1-2 Assistance Necessary to Promote People-centered Development that Supports Basic Human Life
Japan has proactively advocated the concept of “human security” to the international community, a notion that seeks to protect people from widespread and serious threats to the survival, livelihood, and dignity of humans and help them fulfill their abundant potential. There can be no quality growth without “human security.” The following introduces the dimensions that support basic human life, including health, water, education, culture, etc. through a people-centered approach.
(1) Health and Population
Many of the people living in developing countries cannot easily access the basic health services that are available day-to-day in developed countries. Even today, more than 5.9 million children under the age of five die annually due to infectious diseases, nutritional deficiency, diarrhea, and other ailments.(Note 11) Over 303,000 pregnant women also lose their lives every year, unable to receive emergency obstetric care from skilled birth attendants including obstetricians, gynecologists, and midwives.(Note 12) Furthermore, due to high rates of population growth, poor countries suffer from greater poverty, unemployment, famine, poor access to education and/or poor quality of education, and environmental deterioration. For these reasons, Goal 3 of the SDGs was set as “Ensure healthy lives and promote well-being for all at all ages.”
In order to respond to the increasingly diversified health issues internationally and locally, it is important to achieve “Universal Health Coverage (UHC)”* to ensure that all people can receive the health services they need at an affordable cost.
Japan has been placing importance on efforts in the healthcare field that are directly linked to human security. In response to the establishment of the Development Cooperation Charter in February 2015, the Government of Japan established the Basic Design for Peace and Health as a guideline for global health policy in September the same year. This policy aims to make full use of Japan's expertise, technologies, medical devices, and services to: (i) establish a system able to respond to public health emergencies such as the Ebola virus disease; and (ii) provide basic health services for all people throughout their lifetimes. These efforts are also important in order to pursue solutions for health-related issues identified in the SDGs.
Furthermore, Japan has led discussions in the international community regarding the strengthening of health systems* and the promotion of UHC. At the G7 Ise-Shima Summit held in 2016, the leaders agreed on the importance of reinforcing the capacity of the international community to respond to public health emergencies such as the infectious diseases, and promoting UHC, which is the key to responding to a wide range of health issues and offers better preparedness for emergencies, and of reinforcing responses to antimicrobial resistance (AMR), and announced the “G7 Ise-Shima Vision for Global Health.”
Moreover, at a side event on UHC on the occasion of TICAD VI in 2016, Prime Minister Abe stated his determination to contribute to strengthening the capacity for responses as well as prevention and preparedness against public health emergencies and to promoting UHC in Africa, while placing importance on the ownership and leadership of African countries, particularly through human resources development, in order to steadily implement the “G7 Ise-Shima Vision for Global Health.”
At the TICAD Ministerial Meeting held in August 2017, TICAD Ministers affirmed that, from the perspective of human security as well as promotion of a resilient society, comprehensive and resilient health systems are indispensable towards enhancing quality of life. In particular, they reaffirmed to share the expertise and experiences on UHC that includes reducing the burden caused by infectious diseases such as HIV/AIDS, malaria, and tuberculosis.
With respect to this commitment, Japan is steadily implementing the relevant measures. These include conducting human resource development programs on measures to respond to infectious diseases for more than 6,700 people since 2016, putting in place measures costing approximately ¥57.6 billion, which includes fostering more than 95,000 personnel in the health sector since 2013, strengthening efforts to counter infectious diseases that also spread in rural regions, and contributing to improving maternal and child health.
For more than 50 years, Japan has been providing a National Health Insurance system and has realized a society in which people enjoy the longest healthy life in the world. Japan will continue to pursue the more effective implementation of bilateral aid, reinforcement of strategic collaborations with the global initiatives of international organizations, the enhancement of domestic systems and the fostering of human resources.
•Public Health Emergencies
In today's globalized world, infectious diseases spread easily beyond national borders and have serious impacts on the entire international community. Hence, it is important to put in place measures to respond to emerging/reemerging infectious diseases.* The outbreak of the Ebola virus disease (EVD) in 2014-2015 took many lives and resulted in the spread of infection to neighboring countries and the secondary infection to medical personnel, thus making the outbreak a major humanitarian, economic, and political challenge for the international community.
