The State of the World’s Children 2023
For every child, vaccination
We want to introduce you to three children: Marwan, Hind and Iman.
Their stories are powerful examples of one of humanity’s greatest public health achievements: vaccination, for every child.
A health centre. An immunization campaign. A camp for internally displaced people.
These are the settings where children like Marwan, Hind and Iman have been immunized for decades. Protected from disease, they’re far more likely to have the opportunity to thrive, the chance to learn and the ability to live healthy lives.
As you’ll discover in this State of the World’s Children report, it’s essential that we act now to make sure that other children just like Marwan, Hind and Iman aren’t left behind.
The State of the World's Children 2023
Marwan, Hind and Iman’s stories embody the child survival revolution. But as this year’s State of the World’s Children report highlights, the reality is that more and more children like them aren’t getting the vaccinations they desperately need. These children often live in the world’s poorest, most remote and most marginalized communities.
The COVID-19 pandemic has been a disaster for childhood immunization. This edition of The State of the World’s Children reports that in just three years, the world has lost more than a decade of progress.
We’re at a pivotal moment. We’re now seeing the reemergence of preventable diseases in parts of the world that for decades we’ve fought tirelessly to control. If we don’t act now, millions of the world’s most vulnerable children may never make it to that health centre or be reached through a vaccination campaign. Tragically, they could be left behind and be at much greater risk from these diseases.
As you’ll learn, it’s not too late. We have the chance to respond and save millions of children’s lives. In this report, we explain what needs to happen to reach the world’s most vulnerable children with vaccines.
Right now, far too many children across the world are not getting the vaccines they need to protect them against death and serious disease. The COVID-19 pandemic severely disrupted childhood immunization, with 67 million children missing out entirely or partially on routine immunization between 2019 and 2021, leaving them vulnerable to a range of preventable diseases.
One in five children worldwide are now zero-dose or under-vaccinated, meaning they’ve missed out entirely or partially on routine immunization. Those are levels we’ve not seen since 2008.
Zero-dose children are those who have not received their first diphtheria-pertussis-tetanus vaccine (DTP1). Under-vaccinated children are those who received one dose, but not a third protective dose.
Diseases are now reappearing in countries where they had previously been controlled. Meanwhile, we’re also seeing surges of cases in nations that hadn’t yet eliminated the diseases. Those include cholera, measles and polio outbreaks.
The story of the children who are not being vaccinated is one of inequity, poverty and underserved communities. More than three out of four of the world’s zero-dose children live in 20 countries. They live in the remotest of rural areas, urban slums, crisis-affected regions, and migrant and refugee communities. These children urgently need to be reached with vaccines.
The COVID-19 pandemic has been a disaster for childhood immunization. But even before the pandemic, the warning signs were there. The pandemic exposed the longstanding issues with global health systems that have contributed to this significant backslide. Here, you can learn more about the key reasons why too many children are not getting the vaccines they need to protect them.
In May 2020, more than half of all vaccination campaigns in 57 countries had to be cancelled or postponed. That represented the loss of almost 800 million vaccine doses.
How the COVID-19 pandemic set back immunization rates
The pandemic placed unprecedented demands on global health systems. To try and cope with the crisis, a lot of health systems were forced to divert scarce resources away from providing routine care, which includes immunization efforts.
The demands that were placed on health workers were extraordinary. As well as being expected to handle a huge increase in their workload, many workers were also coping with additional burdens at home, including caring for their own families. At work, many could not access essential equipment, including personal protective gear. These health workers also faced the risk of infection as well as social discrimination and attacks. Therefore, burn-out became a critical issue that had a profound impact on immunization campaigns. Meanwhile, stay-at-home recommendations had a significant impact on families’ ability and willingness to access health facilities and get their children vaccinated.
Even before the pandemic, the warning signs were there
Most zero-dose children live in the poorest and most marginalized parts of the world, where historically primary health care systems have been ill-equipped to reach these children. The health systems operate with limited resources and suffer from a lack of skilled health workers. And for those health workers who do work in these communities, they often have limited access to vaccines and the supplies that are needed to administer them. Additionally, data collection in these communities is often very challenging and limited, so monitoring where under-immunized children live and reaching them with vaccination campaigns becomes extremely complicated.
How poverty contributes to low vaccination rates
Poverty has a profound impact on whether a child has access to vaccines. Many of the growing number of zero-dose and under-vaccinated children live in settings where they face significant economic barriers. Globally, in the poorest households, just over 1 in 5 children are zero dose; in the wealthiest, it is 1 in 20. These zero-dose and under-vaccinated children often live in remote rural areas and urban slums.
In remote communities, health services are often scarce, and families live far away from health facilities. Supply chain issues, shortages of health workers and a lack of electricity, water and sanitation are all significant barriers to the availability of vaccines.
