Country Learning Hubs

The ZDLH helps generate, synthesize, and share ZD data and evidence at both the global and country levels. The structure is a hub-and-spoke model: JSI, the global learning partner manages learning and evidence at the global level, and four country learning hubs (CLHs) in Bangladesh, Mali, Nigeria, and Uganda, comprised of local partners/consortiums, capture and use country-level programmatic data and evidence to provide insights on how the ZD strategy is being translated at the subnational level through improved monitoring and evidence generation.

The four Learning Hubs include:

1. Bangladesh: Led by the International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b) with partners Jhpiego and RedOrange Communications.
2. Mali: Led by GaneshAID with the Center for Vaccine Development-Mali (CDV-Mali) and the University of Bamako.
3. Nigeria: Led by the African Field Epidemiology Network (AFENET) with the African Health Budget Network (AHBN).
4. Uganda: Led by Infectious Diseases Research Collaboration (IDRC) with partners PATH and Makerere University School of Public Health (MakSPH).

The CLH countries were selected to ensure variation by region and context, including rural, urban, conflict, or refugees, and based on a relatively high number and proportion of ZD children. Other considerations included feasibility and risk mitigation.

ZDLH Global Consortium

In addition to the four CLHs, the ZDLH mechanism includes a global consortium led by JSI Research & Training Institute, Inc. (JSI), in partnership with the International Institute of Health Management Research, New Delhi (IIHMR) and The Geneva Learning Foundation (TGLF). The global consortium provides technical and operational support to the CLHs and disseminates learnings at the community, regional, national, and global levels.

Technical Assistance

As the global learning partner, ZDLH supports country learning hubs in executing their IRMMA-aligned learning agendas by offering customized and collaborative capacity strengthening, technical assistance, and mentorship. During this reporting period:

• In Bangladesh, JSI worked closely with IIHMR on the political economy assessment draft report, provided feedback on the baseline implementation report, and offered guidance on the tools and protocol for a research activity involving Forcibly Displaced Myanmar Nationals, advising on best practices for working with refugee populations.
• JSI provided feedback on the Mali Learning Hub's implementation research (IR) protocol, discussed IR methodology,and is assisting the CLH in finalizing the IR protocol and tools in preparation for a household coverage survey. JSI also prepared to conduct a lot quality assurance sampling training workshop for the Mali CLH team and assist with data collection.
• In Nigeria, JSI collaborated with the African Field Epidemiology Network (AFENET) to support the Decentralized Immunization Monitoring initiative to review pilot data and address challenges. JSI also offered recommendations for enhancing survey reports, led a refresher training in Abuja, assisted in developing an implementation plan and sampling frames, and provided ongoing remote support as well as feedback on AFENET's implementation research protocol.
• In Uganda, JSI reviewed and provided feedback on several key reports, including the learning agenda report, rapid assessment report, systems landscape report, and community survey baseline report. Discussions with the CLH team revealed the need for further support on the theory of change, with plans for additional assistance.

Facilitating Learning and Sharing

Zero-Dose Resource Library

The ZDLH resource library features a curated repository of evidence-based measurement, monitoring, and learning resources; tools; guidance; and approaches, as well as existing evidence from each country and resources generated by the ZDLH. During this reporting period, ZDLH uploaded 22 resources to the website. The most downloaded resources included:

1. Nigeria Zero-Dose Landscape
2. Webinar slides - Country Learning Hub Spotlights: Reflections on Identifying and Reaching Zero-Dose Children
3. Uganda Zero-Dose Landscape
4. Early Learning from Zero-Dose Practitioners in Nigeria and Uganda: Gavi ZDLH Inter-Country Peer Exchange (ZDLH-X2)
5. Webinar slides - Early Learning from Zero-Dose Practitioners in Nigeria and Uganda: Gavi ZDLH Inter-Country Peer Exchange (ZDLH-X2)

Zero-Dose Webinars

During this reporting period, ZDLH completed five webinars that reached 1,359 unique viewers:

