One of the reasons is chronic social norms resulting in parental refusal of vaccines. Some parents believe that vaccines are not safe, or not halal, and refuse to have their children vaccinated. Secondly, families do not see the immediate necessity of immunization when they also lack access to basic services such as clean water and food. People sometimes demand water and food for today over vaccination to prevent possible diseases of tomorrow. Thirdly, inaccessibility due to bans and active conflict remains a major concern. Since May 2018, a ban on the house-to-house immunization strategy in most of the Southern region, including Kandahar, Helmand and Uruzgan has led to an upsurge in the number of inaccessible children. Many children in these three provinces have missed five consecutive polio vaccination opportunities and are a risk of poliovirus. In countries like Afghanistan where health facilities are often scarce, house-to-house campaigns where social mobilisers and vaccinators visit each house to vaccinate children are proven to be the most effective method to reach every child, so the restriction on the campaigns decreases the access to children. The fourth reason why eradication has been hampered is the high mobility of people in the eastern region which shares a border with Pakistan. There is ongoing transmission between Afghanistan and Pakistan, and despite the good monitoring and tracking system, due to the porous borders between the two countries, there is a highly mobile population group that is difficult to trace and reach with immunization.

Strategic measures implemented

Under the leadership of the Ministry of Public Health together with partners, a framework of change has been developed to address the remaining challenges in Afghanistan. To overcome the social norms which cause refusals from some families, during nation-wide campaigns more than 70,000 front-line workers are recruited from their communities to deliver vaccines house-to-house. The programme also works with influential people in the communities such as religious leaders who are trusted and can mobilize and convince people. Refusal Oversight Committees have been formulated at national and provincial level to systematically guide, monitor and track progress of reduction of refusals.

Secondly, for those families who are deprived of basic services and therefore do not see the immediate need for immunization, UNICEF coordinates with other services related to health, water, sanitation, nutrition and education to go along with immunization services to increase the families’ demand.

Thirdly, UNICEF and our partners have implemented a number of contingency approaches in areas where house-to-house approaches are not permitted to enhance population immunity. UNICEF will continue to advocate for house-to-house campaigns as the most effective eradication approach. In the meantime, site-to-site campaigns, adding polio to measles campaigns and expanding permanent transit teams are being implemented.

To reach out children on the move between Afghanistan and Pakistan, cross-border coordination has been improved with Pakistan to facilitate vaccination of moving populations between the two countries. Population movements are being tracked and mapped, and supplementary vaccination posts are being established at key gathering sites and border crossings. More than 100,000 children are immunized every month by the 15 cross-border teams.