Creating a second chance for the Fifth Child

The Challenge

How can we shift the balance of power to serve the poorest families?

The Context

1 in 5 children across the world are not fully vaccinated. ​The ‘fifth child’ desperately needs champions who understand their circumstances and can design immunization services just for them. T​hose closest to them – civil society organizations (CSOs) – are an untapped resource.

Vaccines have become more affordable and widely available, thanks to organizations like Gavi. Yet whether a child is vaccinated or not still depends too much on where they are born and raised, who their parents are, and the language they speak. Every day, local CSOs strive to connect people to health services and adapt these services to their communities’ needs. For millions of children, the unique ability of CSOs to build trust and make connections can mean the difference between life and death. Gavi called on us to help them understand how to partner more effectively with CSOs to ensure no child is left out of immunization services.







India, Indonesia, Pakistan and Nigeria are home to half of the world’s under-immunized children.

On the move, living in extreme poverty or insecurity, the ‘fifth child’ is the most difficult to reach and engage.

The Gap

In Nigeria and Pakistan the richest children are 7 times more likely to be immunized than the poorest.

Every $1 invested in immunization on average saves $16 in healthcare costs, lost wages, and productivity due to illness.

What We Heard

We spoke to both CSOs and Gavi to understand their ambitions, the barriers they face and the solutions they see for a more successful partnership. We brought the two perspectives together to identify common ground and issues to hammer out further.

Often unheard or misrepresented are the voices of the poorest, the fewest in number, and the lowest in resources. But we found that Gavi and CSOs have a lot in common. Both think that civil society is uniquely placed to reach the fifth child. Both agree that CSOs – especially those representing the poorest, most marginalised children – are largely untapped. Mobilize this resource for new ideas and access, they both urged and we will see a dramatic reduction of disease.

Our Solution

We created a roadmap for Gavi, and identified solutions that would lead to change – some that would shake up business as usual and others that would gradually create transformation. We mapped out a shared vision to build demand for immunization with CSOs in the lead. This blueprint will make the most of every engagement with the civil society organizations closest to the world’s most underserved and hardest-to-reach unvaccinated children. Gavi is taking this forward to co-create tailored local strategies for CSOs with the countries who most urgently need them: Nigeria, India, Pakistan and Indonesia.

See the tool ›

  1. DHS 2012–2016 and NFHS 2015.
  2. Closing the Immunization Gap, Immunize Colorado.

We can do great things together.