1.1.1. Democratic Republic of the Congo

The DRC remains among the most vulnerable countries in the world for the spread of vaccine-preventable diseases, as evidenced by the most recent outbreaks in measles, polio and yellow fever. DRC is home to poor infrastructure and difficult access, as well as remote missed communities, mobile and conflict-affected populations, and weak health systems, all leading to a high proportion of zero-dose and under-immunized children, and substantial within-country inequalities. In 2021, the WHO and UNICEF estimated that more than 700,000 children in the DRC were zero-dose [2]. Causes of no immunization and underimmunization include frequent vaccine stockouts, weak funding and governance, limited and demotivated human resources, poor service experience [15], and access difficulties. Analyses of the 2013 Demographic and Health Survey (DHS) survey data indicate a DTP3 coverage gap of more than 20-percent points between the lowest and highest wealth quintiles, and between rural and urban residents [6].

## 1.1.2. Mozambique

Mozambique has a history of political commitment to vaccination and primary health care; however the WUENIC estimate of DTP3 coverage dropped from 88% in 2019, to 79% in 2020, to 61% in 2021, in large part due to vaccine stockouts. Equity analyses of the 2015 DHS data show that while the wealth gap has narrowed since 1997, there remains a 20-percent point difference between the lowest and highest wealth quintiles. Children of educated mothers and mothers living in urban settings have DTP3 coverage approximately 15 percentage points higher than uneducated mothers or those living in rural areas [6]. Mozambique also has substantial within-country geographic inequalities,

with a DTP3 ranging from 74.6% in Nampula, to 97.5% in Maputo Province in the 2015 DHS survey [16]. Evidence suggests that the general public and caregivers of young children, in particular, have positive attitudes toward child vaccination [17]. However, long travel distances, frequent stockouts, the perception of adverse outcomes from administering multiple vaccines at the same time and fear of being mistreated by healthcare providers contribute to low vaccine coverage and wide geographic inequalities [17–19].