1. Country Learning Hub Spotlights: Reflections on Identifying and Reaching Zero-Dose Children
2. Vaccinating Every Child: Promising Strategies for Reaching Zero-Dose Children in Bangladesh & Nigeria
3. Vaccinating Every Child: Promising Strategies for Reaching Zero-Dose Children in Mali & Uganda
4. Equity in Action: Local Strategies for Reaching Zero-Dose Children and Communities
5. Pro-Equity Strategies to Reach Zero-Dose Children

ZDLH compiled data from global and country-level sources to create a dashboard of indicators for each country. The following section presents data on key immunization indicators in Bangladesh. An explanation of the data sources and interpretation of the figures is presented in the text that follows. Download the Bangladesh dashboard.

DTP1 Trends in Bangladesh, 2019–2023

Trends stable over time with declines due to COVID-19

Study Sub-districts (upazilas) in Bangladesh: Trends in DTP1 Coverage from Q4 2022 to Q1 2024

Source: Bangladesh DHIS2 reported in Bangladesh CLH Quarterly Progress Report

This figure displays subnational data on DTP1 coverage from the Bangladesh DHIS2 over an 18-month period, Q4 2022 to Q1 2024. Trends in DTP1 coverage across the eight LH study upazilas show a noticeable drop in Q3 2023 except in Rangamati district where the data appear relatively stable. With the exception of the two upazilas in Rangamati, coverage rates exceeded 100% across most reporting periods (Q3 2023 notwithstanding) suggesting there are likely persistent issues with the quality of reported data in most of the learning hub study areas. In the most recent quarter (Q1 2024) reported data appear to have stabilized in the study upazilas in three districts (Rangamati, Gaibandha, and Noakhali), which aligns with results from the recent LH coverage survey in the same districts.

Overview of Vaccination Coverage: Household Survey Data from Baseline Implementation Research Conducted September-December 2023

Data represents all children in intervention and comparison districts; Data represents children ages 4.5–23 months in study areas; Immunization status determined through combination of immunization card and caregiver’s report.

¹ ZD: A child is considered as ZD if s/he missed 1st dose of DTP (Pentavalent).
² UI: A child is considered as UI if s/he missed 3rd dose of DTP (Pentavalent).

Note: Weighted percentages are shown in the table.

ZDLH compiled data from global and country-level sources to create a dashboard of indicators for each country. The following section presents data on key immunization indicators in Mali. An explanation of the data sources and interpretation of the figures is presented in the text that follows. Download the Mali dashboard.

Trends in National DTP1 Numbers and Coverage (October 2019–March 2024)

Interpretation: Trends in DTP1 appear to be increasing since mid-2022, although trends are less evident in Learning Hub districts due to smaller numbers. According to DHIS2 data, DTP1 coverage levels remain stable, though concerns about data quality may affect the reliability of these estimates.

Study Sub-Districts in Mali: Trends in DTP1 Coverage from Q4 2022 to Q1 2024

(Source: Mali DHIS2 reported in Mali CLH Quarterly Progress Report)

This figure presents subnational data on DTP1 coverage from Mali’s DHIS2 system over an 18-month period (Q4 2022 to Q1 2024). Trends across the four study districts and eight sub-districts targeted by the Learning Hub study reveal significant fluctuations in coverage over time, with notable variations between sub-districts. Sub-districts such as N’Debougou, Niono Central, and Kologo exhibit substantial variability, with coverage rates starting in the 40–50% range in Q4 2022 and fluctuating by as much as 39 percentage points each quarter. Despite these shifts, no clear upward or downward trend emerges over the observed period. In contrast, Aniasco and Bougouni Ouest generally maintain high coverage rates of around 100%, except for a sharp drop in Bougouni Ouest to 48% in Q4 2023, which rebounds to 142% in the following quarter. Notably, coverage rates in these sub-districts often exceed 100%, reaching as high as 155%, indicating potential data quality issues or underestimation of target populations. The most dramatic fluctuations are observed in Asaco-Sodia and Boura. In Q4 2022, Asaco-Sodia reports a high coverage of 142%, while Boura starts at 107%. Both sub-districts experience steady declines, reaching their lowest points in Q2 2023 at 74% and 62%, respectively. Following this period, Asaco-Sodia continues to fluctuate, hitting a low of 59% in Q1 2024, whereas Boura gradually recovers to 100% coverage.