In urban slums, health care systems are often ill equipped to meet the needs of large populations and affordability is a serious barrier. Parents and caregivers who juggle multiple jobs and responsibilities often can’t afford to take time away from work and pay for the transportation needed to reach health facilities, as that has a significant impact on a family’s financial bottom line.
Conflict and displacement are having a devastating effect
Instability and violence – the hallmarks of conflict – are significantly hindering children’s opportunities to be immunized. In 2018, 40 per cent of the world’s zero-dose children lived in fragile or conflict-affected settings.
Reaching children with health services in these settings is very challenging. Health workers themselves are often displaced, financing for health services is halted and vaccine supply chains are disrupted. Health facilities are also sometimes targeted, making it dangerous for families to access care.
Meanwhile, in recent years, conflict has forced millions of children to flee their homes and migrate to camps for refugees or internally displaced people. Given that families in these settings are often transient, it’s much harder to monitor vaccination rates among these communities and reach children with the life-saving vaccines they need.
Vaccine misinformation and mistrust is spreading alarmingly
The decision to vaccinate a child depends in part on trust. A parent or caregiver must have faith in the health care system, vaccine producers and government health institutions. Even before the COVID-19 pandemic, vaccine hesitancy was identified as one of the top 10 threats to global health.
There are now worrying signs that in many countries we’re witnessing significant declines in vaccine confidence, with growing access to misleading information on social media contributing to this trend. And in some parts of the world, there’s declining trust in the authorities that are responsible for carrying out vaccination campaigns. All those factors are contributing to the backslide.
Women health workers are not being sufficiently empowered
As health workers, women are often on the frontline, administering vaccines to the children that need them most. But in most parts of the world, they’re often low-paid and denied opportunities for training and professional growth. Although women form the bulk of the health workforce, they have long been underrepresented in leadership roles. Part of the reason behind the inequity in pay in the health care sector is that many women serve in unpaid and underpaid roles, typically as community health workers. Additionally, the security of women health workers is sometimes at stake, as they face threats of violence and verbal abuse. These factors are contributing to global shortages in the health care workforce, as governments struggle to maintain the resources required to provide health care. That has a significant impact on the provision of vaccination services.
This State of the World’s Children report introduces you to some of the extraordinary women, who despite the challenges they often face, are going above and beyond to make sure children in their communities have access to vaccines. It’s imperative that health workers like these are empowered and supported.
UNICEF/UN0692740/Arcos
Marìa Ortencia Catucuago is a community health worker in Ecuador. She cares for the indigenous Turucucho community, nestled in the foothills of the north-eastern highlands. In addition to her work engaging the community on the importance of vaccines, she tends to a dairy farm and delivers milk. “I feel passionate about helping others,” she says. “I want all the children in my community to grow up healthy, happy and with the same opportunities.”
UNICEF/U.S. CDC/UN0695546/LeMoyne
Mona Yvrose Jean Claude has worked as a nurse in Haiti for more than a decade. During that time, her country’s health care system has been deeply affected by natural disasters, political instability and violence. Nevertheless, she continues to serve. “For me, it is not the salary but rather the patient's feelings,” Mona reflects. “Every morning, I know that I will help someone in their physical or psychological suffering. This is what drives me to get up and come to work.”
UNICEF/UN0679361/Hayyan
For Ghada Ali Obaid, vaccinating children is not a job. It’s a calling. She dashes through the Dar Sa’ad Medical Compound in Yemen, counselling mothers about the benefits of immunization and takes to the road to reach children who might otherwise miss out. Ghada’s husband, Ehab, takes time off from his job as a taxi driver to bring her to more remote areas. “I encourage her to show up every day because she is so passionate, and she has my full respect," Ehab says.
Despite undeniable progress over many decades, this State of the World’s Children report reveals that we are consistently missing one in five children with life-saving vaccines. It’s essential that we act now to vaccinate every child, no matter where they were born, who they are and where they live. By doing so, we’re giving today’s children and tomorrow’s adults the chance to thrive. These are the actions we can and must take:
Vaccinate every child through effective immunization programmes and catch-up campaigns
- Catch-up on the vaccination of children missed during the pandemic. 67 million children missed out entirely or partially on routine immunization during the pandemic. These children are moving past the age when they would normally be vaccinated. Urgent action and tailored immunization campaigns are needed to reach them, backed by sufficient financial support for the countries most affected. These catch-up campaigns are necessary in addition to strengthening existing routine immunization programmes that are embedded in primary health care.
- Identify zero-dose and under-vaccinated children and understand their needs. By gathering high-quality immunization data, we can identify and locate zero-dose children and communities that have been missed. A key component of this work is engaging with these communities and their leaders to help identify barriers to children being vaccinated, and to develop approaches that meet the needs of these families.
- Identify children in urban areas and access children in rural areas who aren’t being reached. This will involve strengthening community engagement, recovering human resources lost due to the need to respond to the pandemic, offering flexible vaccine services and empowering local health workers.
