**3. Results**

Overall, 51 of the 56 HSS proposals reviewed (91%) included at least one pro-equity intervention. When ranked by frequency (Figure 1), we found that the 15 most common pro-equity intervention categories included a mix of supply-oriented, demand-oriented and multifaceted strategies (see Table A1 for a complete list of categories and their respective definitions). We found the most common category was "outreach/tailor location of service delivery and partnerships", with 46/56 proposals reviewed (82%) planning to implement this. This category included any activities that sought to increase immunisation coverage by either conducting outreach services or tailoring the location of service delivery to reach underserved populations. It also included mobile vaccination efforts, building new infrastructure, and creating or leveraging partnerships (e.g., with non-governmental organisations, private sector) to expand vaccine access. The second most common category was the development of microplans at the health facility or district level and/or the implementation of other "Reach Every District" (RED) strategies [20]. Microplans and RED strategies were often implemented together, but if proposals planned just one of the two, it was still included in this category.

**Figure 1.** The 15 most common pro-equity intervention categories listed in the HSS proposals.

Three of the top six most common categories aimed to generate demand at communitylevel (community-level education activities, communication strategies to generate demand and engaging community and/or religious leaders to promote immunisation). On the supply-side, several countries invested in transportation (motorcycles, boats, etc.) and cold chain equipment for their most hard-to-reach districts.

Next, we looked at the proportion of HSS proposals addressing the close-ended variables of the analytical framework (Yes or No response type) as shown in Table 2. Of note, civil society organisations (CSOs) were often mentioned as key partners in implementing activities and reaching vulnerable populations. This was most often performed through implementing sensitisation and social mobilisation activities at community-level to generate demand.

**Table 2.** Number and proportion of HSS proposals (out of 56) which addressed the close-ended variables (Yes or No response type) of the analytical framework.


Interventions addressing demand-side barriers included, for example, tailored immunisation sensitisation activities to different groups (women, religious, etc.) and conducting information, education, and communication (IEC) sessions in priority districts with communities, including educational chats, film showings, and outdoor theatres. Interventions

addressing supply-side barriers, on the other hand, included conducting outreach and mobile sessions, investing in targeted infrastructure and procuring motorcycles, boats and other transportation equipment for health workers to access hard-to-reach areas.

Less than one third of the proposals (17/56) explicitly addressed gender-related barriers. Of those, sixteen included gender-responsive interventions and five proposed gender-transformative ones. Considering Gavi's gender policy, gender-responsive approaches "adopt a gender lens to consider individual needs of different gender identities without necessarily changing the larger contextual issues that lie at the root of the gender inequities and inequalities" [21]. For example, employing female health workers may facilitate enhanced immunisation service acceptance and uptake, but would not address the underlying cultural barrier that prevents female caregivers from seeking immunisation services from male health workers. Gender-transformative approaches, on the other hand, "attempt to re-define and change existing gender roles, norms, attitudes, and practices. These interventions tackle the root causes of gender inequity and inequality and reshape unequal power relations" [21]. For example, one country planned to have community health workers promote a gender approach with the involvement of fathers for the vaccination of children in households and another sought involvement of national and local leaders to promote, advocate immunisation and serve as 'role models' to help increase male participation.

Regarding geographic areas of focus, namely ERG settings, twenty-seven proposals selected remote-rural areas (including hard-to-reach areas) as a priority whereas only four prioritized urban poor areas (though twenty in total selected "urban") and four selected conflict-affected areas.

The correlation matrix of different interventions in each country showed that "outreach/tailor location of service delivery and partnerships" was very strongly correlated with other interventions. Indeed, this type of intervention was planned along with developing district microplans/RED strategies in 29 HSS proposals, with community-level education activities in 27 proposals and with communication strategies to generate demand in 25 proposals (Figure 2). Thus, this suggests that outreach sessions in countries were often planned along with microplanning and community engagement activities as a "bundle" of interventions. Figure 2 depicts the correlations between the eight most common categories and the complete correlation matrix can be found in Figure A1.


**Figure 2.** Correlation matrix representing the number of times the eight most common intervention categories were planned with each other in HSS proposals.

We additionally found that the theory, or rationale, behind the selection of specific proequity interventions in the HSS proposals was often not provided. When it was provided, it was generally for unique interventions that were not commonly used by countries, such as immunisation ambassadors programs and the tool "My Village My Home" implemented in a few countries, for example. Lastly, even though most countries included some pro-equity interventions, many activities listed in the HSS proposals overall were not targeted at the

priority groups or areas identified as being most vulnerable but were instead planned to be implemented at the national level or in the other, non-priority areas. These were not included in the database, nor the analysis presented here.
