A Guide to the Strategic Approach to Immunisation in New Zealand
Context
The Strategic Approach to Immunisation in New Zealand (the ‘strategic approach’) will be a high-level A3 and a roadmap (a long-term plan) which sets out our aspirations for the immunisation system and how we will get there. It is an opportunity to establish a shared understanding of our immunisation objectives, align work across the system, and drive collective action towards a common goal.
Immunisation is a highly successful public health intervention which safeguards our communities and whānau against vaccine-preventable disease. It is a key indicator of access to primary health care and critical to the prevention and control of infectious disease outbreaks. When vaccination coverage is high, tamariki and whānau are better protected and enabled to achieve pae ora (healthy futures). However, when vaccination coverage decreases, the risk of infectious disease, morbidity and unnecessary death greatly increases.
Since 2017, immunisation rates, particularly for children, have been decreasing – a decline which was accelerated by the COVID-19 pandemic. Current Health New Zealand reporting shows that national immunisation coverage for all children at 24 months of age is 81.0%, which is below the target of 95%.1
There are significant and persistent equity gaps in immunisation coverage across the country, particularly for Māori, Pacific peoples and other underserved populations. For example, data shows that 65.1% of Māori tamariki and 80.0% of Pacific children are fully immunised at the 24 months milestone age (compared to 87.5% of non-Māori non-Pacific children). This leaves Māori and Pacific tamariki disproportionately at risk of getting sick or even dying of vaccine-preventable disease.
This work has been guided by what communities, whānau, providers, professionals and other stakeholders have already told us about their experience of the immunisation system, what has and has not worked for them in the past, and lessons they have learned.
This document is intended to supplement the A3 and explains our approach in more detail.
We want to hear your views
We want to sense-check whether what is outlined is still relevant and accurately reflects what you have told us is important to you, your community and whānau, and the system as a whole. We want your feedback on the proposed strategic approach (or just on the parts you are most interested in) and we encourage you to share what matters most to you.
Each section below includes some questions which you can use to guide your feedback. You can provide your feedback via email to immsgovsec@health.govt.nz.
1 Data is for the three-month period ending 31 December 2023. Health New Zealand national and regional immunisation data is available here: https://www.tewhatuora.govt.nz/for-the-health-sector/vaccine-information/immunisation-coverage/
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The Strategic Approach to Immunisation in New Zealand
Our Vision
A vision statement sits at the top of the A3 to represent a long-term aspiration or goal to strive towards. Our strategic vision for the future is: an Aotearoa New Zealand where whānau are enabled to achieve pae ora (healthy futures) through the benefits of immunisation.
Guiding Question:
What would be an ideal immunisation system? Does this vision statement capture that ideal future?
Te Tiriti o Waitangi
Te Tiriti o Waitangi (Te Tiriti) sits above our priorities and objectives to affirm our commitment to upholding and honouring the special relationship between Māori and the Crown under Te Tiriti.
The Crown – as kaitiaki and steward of the health system (under Article 1 of Te Tiriti) – has a responsibility to enable Māori to exercise authority over their health and wellbeing (under Article 2) and to achieve equitable health outcomes for Māori (under Article 3) in ways that enable Māori to live, thrive and flourish as Māori (Ritenga Māori declaration).2 Our commitment to Te Tiriti and priorities for hauora Māori are articulated in greater detail in Pae Tū: Hauora Māori Strategy.
The health sector principles in section 7 of the Pae Ora Act guide the Minister of Health, Manatū Hauora and all health entities in how to carry out their functions. The health sector principles incorporate key outcomes and behaviours derived from the principles of Te Tiriti, as recommended by the Waitangi Tribunal. These principles will apply to the strategic approach in the following ways:
• Tino rangatiratanga - provide for Māori self-determination and mana motuhake in the design, delivery and monitoring of the immunisation system.
• Equity – commit to achieving equitable immunisation outcomes for Māori.
• Options - provide for and properly resource kaupapa Māori immunisation services and ensure that all immunisations are provided in a culturally appropriate way that recognises and supports the expression of hauora Māori models of care.
• Partnership - work in partnership with Māori in the governance, design, delivery and monitoring of the immunisation system – Māori must be co-designers (with the Crown) of the immunisation system.
• Active protection – act to the fullest extent practicable to achieve equitable health outcomes for Māori. This includes ensuring that the Crown, its agents and its Treaty partner under Te Tiriti are well informed on the extent and nature of both Māori health outcomes and efforts to achieve Māori health equity.