Japan has seamlessly provided various forms of assistance to affected countries and international organizations, including the dispatch of experts and provision of emergency relief goods in addition to financial assistance. Moreover, Japan supported the efforts to overcome the Ebola crisis through public-private cooperation such as the development of medicine, rapid test kits, and thermography cameras utilizing Japanese technologies. Building a sustainable and resilient health system is crucial to control infectious diseases. Based on this view, prior to the EVD outbreak, Japan has prioritized development cooperation for health, an issue that is directly linked to human security, and has continuously striven to enhance health systems under the banner of promoting UHC. Japan strengthens the capacity to prevent, prepare for, and respond to public health crises, in order to enable that all people in Africa have access to health services. Japan is swiftly implementing assistance that contributes to their social and economic recovery, including capacity building of medical professionals, assistance for health fields such as improvement of medical facilities, infrastructure development, agricultural productivity improvement, and food security enhancement.
Furthermore, Japan, as a nation that proactively contributes to the peace and prosperity of the international community, has led discussions in fora such as the G7 and TICAD regarding the establishment of a framework of the international community for responding to this kind of health crises (the Global Health Architecture). In particular, on the occasion of the G7 Ise-Shima Summit held in 2016, Prime Minister Abe announced a contribution of $50 million to the WHO Health Emergencies Programme; of this amount, Japan contributed $25 million before the end of the year. In addition, Japan has contributed approximately $10.80 million to the Contingency Fund for Emergencies (CFE). In response to the support from the Government of Japan, the World Bank took the opportunity of the summit to launch the Pandemic Emergency Financing Facility (PEF),* and Japan announced a contribution of $50 million to the PEF before any other country. Japan also led in the establishment of the Standard Operation Procedures (SOP) by WHO to respond to emergencies, in cooperation with the United Nations Office for the Coordination of Humanitarian Affairs (OCHA). In 2015, Japan newly established the Japan Disaster Relief (JDR) Infectious Diseases Response Team, which aims to provide swift and effective assistance to countries where outbreaks of infectious diseases are occurring.
The Project for the Provision of Quarantine Equipment at Jose Marti International Airport
Grant Assistance for Grass-Roots Human Security Project (March 2015 - November 2016)
A large incidence of Zika virus infection cases have been reported in Latin America and the Caribbean. Since reporting its first case in March 2015, Cuba has seen 32 confirmed cases of Zika virus as of October 2016. Most of these have been determined to be cases brought in from outside the country. To improve this situation in Cuba, Japan signed onto a project providing grant aid of 76,563 euros to MediCuba, an institution under the country's Ministry of Public Health. This allowed the country to purchase four cutting-edge thermography cameras made in Japan for use at José Martí International Airport (terminals 2, 3, and 5) in the capital of Havana. The handover ceremony for these thermography cameras was held in November 2016.
These cutting-edge thermography cameras can simultaneously measure the body temperature of multiple people without contact. For this reason, they prevent the spread of infection during quarantine process and enable the safe and secure immigration control at the airport where there is traffic of large numbers of people. This project is expected to heighten the airport's system for preventing epidemics from spreading to Cuba and prevent the transmission of Zika fever and Dengue fever inside the country.
•Promotion of UHC
UHC refers to a situation where all people can access and receive the health services they need, at an affordable cost. The achievement of UHC is important for narrowing disparities in healthcare services, meeting the basic health needs of all people, and enabling aid recipient countries to review and respond to their own health challenges. The Government of Japan has actively advocated the promotion of UHC as a “Japan Brand” in fora for international discussions, including the G7, TICAD, and the United Nations General Assembly. Because of these kinds of assertions by Japan, the 2030 Agenda adopted in September 2015 included the achievement of UHC as one of its global goals.
Japan played a leading role in the establishment of the IHP for UHC 2030 (commonly known as UHC 2030), which further develops existing aid coordination frameworks in the health sector. Japan stated that it is necessary to share expertise and experience among international organizations and donor countries, as well as to strengthen collaboration for enhancing a health system in developing countries in order to promote UHC, at the United Nations and the G7 Ise-Shima Summit.
