Each year, countless illnesses and disabilities are prevented, and 2 to 3 million deaths are averted, with a simple, inexpensive tool: vaccines.

Vaccinations are one of the most successful and cost-effective ways to protect children’s health and futures. Improving vaccine coverage could prevent an additional 1.5 million deaths annually. But in recent years, global vaccination coverage has stagnated.

In countries where child mortality takes the heaviest toll, more than half of children still miss out on the vaccines they need to survive and thrive.

Most of these children face multiple deprivations – from poor nutrition to inadequate health, water and sanitation services – leaving them even more susceptible to diseases like pneumonia, diarrhoea and measles. Many live in camps for displaced persons or in countries wracked by conflict.

Today, a growing number of unvaccinated children live in densely populated, urban poor communities, including slum environments, where immunization coverage is limited.

Low vaccination rates increase the risk of vaccine-preventable disease outbreaks. In poor urban communities, overcrowding, limited health services, and a continuous influx of new people only intensifies this risk.

As urbanization continues to rapidly increase in the coming decades, the population of urban slum dwellers is only expected to rise, particularly in Africa and Asia.

We cannot afford to let any child go unprotected against disease, disability and death.

To reach every child, UNICEF works with governments and other partners to expand the benefits of immunization for children, with a focus on the most disadvantaged.

Read on to learn more about how we are making vaccines accessible for the world’s most vulnerable children.


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Cambodia: Immunization on the move


“Bring your child for free vaccines tomorrow!” Sokly Ye called out to passers-by as she slowly drove her motorbike down a narrow dirt road lined with ramshackle homes.

It was 7 a.m., and Ms. Ye, an experienced village health volunteer, knew this was the best time to catch villagers at home and let them know that outreach workers from a local health centre would be coming the next day.

After weaving through the streets, she parked and went door to door, speaking directly with residents about the free life-saving services scheduled.

Ms. Ye has been a village health volunteer for 10 years in Svay Pak, an urban poor settlement 9 kilometres north-west of the Cambodian capital, Phnom Penh. She acts as an important messenger to this vulnerable community, sharing the benefits of practices such as vaccination and appropriate pre- and postnatal health for mothers, while also encouraging regular check-ups at the local health centre for all family members.

Around 5,000 people live here. A third are migrants from rural areas in search of work. They live in informal settlements composed of small wooden houses with tin roofs squeezed tightly together. Most are packed beyond capacity with inhabitants, including many small children.

A boy stands next to a house, Cambodia
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Because these settlements are typically illegal and unorganized, they are not registered with the municipality and therefore receive no public services. Clean water and electricity are supplied by private providers, which are more expensive than public lines. In such communities, there is neither proper drainage nor garbage collection, resulting in a dangerous situation of poor sanitation and hygiene.

Diarrhoea, pneumonia, dengue fever, skin infections and malnutrition are commonplace, particularly among children.

Barriers to care

A 2014 UNICEF assessment showed that of Phnom Penh’s population of 1.6 million, a quarter earn less than US$1.60 a day – many of them migrant workers like those in Svay Pak. These economic hardships mean disadvantaged communities are disproportionately affected by disease. In Cambodia’s poorest households, only 6 of 10 children are vaccinated, compared to 9 of 10 in the wealthiest homes.

At the local health centre, villagers need to pay around 2,000 riels or US$0.50 for administrative services (the vaccines themselves are free). Those classified as ‘very poor’ by local authorities are entitled to free health care. But without legal documentation of residency, migrants cannot claim this benefit.

Chanreourn Meas and her husband migrated from the eastern province of Prey Veng four months ago. They live with siblings and work as garbage collectors. The 27-year-old mother says her family simply cannot afford to wait at the health centre.

“Every day we earn between 10,000 and 20,000 riels (US$2.50 to US$5) and can only cover the cost of our food; we cannot spend time at the health centre as we must go out and work,” she says.

