Having led our response to the food crisis in 2010, the memories are still fresh in my mind. I know the earlier we respond, the more lives we can save.

I’ve worked on emergency responses for over a decade — from the earthquake in Haiti, to civil war in Sierra Leone and the Democratic Republic of Congo.

After years living and working in conflict zones, I’m currently based in our head office in London and advise our teams in West Africa. In times of emergency, I fly out to lead the response — as I’m doing now in Niger.

Never a quiet moment

As Team Leader my days are always busy — often ten hours a day, seven days a week — it’s a demanding role.

The first step is for teams on the ground to meet with communities and assess the situation, asking questions such as ‘How many meals are you eating?’, ‘Are you having to work longer hours to meet your survival needs?’.

Once we have that information, I set about planning our response and securing funding.

I have regular meetings with high-level donors where I explain our plans and ability to respond to the crisis. I assess how many staff we’ll need and when, make sure we have a good supply of vital medicines and food, and ensure our staff are always safe. There are a lot of moving parts to get right!

This year our advocacy department published a new report – A Dangerous Delay – calling for early funding to stave off food crises before they peak. This has already been mentioned by some key donors and is helping us to raise the money desperately needed to help save lives.

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Already a crisis

Over the years I have seen first-hand how vulnerable communities are in Niger. Families often depend on their crops for survival and their limited diet means many children grow up malnourished — stunting their development and making them vulnerable to disease.

Now that the rains have failed, insects have destroyed some of the crops and prices are rising — over five million people are facing hunger.

Parents are being forced to migrate in search of food and work, leaving children alone and vulnerable.

There are reports of children withdrawing from school to help their parents earn money or farm the land and our health workers are expecting to see an increase in children suffering from severe malnutrition.

I hope that now we have raised the alarm, the international community will respond with early action to stave off this crisis before it’s too late.

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This blog was written by Michelle Brown, Team Leader, Niger Emergency Response.

So far, so riveting, hey? Stick with me.

Imagine if you wanted to introduce a brand new shiny high-speed train to the network that would alleviate over-crowding and shorten journey times.

This is a train so great that it would laugh in the face of leaves on the line, plough through snowdrifts like a hot knife through butter and could essentially revolutionise the face of rail travel. Sounds good.

The challenge

What if you have this amazing new train but the tracks weren’t strong enough, the source of fuel was unreliable and there weren’t enough train drivers or guards that knew how to operate it?

What if it there were only a few stations in major cities so that only those in the places that already had good rail links were able to use it?

It’s starting to appear less like a magic solution.

This is the challenge that faces immunisation. We have these amazing new vaccines that can save the lives of millions of children, but the health services through which they are delivered are poorly resourced and rely on weak infrastructure.

They are also massively understaffed — there’s a global shortage of at least 3.5 million health workers who are needed to put the jab in the child’s arm.

The solution

The solution is to strengthen the health systems and make sure that immunisation is an integral part of the health service, rather than operating through one-off campaigns. This is the fourth target outcome of the Decade of Vaccines Action Plan.

In discussions around this target there were many questions on what ‘integration’ means. Should vaccination programmes run alongside existing health services? Should they be joined together or should they merge?

If immunisation and the health service are both 20-seater buses, do we send two buses, do we tie one to the other or do we create a new 40-seater vehicle? (Thanks to Raj Kumar at GAVI for another transport analogy).

One size doesn’t fit all

There can be disadvantages in integration (lack of focus, dilution of funding, etc) so the route to integration is not one size fits all.

To combat this lack of coherence and clarity, the Decade of Vaccines should commission a report as a guide, bringing together best practice on integration and disseminate it to practitioners.

To create incentives for innovations, the Decade of Vaccines could launch a scholarship for individuals or a research grant for institutions that is specifically designed to spur innovation in this area. 2020 seems like a realistic deadline for this to deliver results.

