Bangladesh often gets held up as one of the great immunisation success stories of the last half-century.
Its Expanded Programme on Immunisation (EPI), launched in 1979, took childhood coverage from around 2 percent at the outset to more than 80 percent today, was certified polio-free in 2014, and has eliminated maternal and neonatal tetanus.
Yet according to Aniqa Tasnim Hossain, an Associate Scientist at the International Centre for Diarrhoeal Disease Research (ICDDR ,B) who has been working on the MIRNA Consortium’s situational analysis for Bangladesh, that record of success masks a structural problem that will shape how, and whether, any new maternal vaccine reaches the women who need it.
“We in Bangladesh, two-thirds of the women actually go to take Antenatal Care (ANC care) from private facilities and they do not go to public facilities,” she explains.
Bangladesh’s Expanded Programme on Immunisation (EPI) system, however extensive its outreach network of more than 130,000 centres, was built around the public sector. If most antenatal care happens somewhere else entirely, a maternal vaccine strategy that ignores private providers is, in effect, designing for a minority of pregnant women.
“At the private facilities there are gaps, and there are a lot of private facilities that are in place,” Hossain says. A 300-facility assessment carried out by the Bangladesh team found shortfalls in both public and private settings, particularly around the accurate recording of gestational age, a detail that matters far beyond bookkeeping, since it determines whether a vaccine like one for respiratory syncytial virus (RSV) is given within its narrow window of effectiveness.
Multiply that gap across thousands of scattered private clinics, and the logistical challenge becomes clear. “So when introducing a vaccine, a maternal vaccine, we have to consider these private facilities,” Hossain notes, “but this is going to be very challenging because providing vaccines to so many ANC clinics would be very difficult.”
This is not a uniquely Bangladeshi dilemma. A recent WHO-supported scoping review of maternal and child health delivery in low- and middle-income countries found that the private-for-profit and NGO sectors are already contributing meaningfully to immunisation delivery, and that in many settings the for-profit sector is often the first to adopt new vaccines and technologies. The same review notes that public health efforts have historically concentrated on the public sector almost by default, even where private provision dominates, precisely the mismatch Hossain describes for Bangladesh. Strengthening both sectors together, rather than treating the private sector as an afterthought, is increasingly recognised as necessary for anything approaching universal coverage.
“Another thing is that more frequently the EPI and ANC are not well integrated or well connected,” Hossain says. “So, they are working in silos. So they need to be sort of linked up.”
This is, in fact, the same structural gap identified by MIRNA’s Pakistan team, where vertically funded, donor-specific programmes have made horizontal integration difficult once systems are already built around separate silos. WHO’s own Maternal Immunisation and Antenatal Care Situational Analysis (MIACSA) project, run with support from the Bill and Melinda Gates Foundation, reached a similar conclusion. This was after mapping tetanus vaccination programmes across multiple LMICs, integration is generally strongest at the point of care, where the same health workers often deliver both antenatal and immunisation services, but weakest at the national and policy level, where separate funding streams and separate lines of accountability pull the two apart. Concerted coordination at the national level, the project concluded, is critical if new maternal vaccines are to be added successfully to existing platforms.
Modelling work following on from that agenda has reinforced the case for closing the gap rather than living with it. Recent analysis of ANC-mediated benefits of maternal immunisation across five LMICs found that integrating vaccination into the antenatal platform produces positive knock-on effects for maternal and child health more broadly and that countries starting from lower baseline coverage, of the kind Bangladesh records for its TT/TD proxy vaccine (currently 58 percent, against roughly 93 percent for at least one ANC visit), stand to gain the most from closing that structural gap.
Yet for all these system-level barriers, Hossain returns repeatedly to a more human factor trust. “Generally, pregnant mothers would accept a vaccine if it is being told by a healthcare provider who they trust,” she says. “So trust is a very big factor here.”
Her team’s work identified distinct dimensions to that trust confidence in the health system as a whole, trust in government, and, crucially, familiarity built through years of contact with the same local vaccinators.
“They trust the system, they have trust in the government, and they also know the provider for a long time,” Hossain says. “So maybe that’s why they trust a lot, so that trust actually supports them to accept the vaccines.”
This chimes closely with WHO’s own Behavioural and Social Drivers of Vaccination (BeSD) framework, developed with SAGE, its Strategic Advisory Group of Experts on Immunisation. The framework identifies “thinking and feeling” including confidence in vaccine safety and in the health system delivering it as one of four core domains shaping uptake, alongside social processes, motivation and practical access.
Reviews applying the BeSD framework across multiple settings have consistently found that health workers are among the most trusted sources of information on immunisation, and that a recommendation from a familiar provider can be decisive in a caregiver’s decision, while poor communication or a rushed encounter can erode confidence quickly, even where baseline trust is high.
For Bangladesh, Hossain’s conclusion draws these threads together into a single, practical instruction for the introduction of any new maternal vaccine. “I think when we’re developing a vaccine demand strategy, we really have to think about that trust and how we build on the introduction of the vaccines using that trust.”
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