Governing the 'Big Catch-up': A Critical Policy Analysis of Immunisation Equity and Governance Frameworks in Post-Crisis Sierra Leone

In the world of public health, a "zero-dose" child is a specific and heartbreaking category: a young person who has never received a single shot of vaccine to protect against diseases like diphtheria, tetanus, or whooping cough. These children are not simply unlucky; they are often the most visible sign that a health system has failed to reach the people who need it most. When a country faces a crisis, such as a pandemic or an outbreak of a deadly virus like Ebola, these gaps in protection can widen dramatically. In response, global health organizations have launched initiatives to "catch up" and vaccinate millions of missed children. However, a crucial question remains: when governments and donors promise to fix these gaps, do they actually understand why the gaps exist in the first place? Often, the solutions offered focus on the mechanics of delivery—like keeping vaccines cold or sending teams to remote villages—while ignoring the deeper political and economic reasons why those villages were left behind.

This is the central puzzle tackled by Sam Soko Bundu, a researcher from the Ministry of Health in Sierra Leone, in a new analysis of how the country is trying to reach its zero-dose children. Sierra Leone is a nation that has faced immense challenges, including a devastating Ebola outbreak that collapsed its health services, followed by the global disruption of the COVID-19 pandemic. The country is now part of a global "Big Catch-up" effort to restore vaccination rates. Bundu did not look at how many shots were given or how many children were missed; instead, he looked at the words, plans, and strategies written by the government and its international partners. He examined official documents from 2019 to 2025 to see how these leaders defined the problem of missing children. By using a method that treats policy documents as stories that shape reality, he asked what these stories leave out, what they assume to be true, and what kind of world they create for the people they are meant to help.

The analysis reveals that the current way Sierra Leone talks about the problem of zero-dose children is deeply flawed. The official strategies often describe the issue as a lack of money or a logistical failure, such as a broken refrigerator chain or a shortage of supplies. This framing suggests that if more international donors provide funds and better equipment, the problem will be solved. However, this view silences a much harder truth: that the country's heavy reliance on outside aid has become a permanent feature of its health system, replacing the need to build a sustainable system funded by its own citizens. By treating the problem as a simple gap in funding, the policies avoid asking difficult questions about how to reform the domestic tax system or how to ensure the country can pay for its own health services in the long run. The result is a system where the government waits for external help rather than taking control of its own health destiny.

Another major finding is that the effort to reach these children has become overly focused on technical fixes. The policies treat the inability to vaccinate as a hardware problem, assuming that if they just build better cold storage or send mobile teams, equity will follow. This approach ignores the social and economic roots of the issue, such as extreme poverty, food insecurity, and the historical neglect of rural areas. It turns a complex struggle for health rights into a simple logistics puzzle. When the problem is reduced to a matter of temperature control and transportation, the deeper causes of why families cannot access care are left unaddressed. The analysis suggests that this technical focus creates a false sense of progress, where the goal becomes moving vaccines to a location rather than ensuring the people living there have a permanent, reliable health system.

Perhaps the most damaging aspect of the current governance framework is a contradiction at the heart of how responsibility is shared. The government has officially decided that local district teams should be in charge of reaching zero-dose children, yet the money to do this work remains tightly controlled by the central government in the capital. This creates a situation where local health workers are blamed for failing to meet targets that they cannot possibly reach because they lack the funds and the authority to act. The policies effectively push the responsibility for solving a national crisis onto the shoulders of overworked staff who have no power to change the system. This dynamic ensures that the people closest to the problem are held accountable for failures that were built into the system from the top down.

Finally, the study shows how the government views rural areas. In the official documents, the difficulty of reaching remote villages is described as a matter of distance, a physical hurdle that can be overcome by sending mobile teams to visit. This perspective treats rural life as an inconvenience to be managed rather than a site of systemic neglect. Because the problem is seen as "distance," the solution is temporary, campaign-style visits that come and go. This approach fails to invest in permanent health facilities in these remote areas, reinforcing a cycle where rural communities are visited only when a crisis demands it, rather than being supported with the infrastructure they need every day. The analysis concludes that as long as the "Big Catch-up" initiative continues to rely on these definitions, it may succeed in giving a temporary spike in vaccination numbers, but it will leave the underlying structures of inequality completely intact.

To truly fix the situation, the researcher argues that the entire approach needs to change. The government must move away from relying on donor money and start building a system funded by its own resources. It needs to stop treating vaccination as a separate, technical project and instead integrate it into a broader, permanent health system that addresses the daily needs of poor communities. Local health teams must be given real control over their budgets so they can respond to their communities' needs without waiting for permission from the capital. Most importantly, the country must stop viewing rural areas as places to be "reached" and start viewing them as places that deserve permanent investment. Only by shifting the focus from quick fixes to structural justice can the "Big Catch-up" become a true step toward lasting health equity for every child in Sierra Leone.