Author: Christina Shaw
In the halls of the health ministry in Tunisia, a team of immunisation practitioners grappled with a pivotal challenge. It was 2023, and they were on the brink of introducing the HPV vaccine – a milestone in the country’s public health journey. Yet, questions loomed: Was their decision to target 12-year-old girls with a single-dose using a school-based delivery platform the right one? How could they ensure community acceptance? Would cultural norms hinder their efforts? Across the world, similar uncertainties echo in the health offices of other middle-income countries (MICs), striving to turn “immunisation for all” from aspiration to reality. Indonesia faced significant declines in vaccine coverage and increased vaccine hesitancy post-Covid pandemic, and Armenia was searching for strategies to address the lack of caregivers’ knowledge about immunisation and the resultant number of under-immunised and zero-dose children.
These countries, though diverse geographically, culturally, and politically, shared a common struggle: bridging the gap between the global guidance they’ve received and the practical “how-to” implementation knowledge that would ensure the success of their strategies to result in transformational change in the protection of their populations from vaccine-preventable diseases. Then, an opportunity emerged, as countries were invited to participate in relevant and timely learning engagements facilitated by the Linked Immunisation Action Network, a collaborative peer learning network where in-depth discussions on their shared challenges and their own experiences addressing these challenges produce the knowledge to effectively implement approaches to strengthen the equity, resilience, and sustainability of immunisation programs.
Tunisia’s Breakthrough in Building Trust for the HPV Vaccine
In a conference room in Tunisia in 2024, a team of health officials poured over plans for their HPV vaccine rollout. The strategy – targeting adolescent girls through schools – was bold, but doubts lingered. How could they navigate cultural sensitivities?
Linked workshops in Istanbul and Geneva became their turning point. There, they connected with their peers from the Philippines, who shared learning from their experience implementing school-based delivery of the HPV vaccine. This helped to reinforce for Tunisia their decision to do so as well. The experience of Mongolia was beneficial to the Tunisians in validating their decision around product choice. Another revelation came from Jordan and Uzbekistan, where involving religious leaders in the vaccine rollout communication strategy was critical to building community trust.
Returning home energized, the Tunisian team revised their strategy. They are now partnering with local faith leaders and educators, co-designing messages that resonate with cultural values. When the first doses were administered, community leaders would stand alongside health workers, dispelling myths, countering misinformation, and encouraging vaccination.
“Learning from peers reassured us we’re on the right track – that we’re not alone.”
– Tunisia’s Director of Primary Care
Indonesia’s Digital Revolution to Accelerate Vaccine Coverage
In 2022, Indonesia was facing post-pandemic turmoil. Immunisation rates had plummeted, with 26% of children having received no vaccinations in 2021. Though they were in the process of implementing a national government-led catch-up campaign, they were facing a huge shortage of human resources and significant vaccine hesitancy challenges among the population and health workers alike. A breakthrough began with a study tour to Sri Lanka, where they observed a successful approach to management and supportive supervision and its positive effects on the immunisation program and health worker capacity. Inspired, a subnational representative from the Indonesian delegation initiated a clinic-based study to test an adaptation of Sri Lanka’s supportive supervision program. After revising and digitizing one of the tools, a pilot was rolled out in a health center in one of Indonesia’s districts. In addition to receiving praise from health workers, there are also indications of reduced vaccine hesitancy and increased coverage. They hope to scale up in other primary health centers across Indonesia and eventually integrate into national health policies.
Additionally, the COVID-19 pandemic spurred significant investment and political commitment towards improving immunisation infrastructure and information systems, namely their electronic immunisation registry (EIR). In 2023, they began implementation of their EIR, a major step forward in Indonesia’s ability to monitor coverage and the routine use timely data to increase coverage and identify and target zero-dose children.
“[The study tour to] Sri Lanka helped us make better training plans – improving target setting, logistics planning, in the quality of immunisation delivery, and reporting.”
– Indonesia subnational representative
Months later, a study tour to Australia connected the EIR experts from both countries to consider how learnings from Australia’s experience of integrating and scaling its information systems, and of improving usability, quality, and uptake of their EIR by providers could be used in Indonesia. Encouraged by Australia’s use of an automatic reminder system for caregivers being integrated into their EIR, Indonesia chose to adapt this same strategy and developed an automated messaging system using Satu Sehat mobile (a data platform for integrated health services) and WhatsApp. In the next phase of development, Indonesia will further refine this reminder feature to enable personalization of the message for each child.
Armenia’s Journey to Reaching Zero-Dose Children and Increasing Vaccine Demand
For years, Armenia has celebrated high immunisation rates, yet challenges prevented the country from reaching optimal levels of coverage to strengthen and reinforce the resilience of their program. They recognized that many caregivers were not aware of the benefits of immunisation, resulting in populations segments of under-immunised and zero-dose children. However, the national EPI lacked the tools to educate these caregivers and the routine data to ensure accountability in reaching these children.
Linked learning engagements became a catalyst for the country’s progress towards a stronger immunisation program. A study tour to neighboring Georgia revealed how legislation could tie immunisation to public health accountability. In the example of Georgia, they had mandatory vaccination laws that tied immunisation to school enrollment. Back home, the Armenian delegation drew on Georgia’s experience to present evidence-based arguments to propose a policy mandating immunisation based on the epidemiological context, helping support accountability toward sustainable and equitable coverage.
But legal frameworks alone weren’t enough. At a subsequent Linked workshop, the delegation from Armenia learned about how other countries were effectively monitoring zero-dose children and ensuring accountability for reaching these children. Impressed by the progress their peers had made in reaching under-vaccinated and zero-dose children, they returned home and developed a new zero-dose reporting mechanism integrated into their electronic immunisation information system. The mechanism has since been integrated nationally and allows primary healthcare workers to generate real-time vaccination data, helping identify and target missed children.
At the same workshop, the team collaborated with maternal and child health practitioners. to design an education program for Armenia’s existing maternity schools, which will improve caregiver awareness as a means of increasing demand for immunisation.
The Ripple Effect
These stories are not unique – they are threads in a global tapestry woven by the Linked Network. Through workshops, study tours, virtual exchanges, and other participatory collaborative learning approaches, MICs are rewriting the narrative of immunisation:
- A school-based vaccination campaign strategy tested in the Philippines becomes a lifeline in Tunisia.
- A supportive supervision model from Sri Lanka revives vaccine coverage in clinics throughout Indonesia.
- A policy breakthrough in Georgia and zero-dose reporting mechanisms from other peers inspires reforms in Armenia.
“Immunisation for all” isn’t achieved through top-down mandates. It’s built in collaborative spaces where health practitioners exchange ideas, strengthen their knowledge and capacities, adapt solutions, and are empowered to effectively address immunisation challenges and improve public health outcomes.
As the Linked Network continues to support country progress toward sustainable and equitable immunisation programs, it is fueled by a simple truth: The most powerful force in global health is the collective wisdom of those on the front lines.
This World Immunisation Week, we celebrate the unsung heroes – the health practitioners, policymakers, development partners, and donors – who prove that equity is not a solo mission, but a shared journey. Their legacy? A world where no child is left behind.
Together, we learn. Together, we protect.
To learn more about the country experiences outlined in this blog, please visit the following resources on the Linked website: