South Asia is home to 34.4 million children - almost a quarter of the world total. The number of fully immunized children in the region is 29.6 million4 leaving 4.7 million children unimmunized during 2017. UNICEF South Asia's target is to fully immunize an additional 3.3 million of these children, especially the most marginalized, by 2021.
In 2014, there were 334 cases of polio in the region. By 2017, this number was reduced to 22 - a 90 per cent reduction.
Cases of polio in Afghanistan and Pakistan, 2014-2018
The fully immunized child
Great progress has been made over the last decade. Overall the number of unimmunized children in South Asia decreased from 6.67 million in 2007 to 3.4 million in 2017. From 2007-2017, in Pakistan, the number of un immunized children fell by 65 percent while in India, by 43 percent.
Number of unimmunized children in South Asia, 2007, 2016, 2017
Data Source: WHO UNICEF Joint Estimates 2017
Out of 19.9 million children globally who did not get third dose of DTP; more than half of them are in just five countries out of which two - India and Pakistan are in South Asia.
There is an increase of 20 percentage points in country averages for DPT-3 coverage range from 65 per cent in Afghanistan to 90 per cent and above in Sri Lanka, Maldives, Bhutan, Nepal and Bangladesh.
DPT-3 coverage in South Asia, 2007, 2016, 2017
The average MCV-1 coverage for South Asia increased to 86per cent in 2017 with significant decrease in the number of children who missed their first dose of measles from 10.6 million in 2007 to 4.79 million in 2017.
MCV-1 coverage in South Asia, 2007, 2016, 2017
Data Source: WHO UNICEF Joint Estimates 2017
By the end of 2017, 44 of 59 priority countries had eliminated maternal and neonatal tetanus. Six of the 44 are in South Asia, the exceptions being Afghanistan and half of Pakistan that is yet to be verified. 5
South Asia is strategically important as it is home to a quarter of the world's unvaccinated children. The countries of the region have varying capacities, reflecting their geographical size, the effects of conflict (particularly Afghanistan) and other factors.
Number of children under 1 year who did not get third dose of DTP- global and in South Asia
Data Source: WUENIC estimates 2017
Gavi, the Vaccine Alliance, supports immunization programmes in Afghanistan, Pakistan, India, Nepal and Bangladesh. The immunization landscape in these countries is continuously evolving with a competitive donor environment. This underscores the ever-increasing need to mobilize domestic funds. For Bhutan and Sri Lanka (which have graduated from Gavi support), and for Bangladesh, India and Pakistan (which will soon transition from Gavi support), financial sustainability is a major challenge. This calls for increased advocacy with governments to create fiscal space for immunization programmes, and technical support for planning and financial management.
A web of complex reasons underlies the slow progress. A vertical programme approach with inadequate cross-sectoral linkages is one issue. Weak governance, constrained fiscal space, weak programme capacity, poor data quality and lack of adequate monitoring and accountability frameworks are other key challenges. Other factors include fragile security situations, conflicts, rapid urbanization and population growth, especially of poor people living in urban slums and remote rural settings.
Weak demand generation
In India, communication-related issues are the main reasons why children are not immunized.
Reasons for children not being immunized in India, 2016-2017
Immunization status of monitored children
12-23 months, India 2016-2017
Number of children monitored 417903 - April 2016 > January 2017
Data Source: Routine immunization house to house monitoring data
Inadequate human-resource management and accountability
The health workforce is poorly deployed and beset by absenteeism. Gaps in the capacity of health workers and mid-level managers affect their ability to make effective plans. These challenges are further exacerbated by weaknesses in the supply chain, loss of trust in vaccines by some religious communities, and poor-quality routine data systems. There is an ever-increasing need for robust data and the implementation of evidence-based, context-specific innovative strategies. This requires strong programme ownership, supportive supervision and good monitoring and documentation.
A focus on polio to the detriment of routine immunization
Pakistan and Afghanistan remains two of the three countries globally with wild polio transmission. This diverts critical political will and resources from routine immunization - in some areas less than 20 per cent of children are routinely immunized. Urban populations have grown significantly in recent years to more than 32 million; urban areas have the largest concentrations of under-immunized children in some states.