Furthermore, in TICAD VI Prime Minister Abe expressed that Japan will provide priority support for countries capable of being a model for promotion of UHC, so that the pioneering efforts of UHC in Africa will spread to the entire African continent. In addition, Japan announced the “UHC in Africa” jointly with the World Bank, WHO, the Global Fund and others, as a project that presents the useful approaches and specific actions that help with UHC achievement. On the occasion of the high-level week of the UN General Assembly in September 2017, Japan called international attention to the significance of UHC by hosting an event aimed for promoting UHC. Following this event, the 2017 UHC Forum was held in Tokyo in December 2017 and Prime Minister Abe, UN Secretary-General Guterres, President Sall of Senegal, as well as other leaders driving the global health sector forward, attended. Based on the discussions, the UHC Tokyo Declaration was adopted as the commitment to accelerate efforts to achieve UHC, which advocates the strengthening of the global momentum towards achieving UHC and of the coordination between the respective countries and organizations. In addition, Prime Minister Abe announced that, Japan will provide assistance amounting to $2.9 billion in the coming years to push forward the efforts towards UHC by countries and organizations.
The Government of Japan stipulated the “Basic Design for Peace and Health” in 2015. It states that Japan will continue to provide the support necessary to make UHC the mainstream trend in the international community. Specifically, it outlines that Japan will promote cooperation that capitalizes on its experience, technology, and expertise, including through physical assistance, such as building hospitals, supplying medicines and medical devices, and through non-physical assistance, such as human resources development and system building. The Basic Design aims to achieve UHC that will “leave no one behind,” including the poor, children, women, persons with disabilities, the elderly, refugees and internally displaced persons (IDPs), ethnic minorities and indigenous people.
Basic health services under UHC comprise all services ranging from nutritional improvement (refer to (3) Food Security and Nutrition), vaccination, maternal and child health, sexual and reproductive health, infectious disease control, NCDs control, and comprehensive community care and nursing care for the elderly.
Immunization is a proven means for controlling and eliminating infectious diseases effectively and at a low cost, and it is estimated that 2 to 3 million lives could be saved through immunization each year.(Note 13) Since Japan's first contribution in 2011 to Gavi, the Vaccine Alliance* established in 2000 to improve the immunization coverage rate in developing countries, it has provided a total of approximately $72.46 million to Gavi. Gavi estimates that since its launch in 2000, Gavi has immunized 580 million children and has averted more than 8 million deaths. During the strategic period from 2016 to 2020, Gavi aims to immunize a further 300 million children to save over 5 million lives. The Government of Japan announced in 2016 a further contribution of $76 million by 2020 to Gavi in order to promote these efforts. As for bilateral assistance, Japan will contribute to increasing the vaccination rates by providing assistance such as for vaccine production and management of vaccines, as well as for cold chain maintenance and management.
Maternal and child health, which was included in the MDGs (Goal 4: reduce the under-five mortality rate; Goal 5: improve maternal health), has made significant gains, including the reduction of the under-five mortality rate and the maternal mortality rate, and increase in the percentage of births assisted by skilled midwives. Nevertheless, the MDG goals were not achieved and significant challenges also remain for maternal and child health in the SDGs. Japan aims to provide assistance focused on strengthening sustainable health systems based on the principles of strengthening the schemes for providing comprehensive and continuous maternal and child care while ensuring the ownership of developing countries and increasing their capabilities. In pursuit of these aims, Japan implements efficient assistance in such countries as Ghana, Senegal, and Bangladesh. Through such assistance, Japan contributes to making the necessary services more accessible for women during pre-pregnancy (including adolescence and family planning), pregnancy, and delivery, as well as for infants and children. Furthermore, Japan is implementing activities utilizing the Maternal and Child Health (MCH) Handbook as a means of improving maternal and child health, taking advantage of the experience and expertise of Japan. The MCH Handbook can contribute to the Continuum of Care (CoC) that spans the entire duration from pregnancy, childbirth, the post-partum period (the period after the birth until the woman recovers to a similar condition before the pregnancy, usually about one to two months after birth), the neonatal period, infancy, and to early childhood. The MCH Handbook also provides health information to mothers, which can encourage the raising of awareness and behavior modification.
With the cooperation of Japan, Indonesia, a country in which the MCH Handbook has already been introduced nationwide, has conducted eight international training programs since 2007, contributing to the adoption of the MCH Handbook and nationwide popularization of the handbook in other countries. In 2017, with the aim of carrying out a “country-based comparison,” Indonesia invited maternal and child health professionals from Thailand, the Philippines, and Kenya - countries where maternal and child health services have been provided through the utilization of the MCH Handbook - to come together and share their experiences, learn from one another, and discuss the further potential and challenges regarding the MCH Handbook. Furthermore, in order to review the need to conduct international training on the MCH Handbook after 2018, Indonesia also invited professionals from Afghanistan and Tajikistan where the Handbook is currently being used on a trial basis, to join in the exchange of opinions.
