On 10 January 2024, South Sudan declared a measles outbreak in its Western Equatoria state. With an alarming number of people never having been vaccinated against measles, there was an urgent need to start a large-scale measles vaccination effort to curb the spread of the disease in the state and its surroundings and, ultimately, save as many lives as possible.
However, obstacles to getting and using the measles vaccine in-country meant that it took almost four months for any measles vaccinations to begin in Western Equatoria. In the interim, thousands of people fell ill and at least 13 died, seven of whom were children under five years of age.
For over five decades, Médecins Sans Frontières has been vaccinating people through routine vaccination programs, preventive vaccination campaigns, and in response to disease outbreaks in some of the world’s most challenging settings. Sometimes, we — and other humanitarian, non-governmental organisations — are the only providers of vaccination for people who are not reached by government-led vaccination activities. This can happen for various reasons, including security constraints, geographic and infrastructural challenges and, sometimes, deliberate exclusion.
Our years of experience have taught us invaluable lessons about vaccinating in fragile and conflict-affected settings, and it’s because of this that we know the delay in South Sudan was not exceptional. Often, getting access to vaccine supplies requires months of negotiations around how and when they can be accessed — negotiations which often start anew each time there is a need. Such slow-moving processes waste valuable time and risk lives.
But we don’t think it has to be this way.
Right now, Gavi, The Vaccine Alliance — an organisation which helps the governments of the world’s poorest countries vaccinate children against some of the world’s deadliest diseases — is preparing to operationalise its strategy for the next five years (2026-2030) and, as part of this, designing a dedicated approach to its work in situations affected by conflict, acute emergencies or large-scale population displacement.
In fragile and conflict-affected settings, such as war zones, refugee camps and hard-to-reach areas cut off from health care, it is often more difficult for people to access routine vaccination services, and “zero-dose” children are disproportionately found in these environments. Gavi defines a zero-dose child as one who hasn’t received any doses of the diphtheria, tetanus and pertussis-containing vaccine — a proxy for immunisation coverage more broadly. For example, as of July 2024, 31 World Health Organization (WHO) member countries containing fragile, conflict-affected settings accounted for 55% of unvaccinated children.
Gavi’s effort to address this is therefore much to be welcomed. However, it must take into account the recommendations of non-governmental, humanitarian organisations — like us — that have spent years working in and building our understanding of these settings.
First, Gavi should seek to enable the creation and funding of in-country stocks of vaccine doses and help develop standing agreements that would allow humanitarian organisations rapid access to these stocks. This would allow these organisations to complement national immunisation efforts by vaccinating children who fall outside of national immunisation programs. Gavi should also ensure direct and rapid access to vaccine doses for humanitarian organisations when necessary.
Returning to South Sudan’s Western Equatoria, a flexible system allowing for rapid access to vaccines could enable faster and smoother emergency vaccination responses. One way to make this happen would be for Gavi to work with governments and humanitarian organisations to achieve closer collaboration: none of us operates in a void and effective cooperation with host-country governments allows all of us to better support them and work in places they are not reaching.
We’ve seen how this can work. In South Sudan’s Upper Nile State, MSF set up mobile clinics to screen and vaccinate displaced people, preventing outbreaks. This relatively simple intervention allowed people outside of national immunisation programs to receive healthcare. It was successful because there were sufficient vaccine supplies and there was space to work.
Second, providing vaccine support for children up to the age of five should become a permanent Gavi policy.
A critical part of getting vaccines to as many children as possible in hard-to-reach places is making sure that when we do vaccinate, including in targeted campaigns, we reach all the children who missed out on their basic childhood vaccines, regardless of their age.
In our experience, missing out on vaccinations can have devastating impacts. In last year’s response to the measles outbreak in Western Equatoria, 20% of children treated for measles at MSF-supported facilities were over five.
The Big Catch Up — an initiative of Gavi, UNICEF and WHO — aims to vaccinate zero-dose children up to the age of five. However, this effort will come to a close at the end of this year. And, unfortunately, Gavi does not have a permanent policy in place that allows for vaccine support for children up to the age of five for all relevant vaccines. In addition, many countries’ national guidelines do not support providing vaccines to children over the age of two. This results in limited vaccine supplies and sees children over the age of two often missing out on vaccination and facing an increased risk of falling ill from vaccine-preventable diseases, making any future response to an outbreak even tougher.
Going forward, we urgently need country policies that allow for vaccination until at least the age of five, matched with dedicated financial support from a fully funded Gavi.
Third, ambitious financial and political support is key.
Of course, sustainable funding for immunisation is essential. And due to the logistical and geographic challenges that often exist in fragile and conflict-affected settings, the delivery of vaccines can be more expensive than in “stable” settings. That’s why it’s especially critical for all institutional and government donors to ensure that the collective effort to reach children in such settings with immunisation is ambitiously supported, both financially and politically.
It’s abundantly clear that we in global health must work better together to reach every child in a fragile or conflict-affected setting with lifesaving childhood, routine or emergency vaccination. Health systems need to be strengthened so that country-led responses remain at the core of immunisation efforts, with humanitarian partners enabled to provide support where children cannot otherwise be reached.
The learnings and recommendations of humanitarian organisations must be reflected in the policies and practices of governments and global health organisations that aim to provide vaccination to children in fragile and conflict-affected settings. Actively dismantling barriers to gaining timely access to and using vaccine supplies is a key part of ensuring that children up until at least the age of five will have a better chance of being protected from vaccine-preventable diseases and getting a real shot at life.
This blog is published as part of a partnership between the Development Policy Centre and Médecins Sans Frontières / Doctors Without Borders (MSF) Australia. MSF provides medical assistance to people affected by conflict, epidemics, disasters or exclusion from healthcare. Their actions are guided by medical ethics and the principles of impartiality, independence and neutrality. MSF Australia does not receive public institutional funding.
Read MSF’s full recommendations on how Gavi can do more to reach people outside of government vaccination activities here, and for more information on Vaccination Barriers in Complex Settings see here.
A version of this blog was first published by Health Policy Watch.
