1 The opportunity and obligation to strengthen national immunization programs Felicity Cutts and Robin Biellik, Consultants to BMGF, December 2010 Summary and recommendations Vaccine-preventable disease (VPD) control is one of the operationally simplest and financially most cost-effective public health interventions available. Immunization only achieves its greatest potential to avoid illness and save lives, however, when it is extended to all corners of society. New, more expensive vaccines such as pneumococcal conjugate vaccine (PCV) and rotavirus vaccine (RV) are a means to prevent diseases which commonly kill children in impoverished communities. In communities with access to high-quality curative care for pneumonia and diarrhoea, however, mortality from these conditions may already be low. It is essential for these vaccines to reach the hard-to-reach groups. The magnitude of immunization's contribution to the achievement of Millenium Development Goal 4 (MDG4: reduce by two-thirds, between 1990 and 2015, the under- five mortality rate) depends upon our ability to achieve and sustain universal vaccination coverage in all countries and districts and to overcome geographic, political, socio-economic or cultural barriers to effective provision and use of health services. Despite considerable progress since the inception of the global Expanded Program on Immunization (EPI) in 1974, routine vaccination coverage during the past 5 years (2005-09) fell or remained stagnant at inadequate levels in 21 of the lowest-income countries. Many of the countries, and areas within countries with the highest numbers of unvaccinated or incompletely-vaccinated children, including Chad, Ethiopia, India, Indonesia, Nigeria and Pakistan, also have high under-five mortality rates. In some of these countries, governments do not recognize that coverage is low and thus lack commitment to improving it. A competently-managed, well-resourced and financially sustainable rou