Prioritise the most vulnerable women, children, adolescents and health workers with covid-19 vaccines and essential health services, write Helen Clark and Anuradha Gupta.
We all know covid-19 is a killer. But what is less known is the devastating collateral damage caused by covid-19. By disrupting immunisation programmes and essential health services, the pandemic gives other deadly diseases more space to spread and claim lives.
Covid-19 has caused colossal disruption to essential health services globally, with women, children, and adolescents in low- and middle-income countries worst affected.  Immunisation, contraception, antenatal care, skilled assistance at childbirth, and postnatal care have all taken a massive hit. Progress and equity achieved over several decades are rapidly unravelling. Global poverty, which correlates closely with poor health outcomes, is set to increase for the first time in 20 years due to the covid-19 pandemic. 
In a normal year, vaccines save an estimated 2 to 3 million lives.  Yet, within just the first few months of the pandemic, disruption to immunisation programmes due to lockdowns and fear of covid-19 put at least 80 million children at risk of contracting vaccine-preventable diseases.  In 2020, by some estimates, vaccine coverage shrank to levels last seen in the 1990s – 25 years of progress rolled back in 25 weeks. 
The figures for just one deadly disease are truly frightening. Measles claimed an estimated 207,500 lives in 2019 alone, and cases were already at their highest level globally for 23 years. With more than 94 million people, mainly children, at risk of missing measles vaccines due to the pandemic, the world could see another surge in deaths and severe illness from the disease. 
Covid-19 magnifies existing inequities
The pandemic has magnified pre-existing inequities. Even before the pandemic, 20 million children born every year remained deprived of the basic course of vaccines, with two thirds not even receiving a single shot – these “zero-dose” children embody communities who face compounded vulnerabilities.  These issues are most acute in low- and middle-income countries and fragile, conflict and humanitarian settings. Here, women, children and adolescents who miss out on vaccinations are also likely to lack access to other essential services, such as sexual and reproductive health, primary health care, education and social protection.
Zero-dose children account for 50% of child deaths that can be so easily prevented with the use of vaccines. It is therefore imperative that we put zero-dose children and missed communities at the centre of immunisation programmes – not only to prevent these unnecessary deaths, but to improve global health security as a whole. The contact with the health system provided by immunisation not only improves the chances of a child living a healthy, successful life, it also means health professionals can be on the lookout for new outbreaks and new emerging diseases. This early warning system is our first line of defence against the next pandemic.
For covid-19 vaccination, the contrast between high-income and low-income countries is stark. On average in high-income countries, almost one in four people have received a covid-19 vaccine. In low-income countries, it is one in more than 500.  Less than 2% of the world’s vaccines have been administered in Africa. 
At heart, these are basic questions of equity: women miss out on essential services because of their gender; children and adolescents miss out because they are young and vulnerable; and within all three groups, poverty, race, ethnicity, income, geography or other forms of discrimination cause further disparities. Inequity of access is often a matter of life or death. For example, the maternal mortality ratio in the lowest-income countries in the world is more than 40 times higher than in Europe, while the under-5 child mortality rate is three times higher in “fragile” than in non-fragile countries. [10,11]
The unprecedented scale of covid-19 vaccination offers us a unique chance to focus on vulnerable people. PMNCH and Gavi have been at the forefront of calls to prioritise equitable and gender-responsive access to covid-19 tools and diagnostics, including vaccines. PMNCH issued a seven-point Call to Action to highlight the needs of women, children and adolescents during the covid-19 pandemic.  We are urging governments to strengthen financing and programming to protect and promote the health and rights of the most vulnerable throughout the pandemic response and recovery phase.
Path to recovery
The Call to Action shines a light on the needs of the global health workforce – 70% of whom are female. Frontline workers in all countries urgently need access to vaccines and other protections to ensure safety and continuity of services, including nursing and midwifery.
To end the covid-19 pandemic, it is imperative we commit to equitable access to vaccines, and to prioritising the health of women, children, and adolescents. If we want to make progress and improve pandemic preparedness in the process, then we must use covid-19 vaccination programmes as an opportunity to reset: to build back better with more equal, just, and inclusive approaches that leave no one behind. We must resume all other vaccination programmes without delay, and redouble efforts to ensure every child gets the shots they desperately need. Above all, we must ensure equity of access in all settings.
We urge governments to join us by committing wholeheartedly to these aims at the next Lives in the Balance Summit, due to take place on 17 and 18 May 2021. Without urgent action, the direct and indirect effects of covid-19 will lead to many more preventable deaths – and will reverse years, if not decades, of global health progress and investments in human capital. The question is not whether we can afford to do it – the question is whether we can afford not to.
Helen Clark, chair of PMNCH Board and former Prime Minister of New Zealand.
Anuradha Gupta, deputy CEO, Gavi the Vaccine Alliance and PMNCH Board Member.
 WHO Pulse survey. https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1
 Data collected by WHO, UNICEF, Gavi, and the Sabin Vaccine Institute. https://www.unicef.org/press-releases/remarks-henrietta-fore-unicef-executive-director-joint-press-briefing-immunization
 Gates Foundation. https://www.gatesfoundation.org/goalkeepers/report/2020-report/#GlobalPerspective
 UNICEF. https://data.unicef.org/covid-19-and-children/
 WHO, UNICEF, UNFPA, WORLD BANK GROUP, UN. https://www.who.int/publications/i/item/9789241516488
 PMNCH Call to Action. https://www.who.int/pmnch/media/news/2020/call-to-action-on-COVID-19/en/