Bridging the immunisation gap: progress, pitfalls and the way forward

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Bridging the immunisation gap: progress, pitfalls and the way forward

Immunisation is one of the most cost-effective public health interventions, saving millions of lives each year while improving health outcomes and driving economic growth. Yet, progress remains uneven both between and within countries. Significant challenges remain, especially with disruptions following the Covid-19 pandemic and shifting societal and geopolitical contexts.

On 10 February 2025, the Duke-NUS APIC Workshop on Strengthening National Immunisation Programmes (NIPs) in Asia took place in Singapore, launching the report: Comparative Analysis of National Immunisation Programmes in Select ASEAN and SAARC Countries: Progress and Challenges. The report, authored by the Innovation Lab for Vaccine Delivery (VaxLab), co-hosted by SingHealth Duke-NUS Global Health Institute and the Asia Pacific Immunisation Coalition. Representatives from over nine countries and international organisations gathered to share insights and explore innovative solutions to enhance immunisation efforts in the region.

Key report findings

The study provided an overview of the National Immunisation Programmes (NIPs) of 13 countries from the Association of Southeast Asian Nations (ASEAN) and South Asian Association for Regional Cooperation (SAARC), and the challenges they face in achieving universal vaccine coverage. To enable comparative analysis, countries were grouped based on their eligibility for Gavi support and level of socio-economic development: Gavi-eligible countries (Cambodia, Lao PDR, Myanmar, Pakistan, Bangladesh), Gavi-ineligible middle-income countries (MICs) (Indonesia, Philippines, Viet Nam, Sri Lanka) and Gavi-ineligible non-MICs (Malaysia, Singapore, Thailand, India).

NIPs in Asia
From left: Prof. Heidi Larson - Professor of Anthropology, London School of Hygiene and Tropical Medicine,
Dr. Patrick Tan - Senior Vice Dean for Research of Duke-NUS, Dr. Shenglan Tang - Mary D.B.T. and James H. Semans International Distinguished Professor of Duke University, Dr. Nima Asgari-Jirhandeh - Director of Asia Pacific Observatory on Health Systems and Policies, Dr. Tikki Pangestu – Visiting Professor, Yong Loo Lin School of Medicine, National University of Singapore

Despite significant variations in socio-economic development, demographic characteristics, health outcomes and the status of NIPs between and within the countries, some trends emerged:

Number of VPDs covered: On average, Gavi-ineligible MICs cover the least number of vaccine-preventable diseases (VPDs) at the national level.
Introduction of new vaccines: All countries introduced at least one new vaccine into their NIP between 2013 and 2023, with most additions occurring before the pandemic. The rotavirus vaccine was the least commonly included among the study countries.
NIP coverage: While most countries had achieved coverage of over 90% for their NIP vaccines in 2023, coverage was generally lowest for the human papillomavirus, pneumococcal conjugate and rotavirus vaccines. A steep increase in coverage was generally observed one to two years after introduction of a vaccine into NIPs.
Immunisation expenditure: Immunisation expenditure per capita in Gavi-eligible countries is generally higher than in many Gavi-ineligible countries. Contributing factors include high vaccine prices and the introduction of expensive vaccines.
Immunisation funding: Gavi-eligible countries rely most heavily on external funding for their immunisation programmes, while Gavi-ineligible countries primarily depend on domestic government financing. In some countries, the private sector also plays a role in supporting routine immunisation.

The study also identified key common challenges that countries face in improving vaccine coverage:

Limited resources: Limited resources need to be prioritised between introducing new vaccines into the NIP or increasing coverage of existing vaccines, as well as competition with other pressing health system issues. Strained resources are exacerbated by limited access to affordable vaccines, especially for countries without domestic vaccine manufacturing capacity. Graduation from Gavi eligibility often also means less funding from other bilateral donors, thus facing countries with a ‘funding cliff’.
Limited capacity: Limitations in health workforce capacity and cold chain systems pose challenges to expanding coverage, especially for countries with large rural populations. Countries also face gaps in surveillance and information systems, with substandard data quality. Additionally, many NIPs and health systems are still recovering from disruptions due to the Covid-19 pandemic.

To address these challenges, the study outlines five key actions for stakeholders, especially international organisations and national governments:

International organisations should strengthen their support strategies for MICs to prevent setbacks after graduating from Gavi
Vaccine inequities within countries should be addressed through diverse context-specific strategies tailored for local needs
Governments should continue to build robust immunisation systems that are well-integrated into the broader health system
Sustainable approaches are needed to maintain immunisation services and mitigate disruptions caused by the Covid-19 pandemic
Regional forums and networks should facilitate the exchange of best practices to encourage peer learning across Asian countries and the Global South

NIPs in Asia
Dr. Xinyu Zhang - Assistant Professor of Research, Global Health Research Centre, Duke Kunshan University

Key discussion takeaways

Following the report’s launch, workshop participants discussed case studies, lessons learned, best practices and ideas for strengthening NIPs in the region. Four key themes emerged as takeaways:

Long-term sustainability: Financing remains a major challenge, particularly in the current volatile geopolitical context. Regional opportunities to address this include pooled procurement to lower costs, transparent pricing and innovative financing mechanisms, especially as traditional funding streams may be running thin. Setting clear priorities helps ensure available resources are used effectively, guided by quality data.
Stakeholder harmonisation: Effective coordination among stakeholders – ranging from local to national to regional governments, NGOs, academia and the private sector – is crucial to avoid fragmentation and work towards a collective goal. Successful examples from Singapore, Pakistan, Indonesia and Cambodia highlighted the importance of collaboration. Effective cooperation requires coordination, commitment and trust, enabled by clearly defined roles and responsibilities, hand-off points, decision processes.
Community engagement: Building public trust and awareness is absolutely critical to counter misinformation and build demand for NIPs. Trust is relational and requires spending time with communities to understand their needs, priorities and local context, especially given the diverse populations in Asian countries. The public should not be treated as passive beneficiaries but must be engaged as active partners.
Areas for research and investment: Monitoring and evaluation of NIPs remain key gaps, particularly in terms of data quality. Investing in data tools and systems will enable evidence-based decision-making ensuring that limited resources are used effectively and efficiently. Other priority research raised include public reception to changes in immunisation policy, factors influencing vaccine hesitancy, and the need for long-term research strategies to build the evidence base in local populations.

Overall, the workshop emphasised the transformative potential of collective regional action. While challenges remain on the road to universal coverage, collaboration and knowledge-sharing will accelerate the whole region’s journey towards this goal.

View the full report of this workshop: VaxLab Partnered with Duke-NUS to Address Immunization Challenges in Asia - Global Health | Duke Kunshan University

Bridging the immunisation gap: progress, pitfalls and the way forward

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