2 see Whakamaua: Māori Health Action Plan 2020-2025.
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Guiding Principles
Guiding principles are a set of core values or ideas that shape behaviours and actions. The strategic approach is underpinned by the health sector principles (as outlined in the Pae Ora (Healthy Futures) Act 2022), and the Enabling Good Lives (EGL) principles.3 We have also developed a set of specific principles to guide the development and implementation of the strategic approach as we work towards our vision. These are:
• Equity – we work to ensure equitable access, experiences and outcomes across the immunisation system
• Partnership & Collective Action – effective governance and leadership enables collective action towards a shared vision in ways that support community led co-design.
• Quality, Safety & Effectiveness – immunisation policies and programmes are evidence-based, ethical, clinically and culturally safe, whānau-centred and driven by quality improvement
• Prevention – we take holistic approaches that support community and whānau well-being across the life-course.
• Accountability & monitoring – we take accountability for achieving stated objectives and outcomes, and continuously review progress
Guiding Questions:
These principles aim to inform and guide how we work collectively to achieve our ideal immunisation system, how services are delivered and how decisions are made.
Are the principles we have identified the right ones to guide our actions in the immunisation system? Are there any others that should also be included?
Strategic Priority Areas
Many challenges faced by the immunisation system are historical and well-documented. People have told us – through past public engagement – what has or has not worked for them when interacting with the health system. These insights, coupled with the feedback collated through consultation on the Pae Ora strategies in 2023, have helped us to consider what an ideal immunisation system would look like and identify four priority areas that will enable us to achieve it:
• Strategic Priority 1: Access – all whānau can access immunisation across the life course where and when they need it.
• Strategic Priority 2: Trust & Confidence - everyone trusts and has high confidence in vaccination as a way to protect their whānau.
• Strategic Priority 3: Effective Delivery – immunisation is delivered in a way that is flexible, whānau-centric and locally-led.
• Strategic Priority 4: System Capability – achieve an immunisation system that is fully integrated, resilient, and efficient.
3 The EGL principles are: self-determination, beginning early, person-centred, ordinary life outcomes, mainstream first, mana enhancing, and easy to use (https://www.enablinggoodlives.co.nz/about-egl/egl-approach/principles/)
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Guiding Questions:
Do you think the strategic priorities identified will enable us to achieve our vision for the immunisation system?
Do you see the principles of Te Tiriti o Waitangi expressed or enabled by these strategic priorities?4
Which areas will have the biggest impact on improving equity for you?
What is already working well for you, your whānau and community that needs to continue or be supported or strengthened?
Does this help to address the low immunisation rates for priority populations?
Summary of insights that inform the strategic priorities
Below we summarise some of the key insights that have informed these priority areas and outline key objectives or outcomes we’d like to achieve under each.
Priority 1: Access - all whānau can access immunisation across the life course where and when they need it
What we heard from communities and stakeholders
Primary care is the basis for vaccine delivery, with General Practice (GP) being the predominant provider of childhood immunisations. Māori and Pacific peoples in particular experience systemic challenges accessing primary care, and this is a major contribution to the ethnic inequities in immunisation coverage. Many of the barriers to accessing primary care are due to inequities in the socioeconomic determinants of health. This includes – but is not limited to – cost, availability of appointments, childcare or work commitments, lack of access to transport and limited ability to travel.
People living in rural and remote areas who are faced with long-distance travel and poor road infrastructure especially struggle to access care when compared to those living in urban areas. Workforce gaps are also significantly restricting the availability of services in rural areas – maternity care was highlighted as a particular concern.
Different types of disability (e.g., blindness and vision impairment, deafness and hearing loss, physical disability, and neuro-divergence) impact access to primary care services in different ways. Disabled people have identified limited hours and location as a barrier to having their primary care needs met. So too are communicating health needs in their preferred means more difficult. Having to get vaccinated away from home or in clinics unfamiliar with their individual needs can make immunisation a difficult experience.
4 Te Tiriti principles that the Waitangi Tribunal recommended in the context of health are: tino rangatiratanga, equity, active protection, options and partnership (Hauora Report, Waitangi Tribunal, 2019).
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There is no one-size-fits-all approach, especially when it comes to a population-wide intervention like vaccination that has touch points across the life-course (ie, maternal, childhood, adolescent and adult). An equitable immunisation system will be one that recognises and can respond to the diverse and intersecting needs of all New Zealanders.
