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Challenges in capacity building of national immunization programs and emergency or pandemic vaccination responses in the Global Health Security Agenda member countries
Sookhyun Lee1,2orcid, Jung Ju Oh1orcid, Sang Hyun Park1orcid, Dasol Ro1orcid, Ye Jin Jeong2orcid, So Yoon Kim1orcid
Osong Public Health and Research Perspectives 2024;15(2):182-185.
Published online: March 28, 2024

1Asian Institute of Bioethics and Health Law, Yonsei University, Seoul, Republic of Korea

2GNPSP (Global Network for Peace and Sustainable Progress), Seoul, Republic of Korea

Corresponding author: Sookhyun Lee GNPSP (Global Network for Peace and Sustainable Progress), 6, 89 Saemunan-ro, Jongno-gu, Seoul 03182, Republic of Korea E-mail:
• Received: June 14, 2023   • Revised: September 12, 2023   • Accepted: January 16, 2024

© 2024 Korea Disease Control and Prevention Agency.

This is an open access article under the CC BY-NC-ND license (

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Coronavirus disease 2019 (COVID-19) triggered a global crisis and economic collapse. Infectious diseases have been reported to impact over 1,430 cities across 210 countries at any given time (United Nations [UN] 2020). During the COVID-19 pandemic, the World Trade Organization (WTO) estimated a 5.3% decline in global trade (WTO 2021), while the International Monetary Fund (IMF) reported a 13.1% increase in global financial debt (IMF 2020). More than 350 million individuals lost full-time employment (African Development Bank 2020). In light of this experience, it has been pointed out that pandemic preparedness was inadequate and must be improved with greater transparency (Organisation for Economic Co-operation and Development 2022). Equity and solidarity are essential principles in pandemic preparedness (World Health Organization [WHO] 2022). The pandemic has starkly revealed and intensified severe and systemic inequalities (UN 2020).
The Global Health Security Agenda (GHSA) Immunization Action Package is developing a methodology that will act as a strategy to enhance and supplement existing resources for national immunization programs (NIP) capacity. It also aims to establish a dynamic library of these resources that will expand over time. Efforts to increase global vaccination coverage are ongoing, as immunization is acknowledged to be one of the most effective and cost-efficient global health interventions for saving lives and preventing diseases [1]. Immunization efforts are carried out through a national vaccine delivery system, which includes efficient distribution, accessibility for marginalized populations, sufficient cold chain infrastructure, and continuous quality control. These elements are crucial for building resilience against public health threats and emergencies [1]. The Joint External Evaluation (JEE) assesses immunization using 2 indicators: vaccine coverage within the national program and the national vaccine access and delivery.
Indeed, the GHSA Immunization Action Package aims to raise the vaccination rate for vaccine-preventable diseases. As part of this initiative, various meetings have been held to share and develop strategies and initiatives of member countries. To assess the challenges and strengths of the NIPs of GHSA member countries, the Immunization Action Package has gathered data for statistical analysis from literature reviews and WHO/United Nations International Children’s Emergency Fund sources. At the Expert Forum of the Seventh GHSA Ministerial Meeting, which took place on November 28, 2022, participants discussed 4 key capacities of NIPs: infrastructure, sustainable financing, and other vaccine-related capacities, including vaccine awareness, access, and development. The forum also addressed several challenges that NIPs may face, along with related emergency responses, such as an insufficient health workforce, inadequate education or training, cold chain issues, and a lack of information management systems and government funding at both central and local levels. These topics were chosen for their relevance as identified in the JEE and other data sources, and for their significance in strengthening NIPs. This paper will explore 4 such topics.
The Expert Forum concentrated on addressing the specific needs and challenges that countries participating in the Seventh GHSA Ministerial Meeting encountered while striving to enhance their NIP capacities. The countries involved in these discussions included Australia, Japan, Finland, Kenya, Lao PDR, Malawi, Pakistan, Saudi Arabia, Sweden, Thailand, Senegal, South Africa, Peru, Singapore, Philippines, Nigeria, Malaysia, Madagascar, Georgia, Gambia, DR Congo, El Salvador, Ethiopia, Bangladesh, Cameroon, Uganda, Argentina, Switzerland, Denmark, Burkina Faso, Liberia, the Republic of Korea, The Netherlands, United Kingdom, United States, and Zimbabwe as of November 14, 2022.
The Expert Forum offered a platform for nations to assess the capacity of their NIPs to develop strategies aimed at preventing potential challenges arising from insufficient capabilities.