Universities, research institutes, pharmaceuticals and others who have the potential to come up with a game-changing idea on vaccines could be contacted straight away and after one year the first Decade of Vaccine Scholars could already be at work.

Closing the health worker gap

A strong integrated health system also depends on having sufficient human resources, so one of the areas where the Decade of Vaccines could make a difference is on health workers. You can’t train an army of health workers overnight, but a decade seems like about the right time scale.

The Decade of Vaccines should seriously consider how it can work with training institutions and ministries of health to help close the health worker gap.

What an amazing legacy that would be.

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It would be a missed opportunity if the plan is adopted only to later flounder because people don’t know how to get started.
 I decided to use this blog to do a little ‘blue-sky thinking’, if you’ll excuse the business speak, and think in terms of actions for the action plan targets.

Target 1: Countries commit to immunisation as a priority

The term ‘political commitment’ is much used, but poorly defined. It boils down to three things: time, money, and people — the government must dedicate time to discussing the issue in ministries and in public; they must dedicate financial resources and assign people to work on it.

Getting a government to make a public pledge to improve immunisation will not guarantee action, but it would indicate the amount of time, money and people they intend to dedicate.

It could also have two immediate beneficial effects: media coverage of a pledge could help counter some of the negative press about vaccines and it would give civil society something to hold governments to account with. Another benefit may be peer pressure — a public pledge from one country could prompt one from a neighbour.

Making it happen

Many governments have already outlined their objectives in their national health plans or immunisation strategies. So step one would be to find those targets, write them up, and write a letter to the right person in government asking for them to be read out at a public event.

The response, and the country context, will dictate the next step and how easy it will be to use this for influencing.

A survey of attitudes towards immunisation in government departments could help measure progress on this target. A survey that asked officials to rate whether they agree with  statements  like  ‘Children in this country do not get enough vaccines’ — would reveal changing attitudes.

Target 2: Individuals and communities understand and demand immunisation

As my background is in PR, I think there is a role for the media here. I’ve seen a number of glossy advertorials in outlets like the Financial Times, the sole purpose of which is to say ‘Hey, rich people, invest in Cameroon!’. So why not a four-page Decade of Vaccines advertorial in media read by decision makers in developing countries? The sole purpose being to say ‘Hey, Cameroon, invest in vaccines!’.

On day one you write a list of the key publications. A month later the  quotes are in and a slot secured, three months later the supplement is published.

Increasing demand

Effective feedback that shows communities their place in the immunisation ‘league table’ could encourage people to demand better coverage. Much like the passenger information boards in train stations that reveal the number of trains that were on time each period, could we not do something similar for vaccination?

Imagine if every clinic had a board outside showing how many children had been vaccinated that month against a target or against a national average.

Imagine if your district was falling behind the next district over — a little bit of healthy competition might go a long way. (Obviously there would be issues around literacy, cost, data, etc. but we have eradicated smallpox, so this seems relatively easy in comparison.)

That’s the first two targets covered, I will look at the more technical issue of health system strengthening and integration in my next blog.

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So it was something a little different for me to be invited to an immunisation conference aimed predominantly at two regions that rarely come onto my radar — the Middle East and North Africa, and Central and Eastern Europe. This part of the world faces its own unique set of health challenges.

Despite a 93% reduction in measles mortality and immunisation rates that are often in the high 80-90% bracket, there are still 250,000 unimmunised children in Central and Eastern Europe. These children are mainly in Russia, Turkey, the Ukraine and Azerbaijan.

The Middle East and North Africa region includes several middle-income countries that contain pockets of unimmunised, hard-to-reach children, making the task of universal immunisation very difficult. Egypt and Morocco fall into this category.

The issues these countries face are not unique, but they take on different dimensions in the context of this region.

Security
In the latter half of the 20th century, conflict in several African countries, such as Ivory Coast and Democratic Republic of Congo, led to the destruction of many health facilities and the infrastructure is still struggling to recover. But conflict, insecurity and political instability have hampered immunisation efforts in the Middle East and North Africa even as recently as last year.