This priority focuses on improving whānau access to immunisation services to ensure vaccines across the life-course are readily available and coverage is high across Aotearoa. The objectives under this priority include:
• Reducing the significant and persistent equity gap in immunisation coverage, particularly for Māori, Pacific and other priority populations.
• Removing or addressing all practical barriers to immunisation (e.g., enrolment, cost/debt, wait times, location, transport, convenience).
• Supporting proactive outreach, ensuring whānau can exercise self-determination and have access to the full range of options so they can choose the service that best fits their needs (e.g., kaupapa Māori services)
• Ensuring immunisation practices, communications and services are culturally safe and accessible to those with disability and reach those who are physically and digitally excluded.
• Utilising high-quality and timely data to identify under-immunised populations and enhance our understanding of the determinants of vaccine uptake.
• Addressing wider determinants of health by working collaboratively across the health system.
Priority 2: Trust & Confidence - everyone trusts and has high confidence in vaccination as a way to protect their whānau
What we heard from communities and stakeholders
Communities have told us that messaging about health and well-being is often not well-targeted to the populations it is trying to reach. This can create a barrier to effective decision-making and supporting health literacy. Access to quality information is critical because knowledge gaps and failure to educate tend to fuel negative assumptions about immunisation which can result in vaccine hesitancy.
Māori have highlighted that messaging needs to be clear, culturally appropriate, non-judgemental, antiracist and emphasise improving the well-being of whānau (rather than focussing on the benefits to the individual). Māori māmā told us that whanaungatanga is key to building confidence and trust in their primary health care providers. Instead of making immunisation feel transactional or like a ‘tick-box exercise’, establishing a connection and taking the time to celebrate motherhood can positively impact on māmā in their decision to vaccinate their tamariki. Networks of whānau and friends who have lived experience vaccinating their own pēpē and tamariki are also important sources of information.
Pacific communities can find the health system and its services complex and difficult to navigate –especially for those who do not have English as their first language. People want more information about the services available and need to know how to find it. Pacific communities highlighted that trusted community leaders and experts have the cultural and clinical knowledge to convey information about health and wellbeing in an effective and meaningful way and must be enabled to do so.
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We heard that accessible health information is imperative in enabling disabled people to exercise their self-determination. Accessible communication methods empower and support disabled people and their whānau to participate equitably in decision-making when it comes to getting vaccinated.
This priority focuses on building and maintaining community confidence in vaccination as a tool to protect our whānau. It envisions a future where there is a strong immunisation culture across the life course, and everyone can readily access good information to support their decision-making. The objectives under this priority include:
• Ensuring that information about vaccines is accurate, easily accessible and communicated in a clear and culturally safe manner.
• Enabling positive peer influence by partnering with iwi, community leaders and providers to convey messages tailored to local community and whānau needs
• Providing the workforce with comprehensive information about vaccines, ensuring they are welltrained to address vaccine hesitancy and support decision making
• Maintaining high standards of quality, safety and effectiveness so that whānau have confidence in immunisation processes
• Continued assurance and transparency through effective communication about the risks and benefits of immunisation.
• Partnering with Māori and co-designing with communities through proactive engagement to better understand and respond to needs and opportunities.
• Ensuring there is enough time for whanaungatanga and to address questions openly and honestly.
Priority 3: Effective Delivery – immunisation is delivered in a way that is flexible, whānaucentric and locally-led
What we heard from communities and stakeholders
Communities have highlighted a need to shift focus from an individualised model of care to one that is culturally grounded and holistic. COVID-19 showed us that whānau-centred approaches to immunisation that are anchored in te ao Māori and shaped by whanaungatanga are highly effective We also heard that, for some women, whānau-centred care meant that they would be considered together with their tamariki.
Communities have told us that a vaccinator workforce that can meet demand and is confident, culturally safe, and reflects the community it serves is needed. In many settings, community providers are often better placed to understand and respond to community needs as they have established relationships with whānau, deliver whānau-centric, community-led immunisation services and support vaccine literacy and access. High trust commissioning gives Māori and Pacific providers the flexibility to deliver whānau-based and bespoke immunisation services to their communities is imperative.
The current workforce is experiencing high demand and fatigue making it difficult to provide the support required to meet the complex health needs of whānau.
The health workforce needs to be better equipped to understand disability rights and disability (and impairment) specific needs – this includes communication needs and cultural needs. Disabled people
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highlighted that increased representation of the disabled population in the workforce, at every level of the health system, will ensure services are designed and delivered by disabled people who have the skills and understanding required to provide accessible, community-based and high-quality care.