In aid recipient countries, Japan works with other development partners such as the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF), to promote maternal and child health that includes sexual and reproductive health services, and thereby improving the health of a greater number of women and children.
Furthermore, in order to strengthen its international contribution to measures against aging, in 2016 Japan as the presidency took up aging as a topic of discussion within the framework of the G7 for the first time.
The Project for Strengthening Basic Health Care Services Management for Universal Health Coverage in Zambia
Technical cooperation project (October 2015 - )
Zambia trails behind other African countries in terms of maternal and child health and infectious disease control. In particular, Lusaka Province and Southern Province, where this project is being implemented, have seen significant increases in population caused by an influx of people from other provinces. This has led to a shortage of health facilities, staff and medical equipment and consumables, resulting in a considerable decline in health services both in quantity and quality.
Japan has been an active proponent of universal health coverage (UHC), which ensures that all people can receive the health services they need at an affordable cost throughout their life. Zambia is in the process of introducing and implementing various policies aimed at realizing UHC. However, over a 12-year period since 2000, Zambia's average life expectancy increased by 16 years, resulting in rapid population growth and aging, while the country's system for providing appropriate medical services has been unable to keep pace due to a shortage of healthcare workers.
Given this situation, Japan launched the Project for Strengthening Basic Health Care Services Management for Universal Health Care in Zambia in an effort to improve the country's management capabilities, by assisting health activity planning, as well as its implementation, assessment and improvement based on community situation and information. Specifically, the project provides assistance to the District Health Offices in four districts situated in Lusaka Province and Southern Province not only for health activity planning, but also formulating management guidelines for activity planning focused on problem resolution in the healthcare system. The goal of the project is to have these District Health Offices use the guidelines to regularly and continually review and manage their health plan, with the hope that in the future District Health Offices in other parts of these provinces will be able to use the guidelines to improve their health services.
In addition, this project is conducting a survey on the state of transport to obstetric hospitals and the provision of services for high blood pressure and diabetes in these communities. The results will be compiled into useful recommendations for the Ministry of Health to formulate their policy.
This project is helping to achieve the Sustainable Development Goals (SDGs) by working to improve basic health services in developing countries. (As of December 2017)
•Responding to Antimicrobial Resistance (AMR)
Antimicrobial resistance (AMR)* is a serious threat for public health, and in recent years the momentum of countermeasures has been growing. Japan formulated the National Action Plan on Antimicrobial Resistance in April 2016 in order to promote its own AMR countermeasures. In the same month, Japan hosted the Tokyo Meeting of Health Ministers on Antimicrobial Resistance in Asia and adopted the Asia-Pacific One Health Initiative on AMR comprising four pillars of surveillance system and laboratory network, and antimicrobial access and regulation. The G7 Ise-Shima Summit also took up AMR as one of the pillars of its health agenda, and compiled policies for the G7 countries to work on in cooperation with each other. Moreover, at the High-level Meeting on Antimicrobial Resistance in the United Nations General Assembly in September the same year, the “Political Declaration of the high-level meeting of the General Assembly on antimicrobial resistance” was adopted, which required each country and the related United Nations institutions to promote countermeasures, and the Secretary General of the United Nations to establish cross-sectoral working groups. In November 2017, the Tokyo AMR One-Health Conference was held.
•The Three Major Infectious Diseases* (HIV/AIDS, Tuberculosis, and Malaria)
Target 3.3 of the SDGs establishes the goal of ending AIDS, Tuberculosis and Malaria as epidemics by 2030, and to achieve this objectives Japan attaches great importance to support activities provided by the Global Fund to Fight AIDS. The Global Fund is the Public Private Partnership with the mandate of responding to these three diseases. The Global Fund was established after the G8 Kyushu-Okinawa Summit in 2000, where political leaders discussed about the necessary measures against infectious diseases for the first time. As one of the founding fathers, Japan has provided financial assistance to the Global Fund since its establishment in 2002 and the total contribution from Japan to the Global Fund has reached $2.838 billion by the end of October 2017. Furthermore, in 2016, ahead of the G7 Ise-Shima summit, Japan pledged a total contribution of $800 million over the coming year, for the Fifth Replenishment. The number of lives saved in Global Fund supported countries achieved 22 million. Japan provides supplemental bilateral aid to some countries which receive the Global Fund support, in order to ensure that responsive measures against these three diseases are implemented effectively in each country. Japan also strives to strengthen mutual cooperation in strengthening health systems, community empowerment, and the policies for maternal and child health in these countries.
