In 2020, 23 million children missed out on essential vaccinations due to the epidemic, an increase of 3.7 million compared to 2019, according to WHO and UNICEF official data. This stark data indicates that a majority of countries, especially developing countries, experienced substantial reduction in vaccination rates.
Immunization data from the World Health Organization and UNICEF indicate that countries’ decades of progress against life-threatening diseases is in serious jeopardy. While vaccination helps ensure children’s safety against deadly diseases, it can also be a marker of health disparities, as differences in access to or availability of services between populations still exist. It is now more urgent than ever to put a strong focus on closing immunization and health disparities.
Immunization Inequity: A Global Snapshot
Vaccination is a highly cost-effective health intervention to save children from life-threatening diseases, but it is a sad reality that not all children benefit from it. The inequity in immunization particularly in low- and middle-income countries persist. This equity is portrayed by the 21-percentage gap between Europe immunization coverage (94%) and African region coverage (73%). According to WHO, although 9 out of 10 children are reached by 2019, each year, 20 million infants are not fully vaccinated with DTP3 – basic vaccines for the children life course. Of these, over 13 million receive no vaccines through immunization programmes – referred to as the “zero dose” children. Up to two-third of under-vaccinated children are concentrated in only 10 countries: Nigeria, India, DRC, Pakistan, Ethiopia, Brazil, Philippines, Indonesia, Angola and Mexico .This demonstrates a vast disparity in immunization access among countries.
Figure 1. Zero-dose national prevalence and top five countries with highest prevalence 
Immunization Inequity: Causes and Perpetuating Factors
There is a pressing need to reach groups and communities who with difficult access to immunization. To do this, it’s critical to identify the obstacles which restrict those groups and communities from immunization services. Gavi confirmed that nearly 50% of zero-dose children live in three key geographic contexts: urban slums, remote communities and conflict zones. These vulnerable communities face extreme poverty, exclusion from basic to health care, and suffer high mortality rates . The COVID-19 is also a magnifier of immunization disparities. During COVID-19 lockdowns, immunization rates fell due to lack of access to vaccination centers, parents’ hesitancy to go out, and vaccinators’ hesitancy to sustain immunization for fear of infection. This perpetuated immunization inequity , evident in a nearly 30% increase in the number of zero dose children in Gavi supported countries in 2020.
Gavi also identified several gender norms that contribute to low immunization rates . Low education level of women is associated with lower immunization coverage of children. Many children miss their vaccines due to restrictions on movement of women in Pakistan, which prevent mothers from taking children to vaccine clinics. Religious practices or cultural values may prevent female caregivers from seeking immunization services from male health workers. Hence, immunization disparities stem from a blend of socio-economic, gender-related, as well as cultural factors.
Figure 2. Determinants of Inequities 
From Immunization Equity to Health Equity
It is unfortunate that the world is not reaping the benefits of vaccines equally. Complicated by the unprecedented scale of COVID-19, countries’ decades of progress against some of the world most dangerous diseases is being severely threatened. Fewer vaccinated children exacerbate health disparities and raise the risk of epidemics, putting overburdened health systems at risk of collapsing. Thus, closing immunization gap is critical to help communities achieve their full health potential regardless of demographic, social, economic or geographic strata. This is also the shared goal for the Immunization Agenda 2030 and Gavi 5.0: to reach every child with every vaccine and prioritize the disadvantaged and most marginalized .
Closing immunization gap is critical to help communities achieve their full health potential regardless of demographic, social, economic or geographic strata.
Putting Priorities into Action
To ultimately eliminate immunization and health inequity, governments should be at the forefront of calls to prioritize equitable and gender-focused policies and strategies to sustain the immunization coverage. Moreover, collaboration is imperative. It is essential to have partnerships to bring together a cross-sector of stakeholders to jointly address the challenges.
It is also critical to highlight the role that everyone in the communities – parents, health-care workers, policymakers, media, and ultimately everyone – can play by working together to ensure that every child in every country gets the vaccines they need. Communities’ awareness of the need for immunization, especially amid the pandemic, can urge greater actions on immunization. Lastly, significant investments should be made to build a strong and well-prepared health workforce. Our first line of defense against disease, protecting health, and keeping people safe is a well-trained public health workforce.
Equity is now the guiding principle for public health policies which aim to ensure healthy lives and well-being for all, leaving no one behind. The overarching promise of a healthy, equitable future for all is within reach if we all join forces to reduce health disparities in one way or another.
Do you have any thoughts on immunization inequity and zero-dose and under-immunized children? Let’s join GaneshAID’s efforts in the progress of reaching these communities! We would love to see your ideas in the comment section below!
 A Double vaccine crisis is endangering millions of children, UN Foundation, 2021
 Immunization Inequities in Southeast Asia, WHO ROSA