A perspective on essential components for adaptability and scalability to enhance equity-driven vaccination interventions: lessons from Mozambique and Malawi.

Global threats, including the COVID-19 pandemic, vaccine funding cuts, and persistent health inequities, are reversing decades of hard-won gains in immunisation coverage, particularly access for vulnerable populations. This highlights an urgent need to rethink how immunisation programs are designed and delivered, ensuring they are adaptable, scalable, equitable, and sustainable. Global partnerships such as Gavi, The Vaccine Alliance, United Nations Children´s Fund, and World Health Organization have been instrumental in strengthening immunisation systems and success hinges on approaches deeply rooted in local contexts. This perspective piece draws on the evaluation of the 'Let´s Talk About Vaccines!' project, which used participatory strategies to co-design and implement two co-created vaccination interventions in Malawi and Mozambique. It incorporates insights from Expanded Programme on Immunisation officials, global immunisation actors, and current literature. Key insights highlight the transformative potential of community-driven immunisation interventions that prioritize local ownership, inclusive governance, and tailored communication. Six essential components identified contributing to successful interventions include 1) Collaborative planning, design and implementation; 2) Innovative and culturally relevant communication modalities; 3) Gender responsive programming; 4) Strategic integration and alignment with health and community systems and global strategies; 5) Inclusive monitoring and feedback mechanisms; and 6) Continuous reflection and adaptation that balances fidelity with flexibility. We would argue that these guiding principles, adaptable and scalable, when embedded in immunisation strategies, can enhance equity and effectiveness across diverse contexts, aligning with global strategies such as Immunisation Agenda 2030, Big Catch Up, and GAVI 6.0. As Africa celebrates 50 years of immunisation progress, we must move beyond conventional models, adopting innovative strategies that amplify community voices, ensure flexibility in program design, and support national health priorities. The future of immunisation must embrace participatory design, local innovation, sustained commitment, and relentless focus on adaptability, ensuring no one is left behind amid shifting policies and limited resources.