- Meet the challenges in emergency and conflict settings. It’s important that we prioritize restoring health workforces and infrastructure in these fragile settings so children on the move have access to vaccines.
Strengthen confidence in vaccination
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Engage effectively with communities. It’s essential to build confidence in vaccines. If we’re going to boost global vaccination rates, understanding specific attitudes towards the safety and value of vaccination in any given community is critical. That requires strengthened engagement and leaning on interventions designed and delivered by trusted members of the communities.
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Tackle gender barriers. Innovative approaches must be adopted to inform and educate caregivers, especially mothers. Services must be tailored to meet the needs of time-pressed caregivers.
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Equip doctors, health workers and religious leaders to address concerns. These individuals often enjoy high levels of trust in their community. Therefore, it’s essential that they’re empowered to counter misinformation and promote the value of vaccination. When these trusted individuals engage in dialogue, they allow people to share their feelings and concerns and can help foster confidence in vaccines.
Invest in immunization and health
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Invest in primary health care. It is vital to prioritize investment in primary health care. Effective vaccination campaigns depend upon strong and well-resourced health care systems. Funding needs to be prioritized to ensure equitable access, especially for underserved communities. Even in a time of tight budgets, the high returns on investment from immunization underscore the benefits of prioritizing funding.
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Focus on health workers, especially women. They’re the heartbeat of primary health care. Strengthening their numbers, their skills and their motivation is paramount. That means improving pay and working conditions, offering access to professional advancement, and protecting them from discrimination and violence.
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Strengthen leadership and accountability. It’s never been more important to ensure that money is well spent and efficiently targeted. For that to happen, strong leadership and accountability to oversee effective spending in health care is a must.
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Better aligned donor support. Countries with fragile and underinvested health systems often benefit from donor support. Rather than focusing that financial support on disease-specific initiatives and campaigns, it’s important we shift that funding to overall health care system strengthening.
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Invest in emerging technology to increase vaccine accessibility and affordability. The COVID-19 pandemic shifted the vaccine landscape dramatically. Using new advancements in vaccine technology, including messenger RNA (mRNA), we were able to safely develop vaccines at rapid speeds. It’s important that we finance this innovation moving forward. We can do this by investing in regional vaccine hubs, particularly in low- and middle- income countries. That will help to increase both the accessibility and affordability of vaccines in the regions where the highest percentage of zero-dose children live.
Build resilient health systems
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Integrate services. Integrating childhood immunization into strengthened primary health is essential to sustainably reach the goal of vaccinating every child. That means vaccination become a routine part of a child’s upbringing.
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Improve disease surveillance. Better data collection helps to monitor rates of immunization and track the spread of preventable diseases, enabling us to take proactive action. Utilizing electronic immunization registries can ensure that every child receives the right vaccination at the right time.
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Secure increased access to vaccines and essential supplies. On top of the vaccines themselves, readily accessible supplies of syringes, protective gear and cold chain storage at affordable prices are a necessity.
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Focus on innovation. By tapping into exciting new technologies, like solar-powered cold chains, drones that deliver doses and heat resistant vaccines, we can reach communities in the most challenging of settings. Meanwhile, mapping systems that use data from vaccinators’ phones can reveal where low-dose communities exist and help to reach them through campaigns.
Time and time again, down the years, when faced with outbreaks of preventable diseases, we’ve responded effectively – reaching and protecting millions of children in harm’s way with vaccines.
We must and we can do better to reach these children once more.
More than three decades ago, the United Nations ratified the Convention on the Rights of the Child. Enshrined in that treaty was a clear commitment to every child:
“The enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.”
Providing children with the vaccines they need to thrive is at the heart of that commitment. To stay true to that value, we know that change is needed. Now is a time for political will to protect the health of every child.
In 1990, 1 in 11 children died before reaching the age of 5. Within three decades, that had fallen to 1 in 27 children. Vaccines have played a crucial role in that remarkable improvement.
That political will should be grounded in optimism and based on the fact that immunizing children makes economic sense. As we know, vaccines do more than just save lives. They enable children to thrive, go to school, learn and become productive members of society.
By taking significant action and prioritizing routine immunization, we can reach children in those places that are so often overlooked.
Children in remote villages, miles from the nearest road.
Children in urban slums where newly arrived families live in anonymity.
Children in war zones who often don’t know where they’ll be sleeping tomorrow night.
These children depend on us. So, now is the time for determination. Now is the time to act and protect the health of every child.
Highlights
The world is facing a red alert for children’s health: Routine vaccination coverage dropped sharply during the COVID-19 pandemic. UNICEF’s latest report, The State of the World’s Children 2023: For every child, vaccination, explores the reasons behind this red alert and the steps we as a global community must take to make sure that no child is left behind.
