Promoting Immunization Equity in Latin America and the Caribbean: Case Studies, Lessons Learned, and Their Implication for COVID-19 Vaccine Equity

"Findings from these case studies add to the toolkit of strategies shown to effectively improve immunization access and equity in low- and middle-income countries..."

The Expanded Program on Immunization (EPI) in Latin American and the Caribbean (LAC) is an effort to prevent vaccine-preventable diseases (VPDs) by promoting a culture of immunisation in which vaccines are viewed as an essential service, a public good, and a right of every citizen. However, high national coverage rates often mask the reality of subnational inequalities and coverage gaps. The Pan American Health Organization (PAHO)'s regional plan calls for multi-faceted approaches to strengthening existing immunisation activities and innovative strategies for promoting immunisation equity, reflecting the Immunization Agenda 2030: A Global Strategy to Leave No One Behind (IA2030)'s core principles: people-centerd, partnership-based, country-owned, and data-guided. To support that strategy, the research shared in this paper applied a descriptive case study methodology to document the implementation of strategic multi-level alliances to promote equitable immunisation access and demand in Colombia, Guyana, and Sucre, Bolivia.

Data collection, carried out between September 2019 and March 2020, included documentary reviews, semi-structured interviews, focus groups, and site visits accompanied by discussions with relevant stakeholders. Case studies include:

Colombia: multi-level partnerships to build technical capacity for the identification and measurement of social inequalities impacting immunisation:

• Examples of activities: Cooperative engagements between the Ministry of Health and Social Protection, EPI, and PAHO include the 2020 "First National Workshop for Strengthening Capacities for Measuring, Analyzing and Monitoring Social Inequalities in Immunization" and the development of Colombia's "National Immunization Equity Booklet". The objectives of these initiatives are to develop equity-focused tools and resources and increase technical capacity for the identification, measurement, and monitoring of social inequalities impacting immunisation. Such efforts are supported by the "Vaccination Without Barriers" campaign, which involves, for instance, departmental EPI directors planning vaccination with local leaders in indigenous communities to ensure community access and acceptance.
• Examples of challenges encountered: A scarcity of adequately trained personnel at the local level made it difficult to monitor social inequalities impacting immunisation in municipalities and districts. Another challenge was getting political support from local decision-makers for the execution of immunisation activities based on inequality monitoring, particularly in remote areas, where transportation demands increased investment. Inadequate provider networks in some jurisdictions, poor compliance of some health service providers, and a shortage of vaccinators were also discussed.
• Examples of lessons learned: Due to the complexity and novelty of the techniques for identifying and monitoring social inequalities in immunisation, training activities and steady multi-level support were indicated as important for effective local-level implementation. In addition, participants underscored the need to sensitise subnational and local-level decision-makers and funders to the value of monitoring these inequalities.

Guyana: intersectoral and community collaboration for pro-equity emergency response to regional VPD outbreaks:

• Examples of activities: Following the declaration of an emergency situation on March 22 2018, Guyana began strategic emergency response planning targeted at ensuring immunisation equity among high-risk border communities and migrant populations to prevent the importation of VPD cases in light of outbreaks in neighbouring countries. Conducted in collaboration with subnational and local authorities including Amerindian village councils and toshaos (community leaders), border personnel, and community health workers (CHWs), rapid assessments involved visits to health facilities, migrant points of entry (POEs), and border communities to assess VPD risks, evaluate emergency response capacity, and mobilise community partnerships. For example, village councils were described as supporting migrant tracking for vaccination follow-up in their communities through responsive, informal data sharing of movement in and out of these closed communities, as well as providing linguistic support, particularly for Warao-speaking migrants. As of December 2020, the country had not reported a single confirmed case of measles, diphtheria, or yellow fever.
• Examples of challenges encountered: Access and outreach to border communities and POEs were complicated by time-consuming travel, difficult-to-navigate terrain, weather-related issues, and linguistic barriers.
• Examples of lessons learned: Intersectoral collaboration and community partnerships were crucial to addressing challenges. For example, partnerships helped address limited data on border communities and migrant populations through informal data sharing. Similarly, the collaborative establishment of migrant health referral practices and outreach coordination with border personnel and village councils amplified immunisation promotion efforts among migrants.

Sucre, Bolivia: strategic alliances with the education sector and civil society organisations for the introduction of the human papillomavirus (HPV) vaccine:

• Examples of activities: In 2008, Bolivia implemented the Family, Community, and Intercultural Health Model (Salud Familiar Comunitaria Intercultural - SAFCI), which was applied to promote equity during the introduction of the HPV vaccine to girls 10-12 years of age in 2017. Health centre staff, school faculty, and SAFCI-based local health committees jointly: organised parental HPV orientation sessions; prepared campaign supplies and data recording materials; coordinated vaccination visits; and planned social mobilisation strategies - a critical aspect of which was engagement with the school board to foster peer-to-peer vaccine promotion and public sensitisation. Other civil society allies (e.g., the Chuquisaca chapter of the Confederation of Indigenous Peasant Women of Bolivia "Bartolina Sisa") also led community-based immunisation promotion within their areas of influence. Complementing these efforts, the EPI collaborated with local media to further expand the reach of HPV vaccine messaging.
• Examples of challenges encountered: Health-sector personnel alluded to national census data quality concerns due to high internal migration and decennial data collection. Non-health sector personnel noted the challenge of ensuring adequate and accurate information at the individual level in the face of growing misinformation about vaccines that generates confusion and vaccination hesitancy.
• Examples of lessons learned: Participants highlighted the importance of educating and empowering community leaders and stakeholders, including teachers, civil society organisations, and parents. Doing so expands the reach and influence of immunisation promotion and sensitisation efforts by leveraging the trust and respect of allies to broadly and effectively inform the public, counter misinformation, and alleviate vaccination hesitancy.

In short, the cases studies highlight avenues for improving the impact of multi-level, equity-focused capacity building, particularly at the local level, and optimising the use of data and resources, partnerships, and community and stakeholder education and empowerment. Indeed, multi-level, intersectoral strategic alliances with education, indigenous affairs, civil society organisations, and community leaders, among others, are shared across Colombia, Guyana, and Bolivia's strategic approaches to promoting immunisation equity. The paper goes on to examine the value of such strategic alliances within the context of the COVID-19 pandemic and vaccine rollout. Some insights offered include:

1. Addressing equity requires relevant data to identify, measure, and monitor coverage inequalities in order to reach underserved populations, funnel resources towards addressing these gaps, and evaluate progress. Intersectoral data sharing strengthens such data-driven decision making.
2. Improving equitable immunisation access should move beyond facility-based services to involve intersectoral, extramural group-focused immunisation services where vaccine recipients commonly gather. The extramural immunisation services discussed in the case studies illustrate the importance of adapting outreach strategies to the needs and contexts of the communities they seek to serve.
3. Strategic alliances with intersectoral and civil society partners are effective, multi-pronged methods for promoting immunisation awareness, sensitising the public to routine and novel vaccines, and countering misinformation about vaccine safety and effectiveness.

The researchers suggest that, while impact studies are needed to better understand the quantitative contributions of such strategic alliances, these case studies illustrate their practical significance and indicate elements of success. For example: "The introduction of the HPV vaccine in Sucre was among the most successful in the country, and intersectoral collaboration and civil society engagement were vital to supporting equitable vaccine access and demand to achieve high and homogenous coverage across the health districts of Sucre."

In conclusion: "Colombia, Guyana, and Bolivia's experiences with promoting immunization equity through strategic multi-level, intersectoral and civil society alliances should be helpful to other countries as they plan, develop, and implement equity-focused vaccine policies and practices."