Many villagers have limited knowledge of public health services, and are unaware of what is available – and affordable – to them. Parents often do not know the vaccines their children need and when to get them.

That is why the work of Ms. Ye is so important.

Vaccination day

Early the next morning, Ms. Ye arrives to the meeting spot in the village where the vaccines will be administered, next to the community’s Kilometre Nine health centre. “I know the mothers will come,” she says with confidence. 

She’s right: shortly before 8 a.m., women start arriving with children on their hips. Ms. Ye greets them as two health workers drive up on a motorbike with a box of medical supplies. The session starts immediately as the health team knows villagers are anxious to get started on the duties of the day.

A three-month-old baby receives two drops of polio vaccine, a seven-month-old cries after getting a shot for measles and a one-year-old boy smiles after swallowing a vitamin A tablet.

Their mothers also receive tetanus shots. Two hours later, more than 20 people have been treated.

Ms. Ye is happy, as are the health workers. “It was as successful as we hoped!” she exclaims.

Since 2011, UNICEF has worked with the Phnom Penh Municipal Health Department to improve newborn and child health services, including vaccination, in urban poor communities. This includes training health staff and village health volunteers to conduct face-to-face educational sessions and outreach activities.

Efforts to boost vaccine coverage are complemented by a host of activities to strengthen children’s overall wellbeing, such as education about proper nutrition and feeding practices to curb malnutrition, and behaviour change campaigns that inform caregivers about the dangers of pneumonia. 

UNICEF also supports the Ministry of Health to organize outreach sessions in remote or disenfranchised communities at least once every quarter, like the services in Svay Pak.

Cambodia’s national immunization programme covers 11 diseases, including tuberculosis, hepatitis B, polio, measles, and tetanus. Children are scheduled to get them six times within the first two years of life to be fully immunized.




India: The rag picker angel


It is pitch dark as 27-year-old Nazaama quietly pats her one-year-old daughter back to sleep, pushing back the torn plastic sheet that serves as a door to her little hut.

Today, like every other day for Nazaama, starts at 4 a.m. She walks empty alleys, rummaging through the trash bins before the garbage trucks make their morning rounds. Using a stick to dig deep into the mounds of mixed household rubbish, she picks out discarded plastic bottles, collecting them in the large sling bag across her shoulders.

After five hours, she hurries back home, happy with her cache that she sells for less than US$3 to the informal shops that recycle the plastic. Today her children will have a full meal.

This is Chandmari – an urban settlement of 417 rag picker families in Ghaziabad, Uttar Pradesh, just 20 miles from India’s national capital New Delhi.

A woman sits with her children, India
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Living in tattered huts made of plastic sheets and bamboo sticks with electric wires drawn illegally from the municipal supply, Chandmari is a settlement that the world has forgotten.

“Kismet. This is fate. Life has to be lived somehow,” says Nazaama sitting on her cot made of rope. She seems tired, but her face, framed by a blue shawl, has a certain strength as her soft voice fills the hut.

Hers was a love marriage – the first in the close-knit community of rag pickers. Married at 18 to Abrar, who earns a living from performing stunts and magic tricks on the streets, she has four children. Unlike many of the parents in Chandmari, Nazaama has made sure all of her children are fully vaccinated.

A vaccine advocate

In Uttar Pradesh, India’s most populous state, only 50 per cent of children are fully immunized. District Ghaziabad where Chandmari is located has over 12,000 families working and living at 365 brick kilns, 118 construction sites, 42 nomadic settlements and 131 slums. Out of 656 sites with high-risk groups, almost 6,000 children under 5 years of age should be fully vaccinated. Fewer than 1,000 are.

Dropout rates are high. Myriad reasons are given. The child was sick. Last time there was fever. We were visiting. I am a daily labourer and if I don’t earn, then what will my family eat? Or simply not knowing. Parents are not educated about the number of vaccines needed, the diseases that they prevent, and the timing of the shots.