As bilateral assistance for HIV/AIDS countermeasures, Japan is providing assistance to spread knowledge to prevent new infections, raise awareness, widely provide testing and counseling, and enhance the distribution system of drugs to treat HIV/AIDS. In particular, Japan International Cooperation Volunteers (JOCV) on Infectious Disease and HIV/AIDS Control are vigorously engaged in activities such as spreading of knowledge and understanding of prevention to even more people, as well as the care and support of people living with HIV/AIDS, mainly in Africa.
With regard to tuberculosis, in 2008, MOFA and MHLW announced the Stop TB Japan Action Plan, a program developed jointly with JICA, the Japan Anti-Tuberculosis Association, and the Stop TB Partnership Japan. Making use of the experience and technology fostered through its domestic tuberculosis countermeasures, and with the public and private sectors working closely together, Japan has strived to contribute to the reduction of the annual number of deaths from tuberculosis in developing countries, particularly in Asia and Africa, setting the target at 10% reduction in the number of tuberculosis deaths worldwide (160,000 people, based on 2006 figures). Based on the new global strategy that WHO adopted in 2014 with the target years for achievement set between 2015 and 2035 (Global strategy and targets for tuberculosis prevention, care and control after 2015), MOFA, MHLW, JICA, and other relevant agencies revised the Action Plan in 2014, and confirmed the continued work on responding to tuberculosis on a global level.
With regard to malaria, a major cause of infant mortality, Japan provides assistance for initiatives for anti-malaria measures, which involve the strengthening of local communities and assistance in cooperation with WHO.
Japan works mainly in cooperation with UNICEF to assist in the final stage of polio eradication with a focus on three polio-endemic countries* - Nigeria, Afghanistan and Pakistan. In Nigeria, where no cases of infection from the wild polio virus had been discovered since 2014, a case of infection from the wild polio virus was reported in 2016. In February 2017, Japan provided ¥4 billion in support of measures to eradicate polio in Nigeria, Chad, Niger, Cameroon, and Central African Republic, in cooperation with UNICEF. As a result, an estimated 72 million children under the age of five were successfully vaccinated.
In addition, Japan has provided support worth a cumulative total of more than ¥11.5 billion in Afghanistan since 2002, in cooperation with UNICEF. Furthermore, in Pakistan, Japan has provided assistance a cumulative total of more than ¥11 billion in coordination with UNICEF since 1996, and provided ODA loans of approximately ¥6.3 billion in 2016. These support measures have contributed to reducing and eradicating new polio infections. ODA loan conversion was adopted as a new approach for these ODA loans. Under this approach, the Gates Foundation repays the debt owed by the Pakistani government when certain targets are achieved. In addition, Japan also provided assistance of approximately ¥1.26 billion to Afghanistan, and approximately ¥404 million and ¥520 million to Pakistan in 2016 and 2017 respectively. By vaccinating children under five years old, this program is expected to help in reducing the number of new polio cases in Pakistan while reducing the polio incidence rate for about 38 million children under five across the country.
•Neglected Tropical Diseases (NTDs)
“Neglected Tropical Diseases (NTDs)”* such as Chagas disease, Filariasis, and Schistosomiasis, affect about 1 billion people worldwide, and cause major socio-economic loss to developing countries. Since infectious diseases have impact beyond national borders, the international community must work to combat them. To that end, Japan cooperates closely with all the relevant countries and international organizations on the respective countermeasures. Since 1991, Japan genuinely engaged in launching a full-scale effort against Chagas disease, which is also known as a “disease of poverty,” in Central American countries. Japan has provided assistance to establish a system for dealing with Chagas disease vectors and contributed to reducing the risk of infection. Regarding Filariasis, Japan supplies antiparasitic agents as well as educational materials to provide knowledge and understanding to a large number of people. Meanwhile, Japan also conducts preventive education through JOCV activities in order to reduce the number of new cases and maintain the non-epidemic status.
