The Joint External Evaluation (JEE), launched in 2016 by the WHO and UNICEF, assesses countries’ capacity to prevent, detect, and respond to public health threats. In 2025, Lawrence R. Stanberry and colleagues advocated for adding a fourth indicator—“Drivers of Vaccine Uptake”—to complement the existing metrics. This addition would shift the paradigm from a “coverage-first” to a “behaviour-driven-first” approach, crucial for realizing the 2030 Immunization Agenda.
Limitations of the Existing Assessment System
Presently, the JEE relies on three indicators: routine immunization coverage (e.g., measles first-dose coverage), national vaccine access and service delivery (e.g., cold-chain integrity, vaccination site distribution) and emergency response capacity for mass vaccination.
These metrics focus on the operational “hardware” of immunization programs while neglecting the “software”—the behavioural and social factors such as safety concerns, accessibility issues, and social norms that drive vaccine uptake. During COVID-19, these overlooked drivers compounded supply issues, leading to inadequate coverage that static data alone could not explain.
The Necessity for a “Fourth Indicator”
A “Drivers of Vaccine Uptake” indicator, based on the WHO/UNICEF 2022 Behavioural and Social Drivers of Vaccination: Tools and Practical Guidance, would systematically assess four dimensions:
- Thoughts and Feelings (cognitions and attitudes)
- Social Processes (group norms)
- Motivation (willingness to vaccinate)
- Practical Issues (accessibility, affordability, service quality)
By employing standardized tools to collect and analyze behavioural data, this indicator would reveal the underlying causes of low coverage. Integrating this fourth indicator would enhance the overall JEE framework by: 1) Identifying Coverage Gaps, 2) Optimizing Communication, and 3) Enhancing Emergency Response.
To effectively implement this indicator, countries must establish robust data systems. However, Low-income countries may face resource constraints
More can be found in the article:
Stanberry LR, Makadzange T, James WG, et al. Proposal for a fourth indicator on vaccine uptake in the joint external evaluation tool. Bull World Health Organ. 2025 Mar 1;103(3):226-228
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