In a community where most mothers do not understand the long-term health benefits of immunization, Nazaama is a rare advocate for vaccines.

She understood the benefits of immunization early. When her oldest child, Aafiya, was born eight years ago, Saarika Khanna, a community mobilizer from UNICEF’s social mobilization network, counselled Nazaama about the importance of protecting the child against polio and other vaccine-preventable diseases like measles and pneumonia.

Ms. Khanna was the one who advised Nazaama to fully immunize her child.

“I was scared of the needle when I got my TT [tetanus toxoid] shots,” Nazaama says. “When I could not bear the pain of the injection, how could I subject my little girl to it?”

But still, she took Aafiya in for her first shots on Ms. Khanna’s insistence. “Jab itne dukh sahe, to yeh bhi dukh seh lenge, when life has given me so many sorrows, let me bear one more,” she remembers. To her surprise, the experience was good. Her baby was soon her smiling self again.

The community mobilizers now had a staunch supporter in Nazaama. The evening before the monthly immunization sessions, Ms. Khanna would inform Nazaama about the list of families whose children were due for immunization.

The next morning, a determined Nazaama would cajole, counsel and persuade them to take the children to the nearby Anganwadi (community centre) where the nurse midwife would be waiting with the vaccines.

One of her toughest challenges was in convincing her own sister-in-law Churchuri about immunizing her five-month-old daughter.

“I have myself taken children for immunization if the mother was not willing to take the trouble of going to the site. I did this for Churchuri too,” says Nazaama.

“These are also my children, aren’t they?”

India’s vast immunization programme reaches around 26 million children countrywide with vaccines covering 12 diseases. The Uttar Pradesh state government has strengthened its health systems to deliver over 160,000 immunization sessions monthly, while increasing the number of urban auxiliary nurse midwives and community workers, and improving the visibility of communication materials.

In early 2015, the Government of India launched an equity-based strategy, Mission Indradhanush, which aimed to rapidly increase India’s full immunization coverage to 90 per cent by 2020, targeting the most vulnerable and underserved communities. Four rounds are held each year in April, May, June and July with additional rounds if required in the last quarter of the year.

The challenges are huge. The Government must reach high-risk groups who are constantly on the move – brick kiln workers, construction workers, slum dwellers and nomads. Maintaining immunization records of children belonging to migratory families is difficult.

Using lessons from the polio eradication campaign, frontline workers have mapped every village, town and city, every brick kiln and nomadic settlement through microplans that detail every household and every child. Pregnant mothers and newborns are tracked and ‘due lists’ for vaccination shared with local health workers. UNICEF supports the programme in a number of capacities, including cold-chain monitoring, planning, capacity-building and communication interventions.




Kenya: Going the distance in close quarters


Sicilia Obwoge, 21, and her husband Joseph, 23, gaze at their newborn baby sleeping peacefully under a mosquito net at their home in the Mukuru informal settlements in Nairobi.

The young couple welcomed their daughter Lakeshia into the world one week ago, and they are beaming with love and pride. They speak in hushed tones so as not to wake her, but the sounds of the city outside still filter in through the window.

Joseph and Sicilia live in a small, one-room house made from corrugated iron sheets, in one of Nairobi’s largest informal settlements. Space is limited here, and families make do with what they can afford. For Joseph, a casual labourer earning less than US$5 a day, and Sicilia, a housewife, it isn’t much. And even as they peer down at their sleeping beauty, the new dad is worried about how he will provide and care for his growing family.

A woman holds her baby under a mosquito net, Kenya
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The Obwoge’s story is shared by millions of other Kenyans living in urban informal settlements. They work hard, earn little and live under poor, crowded and hazardous conditions. Children born into these homes face multiple deprivations that limit their potential in life. The first being access to affordable quality healthcare, including immunization.

