**4. Discussion**

Despite the remarkable achievements in India's vaccination efforts over the last several years, equity challenges remain to consistently and sustainably reach the most underserved populations. This is not unique to India. Shifts in immunization program focus and strategy, as outlined in the Immunization Agenda 2030, need to align with what immunization data are showing us on continuing inequities. These shifts include addressing disparities across countries and within large countries, such as India, through tailored approaches that are designed with and resourced to the specific fragile and conflict-affected, rural (remote and non-remote), and urban populations.

How can public health programs and donors adapt learning from the Indian immunization evolution and apply the latest equity approaches and tools, particularly in lower-resource settings? A key priority is to foster coordination and long-term resourcing with local institutions that are best placed to generate workable solutions with their populations. This can be achieved through supporting and partnering with civil society networks, particularly those that are established and have a track record of managing resources. As noted earlier with Rotary's involvement in polio eradication, civil society networks are more likely to garner local support, including for day-to-day operational funding, if they are part of planning and monitoring. This includes having access to data and opportunities for regular review meetings with health service representatives. The broader public and private sector health practitioner networks, such as the International Pediatric Association and the International Council of Nurses, also play a critical role in linking people with services for a positive experience of care.

Why is this important? As the COVID pandemic demonstrated, health workers are not only essential for preventing and managing outbreaks but they are also clients themselves. However, oftentimes health systems are not meeting their basic needs for a positive service experience, such as balanced workloads and sufficient supplies. In their delivery of immunization and primary health care, health worker networks will benefit from further adaptation of existing resources that have shown potential across many countries, such as the Reaching Every District and Tailoring Immunization Programmes guidance [17,18]. Pre-service and in-service training and on-the-job learning and mentoring can integrate the fundamentals of immunization service planning and service experience [19,20]. Figure 2 provides a visual example of service experience components that consider the needs of both health worker and service recipient clients.

As mentioned previously, funding for operational resources is also critical and requires a paradigm shift back to the fundamental platform of a functional public health program. Donors should require—and hold themselves accountable—in building health systems, such as USAID's commitment to championing global health and the health workforce in their 2024 budget allocation. This includes funding and monitoring innovations that

embody frameworks for local ownership and equity analyses that involve sufficiently representative populations that lack technology access. Indicators, such as consistent availability of data minutes and evidence of use of a mobile device, should be required, not just ownership of a mobile device. Equitable sustainability also requires partnering with local institutions and engaging with communities, which often takes more time and investment but is arguably more likely for public health programs to be able to maintain, particularly in lower income countries.

**Figure 2.** Person-centered immunization service experience graphic.