Equity
Equity is an issue in many countries. National coverage rates often conceal huge disparities in terms of wealth, geographical location, gender and the urban/rural divide. This region is no different; but here the groups missing out tend to be immigrant communities or particular cultural groups, such as Roma children or certain tribal groupings.

In Bosnia, less than half of the districts in the country have reached 90% coverage and in Georgia that figure is 57%. According to regional targets, not one single district should be below 90% coverage.

Reverse Equity

Three Eastern European countries demonstrate an unusual trend whereby the poorest children are more likely to be immunised against measles than the richest.

Further investigation is required to uncover the exact reasons why Armenia, Turkmenistan and Belarus are displaying this phenomenon, dubbed ‘reverse inequity’, but one suggestion may be that measles campaigns are targeting the most vulnerable children but at the expense of the richer children, or alternatively that these children are obtaining vaccines outside of the public sector.

Private Sector
In some countries private sector healthcare providers are delivering immunisation services, particularly to the richer sections of society, thus creating a two-tier system. This is more salient in light of the expensive new vaccines coming to the market that can only be afforded by the few.

A parallel service provided by the private sector can create inaccuracies in data and coverage levels as private monitoring systems are not always co-ordinated with central government records.

A global challenge

So the challenge for the Decade of Vaccines is not just on the plains of Africa and in the slums surrounding Asia’s megacities; much work also needs to be done closer to home and in middle-income countries.

If the Decade of Vaccines initiative is to be the game changer it desires to be, every child in every country — rich or poor — must receive the benefits of immunisation.

Sincere thanks go to Dr Mahendra Sheth, from the Unicef Middle East and North Africa Regional office (but formally of Save the Children UK in Ethiopia), for his excellent presentation, upon which much of this blog is based.

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Today, the Decade of Vaccines Collaboration – a project that is bringing leading global health professionals and organisations together behind the shared goal of saving millions of lives through expanding immunisation – began a regional consultation on its Global Vaccine Action Plan.

Now, that may sound like a big meeting to discuss a document (and ok, that is essentially what it is) but after day one, I believe this event has the potential to make a huge difference, and that it is, genuinely, exciting. And here’s why…

Great potential

Take a conference centre in Rabat, Morocco, and fill it with some of the world’s leading experts on immunisation including, most importantly, those from countries that are home to the highest numbers of unimmunised children.

Add in a few NGOs, a few representatives from pharmaceuticals and a couple of translators, and give them all a shared objective to contribute to a global action plan that will guide our joint efforts towards the ultimate goal of ensuring that in the next decade all people, no matter where they are born, receive the full benefits of immunisation. Achieving that would save millions of lives.

If you have a big problem – and the fact that 24 million children miss out on routine immunisation every year is a very big problem – getting as many people with expertise as you can squeeze into a room to think collaboratively about solutions and bounce ideas off each other has great potential. Today I saw new alliances forming and watched participants challenge each other and share information and experiences.

Different perspectives

Three issues stick in my head that are the result of an exchange with someone from a different perspective to my own.

1. The concept of ‘not for profit’ is not as straightforward as it may first appear. Say a vaccine manufacturer develops a product and agrees to sell it at cost price without profit, job done. But what happens a week later when the price of a key component fluctuates or when the manufacturing plant discovers how to make an efficiency saving.  With complex supply and procurement mechanisms, reflecting these changes will not be as simple as changing a price on supermarket shelf.

2. Whoever is in charge of a country’s health budget is responsible for providing both preventative treatments (eg vaccines) and curative treatments (eg hospital care and drugs). Switching money from the second category to the first may save money in the long term, but would create a gap while the health service waits for the preventative treatment to take effect and for demand for curative treatment to fall.

