Originally appeared on the WHO blog dedicated to the European Immunization Week (22-26 April 2014).

Vaccination is a key element in ensuring universal public health systems built on solidarity, equality and equity. It is proven to be highly cost-effective in the fight against many communicable diseases. Yet the data collected by Doctors of the World over the last few years show how vaccination is still far from accessible for people facing multiple vulnerability factors, even in European high income countries.

The most destitute people around the world are in the worst state of health, as confirmed by the work of the WHO on the social gradient. This principle also applies to vaccine-preventable diseases across the EU, where groups facing multiple vulnerability factors have lower vaccination rates and are at the same time at higher risk of vaccine-preventable infections and cancer. Some would call these groups “hard to reach”. In our experience, they are quite ‘reachable’ with healthcare programmes that are adapted, e.g. through mobile units that go to the places where they live (i.e. doing street work, visiting squats or camps and going to isolated villages), or with the help of intercultural health mediators or peer educators that allow building a relationship of trust and that help in (re)entering the public healthcare system.

Several barriers prevent universal access to vaccination: administrative, legal, and financial barriers as well as lack of knowledge on where and why to get vaccination. These barriers lead to delayed diagnoses, cause increased morbidity and allow contagious pathogens to spread faster. For instance, in Germany, undocumented migrants have a theoretical right to free vaccination at the point of use. Yet the duty upon civil servants to denounce them to the immigration departments creates fear of being turned in and deported. As a result, they often choose not to seek vaccination for themselves or their children.

Due to the crisis and austerity measures, near to 3 million people in Greece no longer have healthcare coverage. Many previously existing public health structures have been closed and vaccinations are only available at a price not even middle-class families can afford anymore.© Giorgos Moutafis, Dr Liana Mailli vaccinating a child in the polyclinic of Perama. In 2013, the teams of MdM Greece vaccinated over 9 000 children without access to healthcare…

© Giorgos Moutafis, Dr Liana Mailli vaccinating a child in the polyclinic of Perama. In 2013, the teams of MdM Greece vaccinated over 9 000 children without access to healthcare…



In 2012, the national government in Spain took the decision to exclude undocumented adult migrants from public healthcare. Pregnant women and children were explicitly not concerned by this new law, yet they too have been frequently denied access to essential services since Royal Decree-Law 16/2012 came into effect: the political message on exclusion of undocumented migrants was stronger than the law. The Spanish legislator omitted the fact that adults might have never received essential vaccines such as DTaP or MMR, or might require boosters.

In 2013, on average only 50% of the minors received in MdM health centres were vaccinated against tetanus[1].

70% on average were not vaccinated, or did not know if they were, against hepatitis B, measles or whooping cough.

Almost 40% of the minors or their parents did not know where to go to get vaccination.

©MdM France – Vaccination card given by MdM team
© MdM France – Vaccination card given by MdM team

Besides barriers to healthcare, other social determinants also negatively impact excess incidence and morbidity. Mould, overcrowded and unventilated spaces, homelessness, lack of sufficient amounts of water and sanitation render people more vulnerable to infections. In 2013, 34.8% of the people we met declared that their housing conditions negatively impact their or their children’s health. Lack of resources and healthy food, and subsequent nutritional deficiencies, can also exacerbate morbidity and mortality.

The right to preventive care is a basic human right and vaccination is an essential element of coherent public health policies. Whether one consults the International Convention on the Rights of the Child, the Millennium Development Goals, the Charter of Fundamental Rights of the European Union, the recommendations and opinions of the European Centre for Disease Prevention and Control (ECDC), the EU Fundamental Rights Agency (FRA), the European Parliament or the Council of Europe institutions… all international bodies and texts insist on this essential, life-saving measure.

Vaccinations have to be proposed to all adults and children, whether they have health coverage or not. There should be no financial and administrative barriers to vaccination. All children must have full access to national immunisation schemes integrated into universal health systems based on equity and solidarity.

Frank Vanbiervliet, Dr Rémi Laporte, Nathalie Simonnot

Find more information about access to vaccination by consulting our previous European reports.

[1] These results are based on 2013 data of the Doctors of the World International Netwok Observatory. They concern a sample of 1 703 minors in six European countries. The total sample of the survey concerns 16 881 patients received in MdM health centres in 25 cities of eight European countries. The report is to come out in May 2014.