30 – Civil society: bridging communities and health systems to reach the unreached

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A discussion among presenters Anne Lafond (of ARISE/JSI in the U.S.), Sharmin Zahan (of BRAC in Bangladesh), Fatima Adamu (Usmanu Danfodyo University in Nigeria) and Lubna Hashmat (Civil Society Human and Institutional Development Program in Pakistan), who uniformly made the case for strengthening the engagement of all stakeholders in countries’ EPI programs (Expanded Program on Immunization) in order to reach the most marginalized populations with immunization

2012.11.08. Zanzibar 2 Jambiani South District - vaccine outreach (4) copyF

Copyright GAVI/2012/Doune Porter

Simon Wright (of Save the Children, UK), facilitated a compelling discussion among presenters Anne Lafond (of ARISE/JSI in the U.S.), Sharmin Zahan (of BRAC in Bangladesh), Fatima Adamu (Usmanu Danfodyo University in Nigeria) and Lubna Hashmat (Civil Society Human and Institutional Development Program in Pakistan), who uniformly made the case for strengthening the engagement of all stakeholders in countries’ EPI programs (Expanded Program on Immunization) in order to reach the most marginalized populations with immunization.

Case studies of successful models were offered as learning opportunities and common roadblocks and challenges were discussed.

Ms. Lafond explored methods of leveraging health systems and community partnerships as a way of increasing immunization rates.

The study she presented explored why immunization coverage improves and what drives routine immunization system performance in Africa? The study looked at Ethiopia, Cameroon and Ghana and found six drivers of routine immunization performance improvement.

She explained three of them:

1)the investment in a cadre of community health workers who raised awareness and improved access by taking vaccination into heart of community;

2) the partnership between the health system and the community which created shared responsibility by planning together, awareness raising together and resource pooling;

3) the tailoring of immunization services to community needs (adaption of national plan to community needs).


Ms. Zahan presented a successful example in Bangladesh where BRAC was able to build bridges between the health system and local communities in order created demand creation. BRAC was founded in the early 1970s and helped achieve universal immunization in Bangladesh by 1990. After that success, the government of Bangladesh asked BRAC to continue to work alongside the EPI program.

BRAC provides volunteer health workers who create demand within communities for immunization—they inform mothers about the benefits of immunization and explain to them how to get their children immunized.

The health workers provide follow up services to the families after the children are immunized and continuously monitor every level of health services delivery.

BRAC began being funded by Donors but because their health care workers are volunteers and because it developed its own social enterprises (microfinances) it now is able to fund 80 percent of its own budget.


Next, Ms. Adamu relayed the experiences of CSOs in immunization service delivery in Nigeria and Ms. Hashmat spoke about achieving equity in immunization by reinforcing community and health system linkages.

They studied Northern Nigeria and found that 20 percent of women in rural northern areas bear 80 percent of the child deaths. These women often lacked social support from their family, friends and husbands and were often not engaged in income generation activities.

Ms. Adamu’s organization mobilized communities to raise awareness and increase knowledge. Participants learned the vaccination schedule by counting out on their fingers and aligning them with community ceremonies (such as the baby naming ceremony, etc.). They established community structures to address barriers and to track immunizations with follow up.

Ms. Adamu emphasized it is best to invest in the community as an integral part of the health system not through campaign approach.


Ms. Hashmat shared about her organization’s efforts in Pakistan and described the different models they employed.

She said that it is important to reach the unreached by promoting ownership from within the community (CBO model).

Another Women Organization model reached the unreached by promoting equity.

The third model reached the unreached by highlighting quality and results.

The fourth model reached the unreached by ensuring follow up (of Penta 1st, 2nd and 3rd dose). It focused on children studying in madrassas in urban areas where dropout rate for 3rd dose of Penta was high.

The last model reached the unreached by working on a large scale.

CSOs helped strengthen supply chain in geographically hard to reach areas. Also created models for reaching out to women in conservative areas.

168 million

GAVI-supported vaccine campaigns have resulted in 100 million individuals being immunised against meningitis A and 68 million against yellow fever since 2000.

Meningitis A Conjugate Vaccine Immunizaton Campaign. Joint WHO/UNICEF 2011 Progress Report: January to December 2012. March 2013, p.3 | 2011 data. Yellow Fever Initiative. Joint WHO and UNICEF 2011 Progress Report Nov 2012, p.13, 15. 2012 data: Based on data from Epidemiology of Yellow Fever in the African Region: 2012 report. WHO Regional Office for Africa. April 2013, p.6.

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