3. Promoting one vaccine can have the result of reducing demand for other vaccines. An unforeseen and unintended consequence of fiercely marketing one vaccine can lead communities to think that they are completely covered after receiving the well-publicised one and demand for other routine vaccines drops.

First steps

The sceptics among us are likely to think that all these discussions will amount to nothing more than a really well-written action plan that will go on to clutter the desks of health ministers the world over for years to come.

And of course there is a risk of that, which is why I was pleased that throughout the day we were asked to think about specific actions– what can we do to turn these grand ambitions into reality; what resources will we need; who do we need on board; how will we make them deliver; how will we know when we’ve reached our goal.

But, ever the optimist, I’m inclined to think that today we took one of the initial steps towards something that could really be a game changer in immunisation. And if we get it right at the start, we are more likely to keep getting it right.

Let’s hope we have the luck of the dragon on our side.

At last year’s WHA, Bill Gates launched the Decade of Vaccines Collaboration (DoVC) – an initiative to accelerate progress towards universal access to immunisation, through the development and implementation of a Global Vaccines Action Plan (GVAP). This will outline the priorities and guiding principles for immunisation over the coming decade.

A statement from civil society

The draft of the GVAP is to be discussed this afternoon, and we plan to make a statement to the members of the board on behalf of Save the Children UK and the 230 organisations that constitute the GAVI Civil Society Constituency.

Below are some of the key points from our statement on the process, content and implementation of the GVAP:

On process

We are grateful to the Secretariat of the DoVC for the inclusive consultative process during the development of the GVAP, with civil society represented on the Steering Committee, on one of the working groups, and invited to input into consultations both in person and online.

Save the Children has been – and will continue to be – closely involved in this process to try to influence the content of the GVAP.  Until the 1 February, all stakeholders are invited to contribute to an online consultation and we urge you to do so too.

After the plan is finalised and launched at the WHA in May, it is vital that civil society remains involved in the process to decide how the GVAP will be implemented.

On content

There is no doubt that immunisation is a crucial component of integrated packages of essential healthcare. Achieving universal coverage will require both demand- and supply-side efforts; only by empowering populations and strengthening health systems will this be sustainable.

It is essential that the GVAP preserves, promotes and practices fundamental principles of universality, equity, quality, accountability and sustainability.

The draft GVAP acknowledges the importance of unreached populations within countries. As the unimmunised increasingly reside in middle-income countries, targeted strategies must be employed in such contexts within a conducive global environment.

Inequities within countries plague progress towards the Millennium Development Goals; addressing such discrepancies must be a central tenet of any post-2015 agenda.

On implementation

At present, the GVAP is an undoubtedly important yet aspirational plan.  How it will be put into practice is yet to be clarified, but it will certainly require a robust accountability framework and this should be sympathetic to aid effectiveness principles.

It is essential that countries take ownership of the GVAP so that its principles and objectives are reflected in domestic health and immunisation strategies. For this, it is vital that various departments of government, parliament and civil society are all actively involved to ensure full understanding of the importance and implications of the GVAP.

For accountability, synergies may be drawn with the recommendations of the Commission on Information and Accountability to improve health information systems, use evidence to inform policy, and strengthen national accountability platforms with wide stakeholder representation.

Finally, the World Health Organization must remain at the core of the GVAP development and implementation, as the normative lead in global health governance.

We’re here to try and ensure that preparations for this year’s World Health Assembly reflect Save the Children’s priority issues.

The Board discussed two new papers prepared by the WHO on the importance of nutrition for the health and wellbeing of women and children.

Well received plan

One of the papers included an implementation plan for maternal, infant and young child nutrition, which was well received by the Executive Board and other member states.

There was broad consensus that the problem of malnutrition needed to be tackled in order to achieve the Millennium Development Goals and to improve the health, development and productivity of populations.

My chance to speak

I had the opportunity to make a statement in front of government officials from around the world and the WHO’s Director-General. This was nerve-wracking! But it was a great opportunity to set out some of our positions on nutrition.

