Equity Case Study: China - Strengthening vaccination protection for vulnerable groups in the context of an immediate response to an imported wild polio outbreak in Western China
© UNICEF China/2012|
Despite having been declared polio-free in 2000, China reported an outbreak of wild polio-virus type 1 in its Western province of Xinjiang in 2011.
By Abhijit Shanker
4 December 2012 – China had been declared polio-free in 2000, but Xinjiang province in Western China borders countries where wild polio is endemic. Xinjiang’s public health system lacked capacity to manage the risk of imported polio adequately. Implementation of the routine expanded programme on immunization (EPI) in Xinjiang is weak. In addition, as many as 40 per cent of children – especially ethnic-minority Uyghur children – lack equitable access to comprehensive public services, including vaccinations. In 2011, an outbreak of imported polio occurred.
Partnering with the Government of China (GoC) and the World Health Organization (WHO), UNICEF-China contributed to an intervention to halt the outbreak and prevent further transmission of wild polio in Xinjiang by strengthening local capacity for delivering routine oral polio vaccinations (OPV) and for communicating about the importance of vaccinations. Because OPV rates act as a general benchmark for equitable access to and use of basic social services, our intervention has galvanized efforts to reduce disparities in access to basic social services, particularly for unregistered ethnic-minority and migrant children.
Despite having been declared polio-free in 2000, China reported an outbreak of wild polio-virus type 1 in its Western province of Xinjiang in 2011. Recognizing a national public health emergency, the GoC acted immediately. Its collaboration with WHO and UNICEF-China included conducting supplementary immunization activities (SIAs) and awareness-raising campaigns.
Because wild polio is endemic in neighboring Pakistan, Afghanistan and India, China has a continuing risk of polio outbreaks. Hindered by sub-optimal economic development in Xinjiang, the public health system is unable to manage that risk adequately. Challenges include: low human resource capacity; weak cold chain management; and insufficient financing for implementation of the routine EPI. In addition, breakdowns in data gathering and management result in undercounting births and migrants. For example, the reported coverage rate for the routine EPI was reported to be over 95 per cent in 2009; the actual percentage of children who received their third dose of OPV was closer to 74 per cent.
The risk of wild polio infection is particularly serious for Uyghurs, the largest ethnic group in Xinjiang. China’s family planning policy allows Uyghurs to have three children, but estimates suggest that Uyghur families average five children. Punitive measures imposed for disobeying the family planning policy contribute to the underreporting of births among Uyghur families. In addition, frequent migration has led to inaccuracies in family registration. As access to public services depends on registration with the authorities, as many as 40 per cent of children in Xinjiang may not have access to regular social services, including vaccinations. Uyghur families that are Muslim may also decline OPV for their children out of a concern that it is not halaal, and general mistrust of officials has spurred misinformation about OPV, including the canard that it has a contraceptive effect.
The objective of this joint intervention is to provide accurate information about OPV, vaccinate the unvaccinated population, and build capacity to administer the routine EPI at the local level, including by improving utilisation rates among Uyghurs and other ethnic minorities. By highlighting the extent to which ethnic minorities in Xinjiang suffer disparate access to the routine EPI, we also aim to improve general access to basic social services for these vulnerable groups.
Strategy & Implementation
Programme objective. The immediate objective was to halt the spread of wild polio and prevent further transmission. The longer-term objective was to build capacity to enable Xinjiang’s public health system to manage its ongoing polio risk more effectively. UNICEF-China worked towards those objectives through strategic partnerships with the GoC and WHO. Together we conducted a field assessment and formulated both short- and longer-term response strategies. UNICEF-China provided logistical assistance for the SIAs and facilitated a communications campaign that raised awareness about the importance of OPV and promoted behaviour change.
Promoting equity. The joint intervention uncovered critical discrepancies in Xinjiang’s routine EPI records, as well as in its population data pertaining to births and migrant populations. These statistics reflect a reality of disparate access to public health services, including vaccinations. This gap highlights the need for substantive measures to improve equitable access to basic social services for Uyghur children and other vulnerable populations in Xinjiang.
Advocacy and social mobilization. UNICEF-China worked with local health authorities to develop culturally-appropriate, bilingual communications campaigns to mobilize and engage religious and ethnic minority communities, and to reach poor and marginalized population groups, including those living in remote areas, children without birth registration and seasonal migrants. After training and capacity-building provided with UNICEF-China support, imams and health staff cooperated to deliver key health messages at ethnic minority cultural events, during religious services in mosques, and at community meetings, while household-based outreach proved an important strategy for increasing vaccination coverage in remote areas with limited transportation access.
