Urban Immunization Global Trends
A unique modeling forecast estimates that about 51 million deaths can be averted worldwide if aspirational immunization targets are met between by 2030.
In keeping with global trends, immunization coverage in India has seen steady growth, increasing from 44 percent (according to the National Family and Health Survey-3, 2005-2006) to 76.4 percent (according to the NFHS-5, 2019-21).
However, the COVID-19 pandemic led to unprecedented backsliding in immunization coverage around the world. Twenty-five million children were either unvaccinated or under-vaccinated in 2021 alone. Additionally, 18.2 million were zero-dose children—those who do not receive basic vaccinations—6 million more than in 2019.
The distinct challenges around implementing immunization programs in urban areas have garnered more attention since the pandemic. A 2022 estimate of the ‘number and distribution of under-immunized children in remote-rural, urban, and conflict-affected areas from 99 Low to Middle Income Countries (LMICs)’ found that around 30 percent of under-immunized children lived in urban and peri-urban areas, compared to just 11 percent in remote-rural areas.
Immunization programs in urban areas grapple with distinct challenges. These include unclear catchment areas for health facilities, lack of appropriately disaggregated data, disenfranchised communities, increase in informal settlements, and the need to engage with multiple stakeholders, including private providers. Rapid and unplanned urbanization further compounds these issues.
By 2014, over half—or 54 percent—of the world’s population lived in urban areas. By 2034, this proportion is expected to swell to 66 percent, adding 2.5 billion new urban dwellers.
A growing number of these urban residents are expected to live on urban peripheries. More than anything else, urban immunization programs are challenged by not having the design and structure of rural immunization programs. With public health care delivery systems across low- and middle-income countries largely focused on the rural hinterland, urban immunization has tended to lag behind. This is true even for India. While the Full Immunization Coverage (FIC) in rural areas increased from 39 percent (NFHS3, 2005-06) to 77 percent (NFHS5, 2019-21), a growth of 38 percent, the corresponding increase in urban areas has only been 18 percent.
Pivoting to Urban Challenges of Reach
The challenge these figures and estimates pose to immunization programs in the developing world is the need to adapt a new, customized approach to urban immunization, which imbibes what has worked across rural geographies while factoring in the urban ecosystem.
This includes the ability to design approaches that weave in multiple governance mechanisms in urban areas, optimize efforts to leverage several stakeholders, including the private sector, provide opportunities for flexible session timings and “vaccination on demand,” and conscious efforts to reach out to marginalized population groups in peri-urban areas, including migrants and urban slum dwellers.
In recognizing the need to prioritize urban immunization, the Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) recently initiated the “City Embrace Model” which aims to strengthen urban immunization systems across 104 National Urban Health Mission (NUHM) cities. This builds on the earlier work undertaken by the World Health Organization (WHO) across 14 cities as part of Gavi Alliance support to the country.
The Bill & Melinda Gates Foundation remains committed to working closely with the government in the area of urban immunization. Our partners continue to provide support to the national initiative and are working with the Governments of Bihar and Uttar Pradesh to improve urban immunization outcomes across 23 National Urban Health Mission (NUHM) cities in the two states. Addressing both supply and demand side challenges, our partners are also seeking to identify macro issues affecting urban immunization, integrate immunization efforts into the state’s urban care agenda, prioritize hard-to-reach population groups by fostering community demand for immunization, encourage learning collaboratives, and improve service delivery.
Urban immunization is a crucial fulcrum for strengthening urban primary care. The Gates Foundation is looking forward to working with government, local partners, and communities to ensure healthy and productive lives for all.