I said that progress on nutrition has been far too slow and as a result 300 children die every hour from malnutrition-related causes and an estimated 178 million children have stunted growth.

I said that Save the Children welcomed the new plan and the WHO’s efforts to establish bold targets for reducing malnutrition and stunting.

I commented that the plan could be strengthened by having a greater focus on reducing inequities in the nutritional status of women and children within countries.

For example, they should make sure that the indicators chosen to measure progress are designed to ensure that the poorest and most marginalised groups are not left behind.

The global health worker gap

I also proposed stronger language on health workers.

Having enough fully trained and supported health workers is essential for preventing and treating malnutrition, yet the current draft of the report makes no reference to the global health worker gap.

I was really pleased that the delegation from Canada echoed our calls for equity, stronger health workforces and for further information on how WHO calculated its global nutrition targets. Ours were the only interventions that made explicit reference to these issues.

Comments taken on board

The WHO Director General concluded the session by calling for the plan to be revised based on the comments received today and for a background paper to be produced setting out the rationale for the global targets.

The plan will then be made available online for further consultation before being submitted to the World Health Assembly in May.

This was a great outcome for the first day of the Executive Board meeting. I hope the rest of the week will be as productive!

Nakale, 30, walking in her sorghum field in Kapoeta North. Her sorgum was destroyed by cows when she was attending to her daughter Natede in the Stabilization Centre. She is now gathering wild fruits to feed her children.

Nakale missed out harvesting her sorghum this year and is now scavenging for lalok (wild fruits) to make ends meet.

The lalok fruit Nakale gathers from trees close to her boma (village) for her and her children are of little nutritional value. The fruit can cause diarrhoea in children, but there are few alternatives.

No choice

Nakale missed the harvest because she was caring for her daughter, Natede.

Natede was admitted to a Save the Children stabilisation centre for three months, after being diagnosed with pneumonia and malnutrition.

“When Natede was in the hospital, I didn’t have time to cultivate,” shared Nakale. ”The little sorghum I did cultivate was then flooded, and what was left was destroyed by cattle.”

“Now I have to labour in other people’s fields to get food. If not for my child’s sickness, I could have harvested.”

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Traditionally, the Toposa women of Kapoeta do all the work close to the house; digging, harvesting and building the tukuls (grass-thatched huts) where they live, while the men are out looking after the cattle.

So if the woman is sick, or away attending to a sick child in the hospital, no agricultural activities can take place, resulting in hunger.

A growing problem

Lots of women like Nakale face food shortages. Nanok and her fellow villagers had two season’s of sorghum crops destroyed by birds and disease.

“I am not happy to feed this (lalok fruit) to my children but what can I do? I will give them the lalok seeds until I have enough harvest next year,” said Nanok.

Nanok breaking Lalok seeds (wild fruits) from their hard casing in Mosingo boma, Kapoeta North South Sudan. Lalok fruits and seeds are eaten when food is scarce.

“There is no good food so our children are eating things that are not helpful to their bodies,” said Lomusu, mother of five.

Michael, the Boma chief of Mosingo, explains: “Hunger has been a serious problem here for the last few years. People are now surviving on fruits, if there are no fruits people can die. The problem is that the climate has changed, it is not raining as it used to before.”

What we’re doing

Save the Children is running a nutrition and health project in Kapoeta North County, where malnutrition is widespread.

Lokitoe, 7, lying on the ground outside the Riwoto stabilization centre. Lokitoe is severely malnourished, as she spent months before her mother brought her to the centre. When she was brought she couldn’t eat or drink. Lokitoe is now recovering.

The general diet of families in this area is of poor nutritional value. If families are lucky, they eat twice a day; many eat only once.

We’ve set up a life-saving nutrition programme for more than 30,000 children, pregnant women and new mothers.

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The centre hosts 23 children on a normal day.