Progress & Results
UNICEF-China and its partners achieved their immediate goal by attaining OPV coverage of over 95 per cent in areas where UNICEF supported communications campaigns.
Policy research. The discrepancies between the reported EPI rates and the actual coverage of OPV have raised the possibility of large numbers of unregistered children in Xinjiang, as well as underscored weaknesses in the current health management information system (HMIS) and other demographic data management systems. To address these issues, the GoC, with UNICEF-China support, is undertaking research in an effort to identify policy-related barriers to accessing basic social services, including routine vaccination coverage, as well as to improve policy and regulations so as to promote equitable access to, and use of, the public health system in Xinjiang.
Increased capacity. As a result of UNICEF-China’s communications-related contributions to this joint intervention, approximately 6,000 Imams and health providers received training to improve their technical communications skills and to build their capacities to support development in their communities. These 6,000 beneficiaries in turn contributed to communications campaigns that helped to raise community awareness and improve practices to support demand for routine EPI services.
UNICEF-China and its partners confronted and managed many challenges in this joint intervention. Any programme designed for and implemented in Xinjiang must contend with the province’s diverse geographic and social factors. Many areas of Xinjiang are rural and remote; transportation and other infrastructure may be limited. Some of China’s poorest and least economically-developed communities are in Xinjiang. Moreover, in a country that is overwhelmingly one ethnicity, Xinjiang has more than ten ethnic minority groups, and ethnic minorities comprise around half its population. Islam is the dominant religion in Xinjiang. The gender dynamics of the various communities in Xinjiang must also be taken into account.
The mobility of the population is another complicating factor for project design and implementation. Xinjiang’s lagging economy does not provide sufficient livelihoods for its population, and many residents migrate to find work. Ensuring receipt of a complete schedule of vaccinations for children and registration of all births requires special determination and persistence, particularly because the existing data management systems are inadequate for capturing comprehensive information on the local population.
With respect to this specific polio intervention, current national and local policies worked against the interventions’ objectives. Family planning policies limiting the number of permissible children per family often create disincentives for ethnic minority parents to register the births of all their children. Unregistered children cannot access public social benefits, including routine vaccinations. Persuading parents to register and vaccinate children born “out-of-family planning” demands powerful arguments and behaviour change communication.
UNICEF-China and its partners overcame these challenges through strategic relationships with a broad range of local health, cultural and religious institutions that were able to influence household-level decision-making about routine vaccinations.
This joint intervention has yielded three important insights that will enrich future programme objectives, design and implementation. First, reported data on standard indicators may not be accurate, especially in Xinjiang, and other areas in China that pose similar challenges in terms of geography, poverty levels and the profusion of ethnic minority communities. Policy research exploring the factors that resulted in this situation will help improve current data management systems and enable development programmes to plan for vagaries in data.
Second, standard indicators like vaccination rates may serve as benchmarks for broader issues relating to equitable access to basic public health and social services. Populations in Xinjiang (and other similarly-situated regions) with significant numbers of unvaccinated children are likely to contend with a wide range of barriers to equitable access to and utilisation of basic social services. Making support for equitable access to and use of basic social services the foundation of programming in these areas may yield substantial improvements across an array of standard indicators.
Third, strategic, multi-sectoral, grassroots-level partnerships can engage and mobilize difficult-to-reach ethnic minority populations through communications campaigns that that are culturally-, linguistically- and religiously-appropriate. This strategy has proven effectiveness in the case of OPV; it may also work for the routine EPI, as well as for maternal-child health care and HIV and AIDS prevention efforts.
This joint initiative will continue with the following projects:
- With UNICEF China support, the GoC is undertaking policy research to identify barriers to routine immunization coverage in Xinjiang. It is also conducting a study to examine how data collection can improve, and how governance can promote more accurate reporting. The results of these studies will inform new policies.
- With our local partners, we are also strengthening and reinforcing grassroots social networks that can deliver public health messaging to, and increase demand for routine vaccinations among, marginalized, poor and ethnic minority populations.
- We will be supporting a pilot project to test EPI interventions in impoverished, vulnerable populations, including in Xinjiang and Tibet. The objective is to improve local awareness and change behaviours to improve rates of use of vaccination services, as well as to improve disease surveillance and the management, monitoring and evaluation of routine vaccination and SIAs.