Due to COVID-19, each member country of the GHSA has recognized the importance of strengthening NIP capacities during peacetime. A study found a correlation of 0.63 between the vaccination rates for diphtheria, tetanus, and pertussis (DTP), polio, and measles in 2019, before the COVID-19 pandemic, and the COVID-19 vaccination rate in 2022 across the 71 GHSA member countries [2]. This indicates a strong relationship between routine immunization coverage and the ability to achieve high vaccination rates during a public health emergency such as COVID-19. This correlation suggests that countries need to maintain high vaccination rates even in the absence of a pandemic to be prepared for public health emergencies. Resilient infrastructure is a critical component in this effort, as it can alleviate the strain on emergency response systems. The JEE assessed the average score for infrastructure among the 71 GHSA member countries at 3.57 out of 5. A low score highlights that infrastructure is a significant area for improvement in the NIP and has become a topic for discussion.
Health system infrastructure is divided into various components, including physical infrastructure, information and communication technology, and medical equipment [3]. The COVID-19 pandemic, in particular, has underscored the importance of a robust public health data infrastructure [4]. The Republic of Korea serves as a prime example of resilient infrastructure, as seen in its management of routine immunization during the pandemic. This involved examining the capacities of information technologies, such as stock management tools and vaccine data management, integrating private sector activities and data into the national immunization system, and utilizing this information infrastructure to enable the government and other institutions to develop more efficient and equitable vaccination strategies [4]. Successful interventions hinge on a strong health system infrastructure and investment [5]. Indeed, the COVID-19 pandemic has revealed vulnerabilities in the current infrastructure, necessitating that key stakeholders undertake initiatives to reinforce infrastructure, thereby enhancing vaccination coverage [5]. The Expert Forum provided an opportunity for countries to present national case studies and deliberate on strategies for building resilient infrastructure.
Sustainable financing aims to improve the generation, allocation, and use of public and pooled funds in healthcare [6]. The financial sustainability of the NIP is increasingly important to meet current and future immunization performance targets, including access, utilization, quality, safety, and equity. It also supports the prevention and early detection of, and effective response to, infectious disease threats, as well as the introduction of new vaccines and technological advancements. Following the JEE Report by the WHO, financial challenges were identified in 15 low- and middle-income countries, spanning 10 in Africa, 2 in the Western Pacific, and 1 each in Europe, South-East Asia, and the Eastern Mediterranean regions [1]. According to the World Bank's 4 income classifications, the 71 member countries of the GHSA include 22 high-income (31.0%), 19 lower-middle-income (26.8%), 17 low-income (23.9%), and 13 upper-middle-income (18.3%) countries [1]. Financial sustainability is a key factor influencing vaccine coverage, access, and delivery. To improve vaccine coverage, a government's strong commitment is essential; this includes co-financing, campaign support, and budget allocation across central and local governments, as well as the development of human resources. Moreover, maintaining vaccine access and delivery requires financial independence, effective negotiation with vaccine manufacturers, and the cultivation of technical professionals. For financial sustainability, the national immunization strategy has developed the national immunization schedule to estimate the costs and implement a realistic vaccine budget [7,8]. A successful strategy will depend on the continuous evolution of previous initiatives, as challenges differ by region and income level. There is still a need for further analysis and action to increase efficiencies in various settings.
Vaccine equity is predicated on the principle that access to and allocation of healthcare should be impartial, regardless of race, religion, political belief, economic status, or any other social condition [9]. However, the inequitable distribution and access to vaccines for COVID-19 have exacerbated the pandemic's effects, leading to an increase in the number of cases and deaths, as well as significant political and economic repercussions [10]. Consequently, the challenges of vaccine access and equity have become a primary focus of discussion at global, regional, and national levels, both before and during the COVID-19 pandemic. According to the JEE of the GHSA, among the 71 member countries, 80% of those in the African region have faced difficulties with vaccine access due to geographic constraints and limited vaccination sites. As of August 2022, the COVID-19 vaccination rates (excluding Ukraine) are as