ZDLH compiled data from global and country-level sources to create a dashboard of indicators for each country. The following section presents data on key immunization indicators in Nigeria. An explanation of the data sources and interpretation of the figures is presented in the text that follows.

Overall trends in the number of DTP1 vaccinations are generally increasing since mid-2022, although this is less evident in Learning Hub LGAs due to the scale of the figure. DTP coverage in the national, Gavi-supported, and CLH study LGAs largely mirror one another, with similar fluctuations over time and a sharp decrease in coverage observed since the period April-September 2023, except for the national coverage levels which remain relatively stable.

Study Sub-Districts in Nigeria: Trends in DTP1 Coverage from Q4 2022 to Q1 2024

(Source: Nigeria DHIS2 reported in Nigeria CLH Quarterly Progress Report)

This figure displays subnational data on DTP1 coverage from the Nigeria DHIS2 over an 18-month period, Q4 2022 to Q1 2024. Trends in DTP1 coverage across the eight LGAs (districts) targeted by the Learning Hub show significant variability over time except in Sumaila, where they remain relatively stable, fluctuating between 69% and 78%. In contrast, other areas show dramatic changes; for example, Wamako's coverage dips to a low of 51% in Q2 2023, surges to 132% by Q4, and then decreases to 76%. Similarly, Jere shows exceptionally high coverage rates, with a low of 200% in Q2 2023 and peaking at 286% the following quarter. These extremes in coverage rates, particularly the figures exceeding 100%, likely indicate issues with data quality or substantial underestimations of the target population.

ZDLH compiled data from global and country-level sources to create a dashboard of indicators for each country. The following section presents data on key immunization indicators in Uganda. An explanation of the data sources and interpretation of the figures is presented in the text that follows. Download the Uganda dashboard. 

DTP1 Trends in Uganda, October 2019–March 2024

Trends stay relatively unchanged, with a drop October 2022–March 2023 (reason unknown) that recovers the next period. Coverage greater than 100 percent point to data quality issues.

CLH Study Sub-districts in Uganda: Trends in DTP1 Coverage from Q4 2022 to Q1 2024

(Source: Uganda DHIS2 reported in the Uganda CLH Quarterly Progress Report)

This figure displays subnational data on DTP1 coverage from the Uganda DHIS2 over an 18-month period, Q4 2022 to Q1 2024. Trends in DTP1 coverage across the three study districts and six sub-districts targeted by the Learning Hub study show increases of different magnitudes in many of the sub-districts, except the Bussi sub-district of Wakiso, where coverage has declined slightly. Over time, coverage trends vary by sub-district. Coverage in the sub-districts of Wakiso remained stable over time while coverage in sub-districts in Mubende showed a slow decline over the first four quarters, experienced a spike in coverage in Q4 of 2023, and then returned to previous coverage levels in Q1 of 2024. In Kasese, coverage decreased over the first four quarters and has slowly returned to the original coverage levels seen in Q4 2022, while Karambi experienced a sharp increase in coverage in Q1 2023 and has largely maintained that growth over the study period. However, coverage levels over the past two quarters have exceeded 100%, suggesting possible issues with data quality.

Proportions of Children Lacking DTP1 and DTP3

By age group (4.5–11 months vs. 12–23 months) in three underserved communities in Mubende District

Mubende district, with the highest number of ZD children, was selected for a targeted survey (survey report forthcoming). Three communities for the targeted survey were purposively selected to represent at least one type of community.