Both Māori and Pacific communities have said that the workforce needs to be comprised of, and led by, more Māori and Pacific peoples to better serve, connect and respond to the needs of these populations. More apprenticeships and ‘learn-while-you-earn’ models in health were suggested as attractive pathways for Māori and Pacific peoples into the work force.
Pacific providers and communities voiced the importance of valuing the Pacific health workforce and increasing their opportunities to enter decision-making and leadership roles in the health sector.
The immunisation system should also focus on non-clinical workforce and providing opportunities for leadership and upskilling (eg, making sure we have a workforce that can be mobilised quickly in the future if another pandemic situation occurs). It should enhance cultural safety requirements and employment conditions for the workforce.
This priority focuses on the design and delivery of equitable vaccination services in Aotearoa New Zealand. It considers how we design and deliver immunisation services in a manner that is appropriate to individual, whānau, community or workforce needs. It talks to designing a system that is flexible, adaptable and ensures people have options. The objectives we want to see under this priority include:
• Maintaining lessons learned from COVID-19 by delivering context-specific immunisation services in ways that are practical for, and meet the needs of, whānau.
• Taking an equitable, flexible and high-trust approach to contracting and commissioning - needsbased and rights-based distribution of funding.
• Ensuring immunisation services are ethical and culturally safe.
• Nationally enabled and community led approaches to immunisation service delivery.
• Enabling whānau to have a meaningful voice in the design, management, and delivery of immunisation services to drive system change.
• Employing sustainable funding models for long-term delivery and resourcing providers to go where they are needed most.
• Maintaining a robust understanding of consumer and whānau needs/concerns and ensuring their experience drives quality improvement.
• Ensuring services are data-driven and use robust data systems to identify coverage gaps.
• Investing in and supporting workforce capacity – increasing the number and kind of people that can vaccinate, ensuring the workforce is appropriately distributed and reflects the community it serves.
• Investing in workforce capability and upskilling – ensuring continuous workforce learning and development opportunities (especially in areas of cultural competency, Te Tiriti o Waitangi etc.) not just for vaccinators, but administrative staff and non-regulated health workers/kaiāwhina.
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Priority 4: System Capability – achieve an immunisation system that is fully integrated, resilient, and efficient
What we heard from communities and stakeholders
Stakeholders experience a number of difficulties when trying to navigate the immunisation system. Immunisation coordinators and providers need to know who is eligible for a vaccination and where to find them in order to direct resources appropriately (particularly in the case of an outbreak response) and develop vaccination services. Data is essential to policy development and responsive decision-making in the immunisation space.
We heard that general lack of data makes it difficult to evaluate the extent to which disabled New Zealanders are currently experiencing poorer health. Without any historic efforts to collect data, the voices, experiences and health outcomes of disabled people are not reflected in current health system priorities, policies or accountabilities.
We need timely and accurate data on immunisation uptake to measure success and identify risks. Comprehensive health needs assessments are needed to contribute to tailoring services to meet local population needs. These should include socioeconomic determinants indicators. Indicators need to be developed in partnership with Māori. Data and measures should be used for continuous quality improvement activities.
Existing services are also under-resourced and constrained by multiple system challenges including commissioning and funding models that are less able to support the innovative approaches required to support whānau through their immunisation journey.
This priority takes a wider lens and considers how the system operates, is resourced, and keeps itself accountable. This priority envisions an immunisation system that:
• is scalable, efficient and effective.
• government vaccination targets are met to maximise the benefits of immunisation
• is better integrated and engaged with primary and community care.
• has effective governance settings with clear roles, responsibilities and decision-making processes across the immunisation system.
• has high standards of oversight, uses high-quality controls and timely data to support and inform decision-making and measure outcomes (particularly for Māori, Pacific peoples and other priority populations).
• is resourced and prepared to detect and rapidly respond to outbreaks of vaccine preventable disease, supported by rapid population health information and surveillance systems.
• effectively manages the supply chain to maintain the quality and availability of vaccines.
• has a shared understanding of what success looks like, with clear monitoring and evaluation to allow for continuous evolving.
• meets international obligations, responsibilities and standards (e.g., World Health Organization Immunisation Agenda)
• upholds our constitutional obligations to the Cook Islands, Niue, and Tokelau, while also taking into consideration the strong ties between Aotearoa New Zealand and the broader Pacific Region.
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