Strengthening Immunization Programs through Action-Oriented Collaborative Learning

Middle-income countries are missing critical vaccine introductions while also being at risk from declining immunization coverage. R4D manages a global network that supports decision makers from middle-income countries to learn from one another while generating and applying evidence about what works — ultimately building stronger national immunization programs.

The Challenge

Middle-income countries have shown strong commitment to building national immunization programs over the past decade and have achieved meaningful progress. However, significant vaccine-access challenges persist. Middle-income countries account for 69% of zero-dose children (children who have never received a vaccination) and 67% of vaccine preventable deaths. In fact, it is estimated that by 2030, 70% of the world’s under-immunized will be living in middle income countries.

Many middle-income countries have received donor support from Gavi, The Vaccine Alliance to increase the equitable and sustainable use of vaccines. But others are not eligible for Gavi support because their gross national income is too high. And some countries that have previously received donor support through Gavi but transitioned to full self-financing have experienced backsliding in vaccination coverage.

Additionally, introduction of key new vaccines — including the pneumococcal conjugate vaccine (PCV) and vaccines to prevent rotavirus and human papillomavirus (HPV) — is lagging behind in middle-income countries.

Many middle-income countries are requesting increased donor support and technical assistance to help build strong immunization systems that can successfully transition away from donor funding and ensure life-saving vaccines are available to all.

The Opportunity

Gavi’s 5.0 strategy (for the period 2021-2025) is focused on leaving no one behind. As part of this vision, Gavi is implementing its Middle-income Countries Approach to ensure vaccine equity within and between countries. The Approach has two key objectives:

  1. to prevent declining vaccine coverage in former Gavi-eligible countries
  2. to drive the sustainable introduction of key missing vaccines in both former and select never Gavi-eligible countries.

The Linked Immunisation Action Network (Linked), co-led by Results for Development, Curatio International Foundation (based in Tbilisi, Georgia) and the Institute for Health Policy (based in Colombo, Sri Lanka), plays an integral role in Gavi’s approach to engaging with middle-income countries. The peer-to-peer learning network recognizes the experience and expertise that exists within these countries and brings together country practitioners, technical experts and immunization partners to identify common challenges and the promising practices that will help them to achieve their goals. The facilitated process allows partners to systematically share their experiences and tap into the implementation knowledge of their peers in other countries resulting in transformative strategies that lead to greater resilience, equity and sustainability.

Our Approach

Linked facilitates highly interactive, participatory engagements such as in-person and virtual learning exchanges, study tours, direct country-to-country dialogue, and collaborative problem-solving sessions. Through these network engagements, Linked member countries identify practical strategies and practices to mitigate and prevent declining vaccine coverage, drive the sustainable introduction of key missing vaccines, and promote improved immunization equity and sustainability.

By working with and through local and regional partners, Linked engages the broader immunization ecosystem facilitating the uptake of the knowledge, strategies, and good practices gained through these network engagements into transformational change in country immunization programs, increasing country ownership and the sustainability of implemented solutions and best practices.

In a 2023 network-wide member survey, 100% of Linked member countries reported being highly satisfied with the technical quality of learning activities and resources, and more than two-thirds (71%) agreed that Linked has contributed to their progress toward sustainable and equitable immunization coverage and the sustainable introduction of new vaccines.

As of 2023, 11 Linked member countries have developed plans to translate learnings from Linked engagements to actions which strengthen their immunization programs — and nearly 90% of network countries with an action plan say that they have made progress in implementation. The learnings from Linked engagements have supported countries to strengthen the implementation of immunization program activities to improve coverage and equity, including the development of a cost-effectiveness study for the introduction of the HPV vaccine in Tunisia; strengthening the interpersonal communication skills of immunization providers in Uzbekistan; the development and operationalization of a strategy for caregiver education in Vietnam; and the integration of a zero-dose reporting mechanism in the national immunization registry in Armenia.

Based on these successes, R4D received a two-year extension and will continue managing the network through 2025. Linked will pilot a new subnational peer learning platform in Indonesia in its next phase and transition its focus from regional engagements to cross-regional and global learning engagements.

Project Name:

Linked Immunisation Action Network (Linked)


Algeria, Angola, Armenia, Azerbaijan, Belize, Bhutan, Bolivia, Cabo Verde, Cuba, Dominica, Egypt, El Salvador, Eswatini, Fiji, Georgia, Grenada, Guyana, Honduras, Indonesia, Iran, Jordan, Kiribati, Kosovo, Lebanon, Maldives, Micronesia, Moldova, Mongolia, Morocco, Nicaragua, Philippines, Samoa, Sri Lanka, St. Lucia, St. Vincent and the Grenadines, Timor-Leste, Tonga, Tunisia, Tuvalu, Ukraine, Uzbekistan, Vanuatu, Venezuela, Vietnam


Gavi, The Vaccine Alliance


Curatio International Foundation, The Institute for Health Policy



Global & Regional Initiatives

R4D is a globally recognized leader for designing initiatives that connect implementers, experts and funders across countries to build knowledge and get that knowledge into practice.