply settings from the EPI structures. Calls were made for innovative solutions to overcome supply chain barriers, suggesting Gavi facilitate more agile and adaptable distribution mechanisms.

    

   • Policy Limitations and Implementation Gaps: Discussions revealed that existing policies often do not account for the age groups most affected in crises, nor do they facilitate swift action in response to emergent health threats. There was a consensus on the need for Gavi to advocate for and support the development of more inclusive and flexible immunization policies that are responsive to the dynamics of fragile contexts.

    

   • Service Integration Needs: The primary focus of humanitarian response is to save lives, but it’s also crucial to consider the long-term impact of our actions. There is need to be mindful of how our efforts in the initial stages can influence outcomes in the future. It’s essential to incorporate health system strengthening initiatives and empower the target population to become resilient, ensuring sustainability beyond the immediate crisis.

    

   Therefore, the necessity of integrating immunization with broader health and social services was stressed, recognizing that vaccination alone is insufficient to attract and retain community engagement in crisis settings. Recommendations included the development of integrated service delivery models that couple immunization with essential health and social services, thus addressing the broader needs of communities in crisis.

    

   • Deepening Community Trust: CHWs are local, trusted care providers who can be trained to support and actually administer vaccines. But are not adequately leveraged for immunization in many settings. They have potential to fill human resources for health gaps and because they are local & have direct access to communities. We know they can be trained to follow up on zero dose children, micro plan (Village Reach is doing this with in DRC), and they can be trained to administer vaccines with the right support. A recommendation for 6.0 is to elevate the CHW role in immunization; endorse them as valuable immunization actors; integrate CHWs into the design of tools & interventions 

    

   Further, there were insights into the critical role of community engagement, underscoring the importance of trust-building, especially in dispelling vaccine-related misconceptions and ensuring the success of immunizations campaigns. Special mention of religion as a determining factor and powerful hence the need to do more to overcome religious initiated resistance. Emphasizing the importance of culturally sensitive and contextually appropriate engagement strategies, suggestions were made for Gavi to support initiatives that build long-term trust and collaboration with communities.

1. How can policies be integrated into Gavi 6.0 to enable timely, context-responsive delivery of vaccination services in fragile contexts?
2. How can we simplify decision-making processes and increase flexibility in implementation in fragile and conflict settings?
3. How can we ensure community acceptance and value of immunization as part of essential services?

The session was rich with insights from various civil society organisations (CSOs), each bringing unique perspectives from the ground. Here, we delve into specific contributions from CSO representatives, focusing on the challenges they face and their recommendations for enhancing immunisation strategies in fragile and humanitarian settings.

Miriam Alia from Médecins Sans Frontières (MSF)

Miriam highlighted significant barriers related to vaccine supply and importation constraints, stock availability for emergencies, and restrictive immunisation policies. MSF’s experience underscores the need for flexible supply systems that can respond to emergencies and policies that extend vaccine coverage beyond the standard age limits to cater to older children during outbreaks.

Dr. Nizam from Shastho Shurokkha Foundation, Bangladesh and Vice Chair of the Gavi CSO Steering Committee

Dr. Nizam shared insights from Bangladesh’s experience with over 1.7 million refugee population, emphasizing the importance of integrating vaccination services with other health and social services. The success in Bangladesh was attributed to strong coordination with CSOs and local government, use of community clinics, and engaging the host community in the supply chain to ensure vaccine availability.

Obina Ebbirim from CMS Nigeria

Obina discussed the use of incentives in immunisation programs within security-compromised areas of Nigeria. The approach underscored the importance of community acceptance and engagement, suggesting that incentives can empower women and indirectly contribute to community acceptance of vaccination programs.

Ilana from the International Rescue Committee (IRC), ZIP programme, HOA

Ilana pointed out barriers related to funding and supplies typically being directed through governments and UN agencies, which might not always reach the needed areas. She advocated for policies that enable a broader range of actors, including NGOs, to access supplies and funding directly, thus enhancing agility in program implementation.

Tahlil Ahmed, Save the Children

Indicated that the typology of humanitarian triggers and situations will inform the critical vaccines needed to save the lives of the affected population during the early stages of humanitarian response, as well as the vaccines to be offered as the situation becomes more stable, throughout the remainder of the response period.

Toni Mpoy from World Vision, REACH programme in the SAHEL

Toni highlighted the challenges of access negotiation, not only from a security perspective but also in engaging with government counterparts to explain the necessity of reaching missed communities. She emphasized the need for profiling and strategic community engagement to overcome these barriers.

Chizoba Wanodi from WAVA, Nigeria

Chizoba’s contribution focused on the challenges faced in reaching women and girls in IDP camps, suggesting that these populations are often considered temporary and therefore not served with routine services. She stressed the importance of mapping these camps into routine micro-plans for service delivery.

• The discussions illuminated the diverse and complex challenges faced in delivering immunisation services in fragile and humanitarian settings. The insights from CSO representatives underscore the critical need for flexible policies, innovative supply chain solutions, and strong community engagement strategies. As Gavi moves towards its 6.0 strategy, these contributions are invaluable in shaping a more responsive and effective approach to immunisation in challenging environments. Some of the recommendation include:

  1. Directly engaging the full complement of actors, including humanitarians, local civil society, academic partners and the private sector.  To facilitate this, IRC recommended that donors ring-fence $1B, about 10% of Gavi’s replenishment budget, for the full range of actors to directly access funds and supplies to provide vaccination services to communities outside of the reach of governments. This equates to mobilizing up to $200M annually to expand the model to the 25 countries that are home to over 90% of the zero dose children in fragile settings.
  Also, there is need for centralizing project management to make timely and context-specific decisions, driving impact and scale. This would systematically delegate decision making much closer to the frontlines. To do so, adopt a results-based financing model for actors operating in fragile settings and outbreak response. This approach would allow significant discretion to project management teams as long as pre-agreed outcomes are achieved within a total budget envelope.  Further, set up a subsidiary within Gavi to better serve fragile settings and emergency functions with a higher risk tolerance. The ultimate goal would be to enable more responsive, less heavily regulated programming.  

• In her concluding remarks, Amy highlighted Gavi’s alignment with the session’s outcomes and pledged to incorporate the discussions into the strategic planning for Gavi 6.0. She underscored Gavi’s commitment to operationalize the fragilities, emergencies, and displaced populations policy and develop operational guidelines for flexibilities in these settings. Also, in terms of sharing of the learnings, indicated that there are some initial learnings which could be shared probably in quarter three, when Gavi will have written operational guidelines to allow flexibilities within fragile and humanitarian settings. The intent of these flexibilities is to guide the ways of doing business. So, it’s not something that the country or the staff at Gavi have to tap into and ask permission to utilize. Therefore, once a setting is classified as fragile or a country or a setting as an emergency setting, that these are just automatically tapped into to make sure it’s simplified and moving forward.