It’s now stretched beyond capacity with 46 children suffering from malaria, diarrhoea and pneumonia, with each case outdoing the other in severity.

Just a normal cough

It all began with what mothers in this area refer to as a ‘normal cough’, which usually lasts a few days then disappears.

But in Osman’s case, time failed to bring reprieve and he broke a fever.

He was rushed to the nearest hospital and admitted for two nights to treat his cough, oral thrush, difficulty in breathing, and his refusal to feed.

Osman, 19 months old, making a recovery in our stabilisation centre.

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Save the Children cases

There’s coded language used here to describe the magnitude of sickness.

‘Save the Children cases’ refer to children who everyone else has given up on and have been referred to our centres for a jolt to life.

Osman is now at the stabilisation phase of his stay here: he’s put on a three-hourly feed and receives treatment for the pneumonia and malaria.

Reason to smile

Although his illnesses have sucked the little life left in him, there’s a reason to smile.

His fever is down, his cough’s subsided and he can sit up.

The next 18 days will be crucial as we continue to give him therapeutic food and treat his illnesses.

One more wish…

I watch as his mother caringly rubs her only child’s head and wishes that of all other gifts bestowed upon women, the power to take disease away was among them.

You can almost read in her eyes the psychological pain of a mother with an ailing child.

She’s almost saying, “If you’re a mother, you would understand the pain of watching your helpless child wear away, crying out to you to fight the pain and protect him like you always have, but you can’t because it’s a force of nature beyond you.”

Again I remind myself of the vital, life-saving work that we do and that we must deal with childhood diseases once and for all.

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With your support we can save more lives.

The desperate look of a mother with an ailing child.

From one of the main roads, a quick turn into Sanjay Colony gives a view of very different world.  There is no road to speak of, make-shift structures abound and a proper sanitation system is obviously absent. 

Sanjay Colony and similar places are often referred to as “pockets of poverty”—deprived communities within well-off areas that have become a fixture in many cities.

Mobile clinics

Save the Children runs a mobile health clinic here.  Mothers and children can access basic health services for free.  The day I went some women were getting ante-natal check-ups, while one mother was seeking treatment for her baby sick with pneumonia. 

I was told that the nearest hospital is not very far but it costs 200 rupees to get there.  That’s only £3 but in a country where 75% of the population lives on less than $2 a day, that’s still out of reach for many families here. 

India has very high child and maternal mortality rates.  In 2009, about 1.7 m children died before their fifth birthday making it the country with the highest burden of under-five mortality globally. 

While it is true that cases of child mortality varies from one state to the other, the harsh reality is that huge numbers of households do not have access to basic healthcare which leave children at great risk of dying from preventable causes.

Earlier this year we wrote about healthcare deserts—a term which sometimes describe geographical area where health services are too physically remote to be reached.

In many cases however it describes a situation in which services are unaffordable, or of such poor quality that healthcare is not sought, or is sought and not available. 

Urban poor communities tend to fall under this state.  Many like Sanjay Colony are within reasonable distance from a health facility but poor households are still unable to access them. 

Prevented

Transport costs, lost daily income from going to a hospital, cultural beliefs, unaffordable treatment or poor quality services prevent people from seeking health services.

Efforts are being implemented to improve poor people’s access to healthcare.  Some have removed user at the point of use for basic health services.

Others are giving conditional cash transfers, i.e. giving cash to poor households on the condition that they let their mothers and children attend a health centre.

Rising demand

Many other schemes exist worldwide. What is clear however is that measures to boost household demand for healthcare should be matched with improvements in the supply side. 

Removing user fees or giving cash transfers won’t significantly improve outcomes among the poorest households if the health facility is too far, health workers are absent or services are inadequate.

Non-economic barriers to accessing healthcare should also be addressed to improve health-seeking behaviour.  Otherwise, these schemes will miss the poorest and most marginalised communities which might risk deepening health inequalities between them and the rest of the population.