In recent years, Kenya has made tremendous progress in reaching every child with life-saving vaccines. Eight vaccine formulations, procured by UNICEF, are provided against ten childhood diseases free of charge in all public health facilities. But far too many children still miss out on this service.

In 2016, an estimated 350,000 children did not receive all of their scheduled vaccines. Many of them came from poor households, in urban informal settlements where health facilities are few and offer low quality service. It is therefore no surprise that Nairobi has one of the highest number of unvaccinated children in Kenya.

But for parents struggling to survive, the only numbers that matter are the kind that put food on the table.

UNICEF Kenya Health Specialist Peter Okoth says, “Caregivers spend a lot of time working for their livelihood. The time to go to hospital is constrained. We are therefore advocating for facilities to open over the weekend to meet the needs of these children.”

Back at the Obwoge’s home, a Community Health Volunteer has come for her first home visit. Susan Aleka dedicates her time and energy to serve the residents of Mukuru and keep children healthy. She is one of 4,500 volunteers that support the Nairobi health system, bringing basic health services to the doorsteps of those that need it most.

Today Susan is visiting Joseph and Sicilia to monitor the baby’s progress, share valuable health information and also remind them of Lakeshia’s routine immunization schedule.

“I have worked with this family ever since the baby was conceived,” she says. “I convinced Sicilia to regularly attend the antenatal clinics and deliver in hospital. Now I must ensure baby Lakeshia is protected from diseases through vaccination, exclusive breastfeeding and practicing safe hygiene and sanitation.”

Community Health Workers are a lifeline for the Expanded Programme for Immunization (EPI) in Kenya. By linking with health facilities, they are able to trace children who are missing out on their vaccinations and check up on them. They go the distance, door to door, to ensure that families are aware of the importance of immunization and how to access this life-saving intervention.

For parents like Joseph and Sicilia, this is one less weight on their shoulders.

With the support of UNICEF and World Health Organization, the Ministry of Health has undertaken numerous mass immunization campaigns. These campaigns target the poorest and most vulnerable children to safeguard their right to survive and thrive.

In 2016, 19 million children (9 months to 14 years of age) were vaccinated against measles and rubella – Kenya’s most successful immunization campaign. Urban areas such as Nairobi, Mombasa and Kisumu cities recorded high numbers of vaccinated children, protecting them from these killer diseases.



Nigeria: Stopping an outbreak in areas affected by conflict


Fanna Alhaji Tujja has the face of a young woman, but the weathered hands of a grandmother. Married at 12, a mother at 13, with four children by 20, Fanna was forced to flee her burning village last year while two uncles and a cousin were killed in the same compound.

A woman sits on the ground with her children, Nigeria
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Fanna never went to school, never learned to read, never visited a health centre, and until this past year, had never immunized her children.

Today she lives in a sweltering lean-to fashioned from corrugated iron, cloth and cardboard on the dusty banks of Maiduguri’s Ngadda River with her husband and four children. She is one of the thousands of internally displaced families who fled their homes for the safety of Borno’s state capital, but couldn’t find a space in the crowded camps, and instead found themselves a few square feet on which to build a shelter. She gave birth to her last child, a son, on the shack’s dirt floor.

A year ago, she was living in the family house in Mairi, Konduga, on the road to Bama in the south-east of Nigeria’s conflict-riddled Borno state. By day she worked the fields, harvesting wheat, beans and maize. “We were several families in a big compound all together, not like this, it had zinc on the walls, and we had our farm. Then we lost everything.”

The insurgents came at night, “between Maghrib prayer and Isha prayer”, surrounding the village and picking out the men to shoot them. “If they find a woman with children they don’t shoot but if they find a man … They surrounded the village, but it was dark and my husband escaped. They killed many people and burned the settlement and we ran.”

When they walked into the Maiduguri rescue centre they were given food, “but there was no space for us – we knew some people from our village were here, so we settled here. Now we’ve been here for more than one year. When the rains come we put plastic up. When the river rises we go to the warehouse on the other side and sleep there.”

