In the decade leading up to the COVID-19 pandemic, global immunization rates stagnated, heightening vulnerability to outbreaks of infectious diseases. This vulnerability was exacerbated by dramatic setbacks in global immunization rates during the pandemic.[1] Recognizing this, in April 2023, Bosnia and Herzegovina launched the Periodic Intensification of Routine Immunization (PIRI), prioritizing measles, mumps, and rubella (MMR) vaccinations for children.[2] With both financial and technical backing from the WHO Country Office in Bosnia and Herzegovina, PIRI reduced disease risks for thousands of young children. Within a span of 10 months, there was a notable increase in the first-dose MMR vaccination rate, rising from 69.3 percent to 76.0 percent. One of the greatest values of PIRI was that it enhanced both horizontal and vertical communication and coordination on immunization among health authorities. It also helped prioritize immunization among numerous health challenges faced and raised awareness of its importance among various stakeholders. The PIRI initiative in Bosnia and Herzegovina, backed by WHO, is a valuable example of putting “Delivering United Action for Better Health – a strategy for collaboration between the WHO Regional Office for Europe and Member States in the WHO European Region,” into practice, using innovative tools and approaches to improve health outcomes. Its success highlights the benefits of improved communication among health authorities, which can enhance vaccination, leading to better health outcomes. In light of recent cases of measles and pertussis reported in Bosnia and Herzegovina and other countries of the WHO European Region, it is imperative to sustain efforts to reach the 95% coverage each year recommended by WHO to prevent outbreaks.

“The PIRI project is essentially the first serious initiative to improve immunization coverage in the Federation of Bosnia and Herzegovina. Though parents generally remain quite sceptical, we certainly noticed a positive shift in almost all municipalities in Herzegovina-Neretva Canton. If we now mainstream the project activities in our routine work, I believe that then we can sustain optimal immunization coverage levels.”

- Mr Dino Peco, team lead from the Department of Epidemiology of Herzegovina Neretva Canton Institute of Public Health

How did Bosnia and Herzegovina, with the support WHO, achieve this?

In April 2023, Bosnia and Herzegovina launched Project PIRI to address under-vaccination and amplify vaccination awareness. While the primary objective of Project PIRI was to address under-vaccination and enhance vaccination awareness in the Federation of Bosnia and Herzegovina and the Republika Srpska, the initiative indirectly laid the groundwork for a future transition from the country’s traditional paper-based health system to a state-of-the-art digital platform. WHO played a crucial role, offering technical expertise to design and develop a digital system. This system, underpinned by meticulous record-keeping and sophisticated data analytics, aimed to spotlight regions with vaccination shortfalls. As Project PIRI progressed, WHO Bosnia and Herzegovina took a lead role in data management. Drawing from WHO’s extensive global health expertise, they facilitated real-time monitoring. Having data of high quality and integrity ensured the creation of tailored strategies that met the unique needs of different regions, and fostered a synchronized approach that could swiftly address challenges as they arose.

WHO provided ongoing technical expertise to ensure that Project PIRI was implemented based on a foundation of evidence-backed interventions and strategies. Numerous campaigns were rolled out as the project progressed. These included championing COVID-19 and flu vaccines, issuing reminders to parents about routine immunization timelines, and launching the HPV vaccine, which was introduced in early 2023 across all of Bosnia and Herzegovina.

^{Project PIRI (Periodic Intensification of Routine Immunization) indirectly laid the groundwork for a transition from Bosnia and Herzegovina’s traditional paper-based health system to a state-of-the-art digital platform.}
Photo credit: WHO Bosnia and Herzegovina

Strengthening ties between health authorities at various levels was a pivotal element of the project. WHO actively promoted effective communication and cooperation to maximize the project's reach and impact. Early on, WHO organized meetings with focal points (FP) - representatives from cantonal public health institutes - to familiarize them with data entry techniques. Subsequent meetings, hosted by the WHO Country Office, engaged epidemiologists to address potential issues and enhance clarity.

The COVID-19 pandemic highlighted a series of challenges for Project PIRI. Insights from the project identified several vaccination barriers, from concerns over side effects, to a fundamental lack of awareness. Added challenges, like forgetfulness, family relocations, and difficulties in reaching out to families, compounded the project's complexity.

“Before the PIRI project, I was hesitant and overwhelmed by all the information out there. But with the clarity and support this initiative provided, I felt confident in getting my children vaccinated. Now, not only are they protected, but I feel like we're part of a community working towards a healthier future for all our kids.”

-Jasmina Kovačić, mother of two from Sarajevo

With financial backing from WHO through the European Commission’s Directorate-General for Neighbourhood and Enlargement Negotiations (DG NEAR), Project PIRI has achieved a sweeping, almost nationwide presence. The project has already shown impressive results across eight of the 10 cantons of the Federation of Bosnia and Herzegovina and was rolled out in the Republika Srpska in September 2023, where there are high hopes for further success. Donor support is projected to continue until the end of October 2023 the project's intended endpoint. Post-project, there's optimism that local authorities will continue the transformative practices introduced by Project PIRI, ensuring its benefits endure and evolve.

With the support and active involvement of WHO, Bosnia and Herzegovina turned the global COVID-19 health crisis into an opportunity to strengthen its immunization programme, displaying resilience and foresight in a time of widespread uncertainty.