Got vaccines? Got life!

Changing demographics

Got vaccines? Got life!

Global outlook

Urbanisation: the challenges for immunisation

Gavi recognises the need for new approaches to reach the increasing number of under-immunised children living in urban slums.

Out of sight

Residents may be recent migrants, or have insecure legal or residential status, limiting access to basic health services and further heightening the risk of disease.[1] Because their lack of public health records makes them invisible to immunisation programmes they are less likely to be including in the planning of immunisation service delivery.

In Ethiopia’s urban areas, for example, approximately one-third of children aged 12–23 months receive all basic vaccinations, compared with almost two-thirds in rural areas.[2] This trend is even more pronounced in urban slums, where influxes of migrants bring new infective agents.[3]


The overcrowding that characterises urban slums increases childhood mortality from diseases that spread more easily among dense populations. To make matters worse, makeshift housing in slums have little or no access to electricity, water and sanitation services.

Slums in South Africa, India, Bangladesh and Kenya have shown increased morbidity and mortality from infectious diseases like measles, mumps, diphtheria, influenza and typhoid.[4]

[1] Immunization, urbanization and slums – a systematic review of factors and interventions, BMC Public Health, 2017, 17:556

[2] Ethiopia Demographic and Health Survey 2016, p 164:

[3] Immunization, urbanization and slums – a systematic review of factors and interventions, BMC Public Health, 2017, 17:556

[4] Immunization, urbanization and slums – a systematic review of factors and interventions, BMC Public Health, 2017, 17:556

In most Gavi-supported countries, urban areas report higher immunisation coverage rates than rural areas. However, a large number of children living in urban centres continue to miss out on basic childhood vaccines – see graph below.

Explore the fastest growing urban populations in Gavi supported countries

Helping countries adapt

Gavi and its partners are helping countries with high numbers of underimmunised children in urban centres to develop and implement tailored strategies.

Urban toolkit

A global working group, which includes UNICEF, Gavi, WHO, the Bill & Melinda Gates Foundation, John Snow Inc. and civil society organisations, has developed an urban immunisation toolkit to guide national Expanded Programmes on Immunization. Countries can also use the toolkit to help ensure that their applications for health system and immunisation strengthening grants support equitable vaccine coverage across geographical regions.

In 2018, Gavi also launched its first programming guidance on urban issues, outlining key considerations that should be taken into account when planning investments in urban immunisation programmes.[1]

Tailored responses

With support from the Alliance, the Democratic Republic of the Congo, Ghana and Kyrgyzstan reviewed their urban vaccination coverage in 2018, identifying specific actions needed to improve performance. Afghanistan, Bangladesh, Djibouti, Haiti, Indonesia, Kenya, Pakistan, Somalia and Uganda are planning to introduce urban immunisation strategies and programmes for 2019. These will include extending clinic opening hours, using platforms to track children, working more closely with private immunisation services and reducing missed opportunities for vaccination at major hospitals.

Urban underimmunised: focus on Pakistan

Pakistan’s cities are among the fastest-growing urban areas in the world. Since 1998, Lahore’s population has almost doubled. The population of Karachi has also grown rapidly, swelled by migrants attracted to the city’s bustling port and vibrant economy.[2] These urban areas are today home to highest number of under-immunised children in Pakistan.

Gavi and its partners are taking steps to map them, the first step to ensuring they can be reached with life-saving vaccines.

[1] Gavi programming guidance – urbanisation—urban-immunisation/

[2] Gavi APR 2016. P 50

Future outlook

As global population demographics evolve, routine immunisation programmes need to adapt with specific interventions tailored to reach every child.

Historically, routine programmes have focused on reaching children in remote, rural areas. While this remains a key strategy, designing and tailoring programmes for urban areas requires further innovation and investment.

The growing number of people living in poor urban areas has brought new challenges for gathering data, planning and communicating – as well as opportunities for new approaches to routine immunisation. These include:

  • integrating preventive services into strengthened urban immunisation programmes;
  • leveraging the expertise of the private sector in major cities.

Gavi and its partners continue to drive urban health-related investments and innovation to reduce geographic inequity and immunise all children.

Further reading

Gavi programming guidance – urbanisation—urban-immunisation/