follows: a vaccination rate of 0% to 20% in 17 GHSA member countries (15 in Africa, 1 in the Eastern Mediterranean, and 1 in the Americas); 20% to 40% in 10 countries (9 in Africa, 1 in the Eastern Mediterranean); 40% to 60% in 4 countries (1 in Africa, 3 in the Eastern Mediterranean); 60% to 80% in 22 countries (1 in the Eastern Mediterranean, 10 in Europe, 4 in the Americas, 3 in South-East Asia, and 4 in the Western Pacific); 80% to 90% in 15 countries (1 in Africa, 4 in Europe, 3 in the Americas, and 7 in the Western Pacific); and over 90% in 2 countries (1 in the Americas and 1 in the Eastern Mediterranean). The inequity in COVID-19 vaccine distribution is anticipated to have a deep and enduring impact on the socio-economic recovery of low and lower-middle-income countries. Without immediate measures to increase supply, share vaccines equitably, and ensure universal accessibility, the consequences will be far-reaching.
Vaccine campaigns aimed at combating COVID-19 depend not only on the efficacy and safety of the vaccines, but also on the level of vaccination hesitancy among the public and healthcare workers. This factor is critical for achieving control over the pandemic [11]. The Strategic Advisory Group of Experts on Immunization defines vaccination hesitancy as a “delay in acceptance or refusal of vaccination despite the availability of vaccination services” [12]. Consequently, vaccination hesitancy can be assessed by the vaccine acceptance rate, which represents the proportion of the population indicating in national surveys that they have been vaccinated or are willing to be vaccinated. Research indicates considerable variability in COVID-19 vaccine acceptance rates across different regions and countries. Acceptance rates falling below 60% can pose various challenges to national COVID-19 pandemic programs [11]. Notably, low vaccine acceptance rates have been observed in the Middle East, Eastern Europe, and Russia [11]. In contrast, high acceptance rates in East and South-East Asia are indicative of effective pandemic control in these regions [11]. Addressing the widespread issue of COVID-19 vaccination hesitancy necessitates a collaborative effort involving governments, health policymakers, and a range of institutions and stakeholders.
As part of category R.7.2 of the JEE, vaccination hesitancy has emerged as a significant topic on the global health agenda. The Seventh GHSA Ministerial Meeting included sessions designed to further the discussion on identifying the primary causes of vaccination hesitancy across various regions and to develop strategies aimed at preventing reductions in vaccine coverage rates due to low acceptance.
Overall, countries have encountered limitations and challenges with their existing NIPs through experiences of health emergencies such as COVID-19. Consequently, they have established common goals to develop practical solutions. At the Seventh GHSA Ministerial Meeting, the Expert Forum convened to discuss the visions for the action package and its implementation process. It is evident that numerous factors contribute to the success of NIPs, including resilient infrastructure, sustainable financing, vaccine equity, and addressing vaccination hesitancy. To overcome these challenges, the Expert Forum served as a catalyst for collaboration between countries with underdeveloped NIP capacities and those with more robust capabilities. Participants in the 7th GHSA Ministerial Meeting selected relevant member countries to discuss specific issues and explore practical approaches. The Immunization Action Package aims to motivate GHSA member countries, as well as non-member countries, to participate in the NIP capacity-building project. This project focuses on 3 areas for countries with lower capacities. It also includes monitoring the cooperation process and developing a tool to measure improvements in NIP capacities.
The Immunization Action Package of the Global Health Security Agenda (GHSA) aims to protect vaccine-preventable diseases by increasing the vaccination rate. GHSA member countries must implement sustainable national immunization programs and respond to emergency vaccination plans. This article emphasizes four significant capacities—infrastructure capacity, sustainable financing capacity, vaccine access and equity, and vaccination hesitancy—to achieve the goals of the Immunization Action Package.

Ethics Approval

The requirement for informed consent was waived because of the retrospective nature of this study.

Conflicts of Interest

The authors have no conflicts of interest to declare.



Availability of Data

The datasets are not publicly available but are available from the corresponding author upon reasonable request.

Authors’ Contributions

Conceptualization: SL; Data curation: SHP, YJJ; Formal analysis: SL; Investigation: SL, SHP, YJJ, DR; Methodology: SL; Project administration: SL; Resources: SL; Software: JJO; Supervision: SYK; Validation: SL, SHP; Writing–original draft: SL; Writing–review & editing: all authors. All authors read and approved the final manuscript.

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