One day last year, a polio vaccination team knocked on her corrugated iron door, part of special emergency campaigns to protect children from the disease after new cases of polio were detected in inaccessible areas of Borno last July – the first cases in Africa in two years. A social mobilizer came too, explaining the benefits of routine immunization and helping the family to attend a health camp, where the children were immunized against all nine vaccine-preventable childhood diseases.

“Before, I didn’t know what vaccinations were,” Fanna says, “but when I came here the polio social mobilizers talked with me and I was happy. My children are getting protection from diseases that I never got.”

Fanna hopes her children can get “a real education” and find work in Maiduguri. She asks her interviewer, Dr Habiba Saidu, what she does. “I’m a doctor,” Habiba smiles. Fanna rests her hand on three-year-old Fatima’s head. “Well I want her to be a doctor like you.”

In July 2016, the Government of Nigeria and the World Health Organization confirmed an outbreak of wild poliovirus in conflict-ridden Borno state. Nigeria – and the continent – had its last confirmed polio case two years ago, and was within a year of being certified polio-free.

In late March 2017, UNICEF participated in a massive synchronized vaccination campaign in west and central Africa as part of urgent measures to permanently stop polio on the continent. More than 190,000 polio vaccinators in 13 countries immunized more than 116 million children.



Ukraine: A near tragedy compels change


A woman of very few words, 43-year-old Halyna Yarych sits quietly with her five-month-old baby Sasha on her lap. Next to her are five of her ten children, all of them waiting to meet the doctor for their scheduled vaccinations.

Halyna keeps track of her children’s immunization schedules with great detail, but has not always done so.

“Three years ago, I woke up to five very sick children. I panicked and went with them to the hospital where they were all admitted for one week,” she says.

The diagnosis was whooping cough – easily preventable through routine childhood immunizations, but until then, Halyna had never bothered much about vaccines. Although her doctors had continuously reminded her of the need to get her children vaccinated, she had opted to trust her neighbours, who had all foregone immunizations for their children.

A woman holds her infant, Ukraine
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“When her children were ill, I again explained to her how vaccines work and why all her children were at risk of this contagious infection because they had not been vaccinated. At that point it sunk in,” says Dr. Nataliya Seredyuk, a paediatrician at her town’s medical facility.

Improving coverage rates

Ukraine has one of the lowest routine immunization coverage rates in the world. In 2016, coverage for diphtheria, pertussis and tetanus was as low as 23 per cent, measles was 45 per cent, while polio coverage was under 60 percent for children under 1 year old. These low vaccine coverage rates led to two confirmed cases of polio in 2015, when Ukraine had previously been declared polio-free.
The conflict in Eastern Ukraine, ongoing since 2014, has caused further deterioration in vaccine supply, forcing mothers like Halyna to always be anxious about their children’s well-being.

“Last year I waited for over six months and considered buying from a private clinic because I was anxious, but I could not afford it,” she says. In a private facility, vaccines cost at least US$18 and for Halyna who is on social welfare this was a very tall order. “So I waited anxiously and worried every time my children complained of anything.”

Realizing that she could have lost five children and risked infecting the rest, Halyna is now a regular at the general practice for family medicine. Although they have not always had vaccines in the last two years, with support from UNICEF, the facility is now fully stocked and she no longer needs to wait for long periods for the vaccines to be restocked.

Once a self-sufficient country, Ukraine could not conduct routine vaccine procurement in 2014 and 2015. The ongoing conflict in the East and the economic recession left the Government without the resources needed to provide adequate investment to the immunization programme, including a steady supply of vaccines. As a result, routine vaccine stocks were depleted.

Critical shortages of essential medicines and vaccines prompted the Ministry of Health to request international organizations such as UNICEF to assist in the procurement as an interim measure, while the reform of the procurement system takes place. UNICEF procured and delivered the first supplies in 2016.