Furthermore, in 2013, Japan launched the Global Health Innovative Technology Fund (GHIT Fund), the first public-private partnership in Japan with the purpose to facilitate the development of new drugs for infectious diseases in developing countries including NTDs. The GHIT Fund aims to control infectious diseases in developing countries through the research and development (R&D) of effective therapeutic medicine, vaccines, and diagnostic products, while promoting global cooperation with R&D institutions both inside and outside Japan. Moreover, in 2016 the Government of Japan decided to make a $130 million contribution for the purpose of promoting R&D of new drugs against NTDs and supply preparation and support of drugs. It is expected to contribute to the treatment of patients suffering from NTDs in Africa and other parts of the world.
- *Universal Health Coverage (UHC)
- To ensure that all people can receive the health services they need, at an affordable cost.
- *Health system
- Health system includes establishing mechanisms for governance, the improvement of healthcare facilities, the optimization of the supply of pharmaceuticals, the accurate measurement and effective utilization of healthcare information, financial administration and securing resources, resource mobilization as well as the development and management of personnel to operate these processes and provide services.
- *Emerging/reemerging infectious diseases
- “Emerging diseases” are infectious diseases that were not previously known and have been newly recognized in recent years, such as SARS (Severe Acute Respiratory Syndrome), avian influenza, the Ebola virus disease, and others.
- “Reemerging diseases” are infectious diseases that had spread throughout the world in the past and subsequently saw a decrease in the number of cases, but have been on an increasing trend again in recent years, such as cholera and tuberculosis.
- *Pandemic Emergency Financing Facility (PEF)
- This is a framework for utilizing insurance mechanisms to mobilize private sector funds and carry out quick and efficient funds mobilization when a pandemic occurs. Donor countries, etc. pay the insurance premiums to the insurance companies. In the case that the conditions agreed in advance are satisfied due to the occurrence of a pandemic, the insurance payout is instantly distributed to the developing countries, international organizations, NGOs, etc. from the insurance companies through the PEF, and allocated to the budget for the emergency response.
- *Gavi, the Vaccine Alliance
- Gavi, the Vaccine Alliance is a public-private partnership, which was established with the aim of saving children's lives and protecting people's health by improving access to immunization in developing countries. Governments of donor countries, developing countries, relevant international organizations, the pharmaceutical industry, private foundations and civil society participate in this partnership.
- *Antimicrobial resistance (AMR)
- Antimicrobial resistance (AMR) happens when microorganisms such as pathogenic bacteria and viruses, etc. develop resistance to antimicrobial drugs, such as antibacterial and antiviral drugs, and the drugs become ineffective.
- *The three major infectious diseases
- The three major infectious diseases refer to HIV/AIDS, tuberculosis, and malaria. Worldwide deaths from these diseases total approximately 3.6 million. The spread of these infectious diseases significantly impacts society and the economy, and is a factor that hampers national development. Accordingly, it is a serious threat to human security, and is positioned as a global issue that must be addressed through the unified efforts of the international community.
- *Polio-endemic countries
- Countries where wild polio has never been eradicated and is still spreading.
- *Neglected Tropical Diseases (NTDs)
- “Neglected tropical diseases (NTDs)” include 18 types of tropical disease, such as Chagas disease, dengue fever, Filariasis, and other diseases that are transmitted from parasites, bacteria, etc. The number of infected individuals has reached approximately one billion worldwide. Many of these diseases are preventable and can be eradicated. As many of the cases are found among the populations living in poverty, and for other reasons, social awareness of this issue is relatively low. Therefore, the development of diagnostic methods, treatment methods and new drugs, and the process of making them available to those in need, are lagging. At the G7 Ise-Shima Summit held in 2016, the G7 countries presented policies for encouraging R&D, and innovation in measures to combat NTDs (the G7 Ise-Shima Vision for Global Health).
- Note 11: Source: WHO “World Health Statistics 2016”
- Note 12: Source: WHO, UNICEF, UNFPA, and the World Bank “Trends in Maternal Mortality: 1990 to 2015”
- Note 13: Source: WHO “Health topics, Immunization”