**1. Introduction**

Young South African women and girls are trafficked internally (within South African borders) and externally (outside the borders of South Africa) for the purposes of sexual exploitation and other purposes, such as domestic labour, for criminal activities, as well as organ transplants.

External trafficking has occurred in this country since colonial times. Molo Songololo (2005), a children's rights organisation, reports that between 1726 and 1834, as many as 36 169 slaves were brought from Indonesia, Java, Ceylon, India, the East Indies, Mauritius, Malaysia and other countries to South Africa to work in mines, and as domestic workers. This was a practice instituted by the colonial authorities to boost the southern African economy by importing cheap labour. Three infamous examples typify the beginning of the trade in human beings internally and externally (Martens, 2003; Martens, Pieczkowski & Van-Vuuren-Smyth, 2003). One known notorious incident was the recruitment, with promises of economic prosperity and educational advancement, of Saartje Baartman, who was transported from the Cape Colony and exploited by European citizens in England and France (Martens et.al, 2003). The promises made to her in her country of origin were not fulfilled – instead, her naked live body was displayed as an object of attraction for everybody to view. She eventually died in France, where her private parts were put on display in a museum. Another, less well-known, example involved European girls who were trafficked into the Cape Colony for the purposes of involuntary prostitution to meet the demand of men for prostitutes (Molo Songololo, 2005). More recently, Mozambican children were trafficked into South Africa to be kept as concubines in the Carletonville mines (Martens, 2003; Martens et.al 2003).

In the last two decades, increasingly, reports of human trafficking for sexual exploitation have surfaced in the print and visual media, fuelled by the South African Police Service

© 2012 Lutya, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

(SAPS) raids on brothels.  These Asian women were brought into the country under false pretences – they were told they would be working in high-end restaurants where they could mingle with and marry rich men. When they arrived in South Africa, they became entangled in debt bondage and their passports were taken from them (Reuters, 1998). Since then, academic institutions and civil organisations have increasingly been reporting on the subject of internal and external human trafficking for sexual exploitation. Furthermore, government and non-governmental organisations (NGOs) are raising awareness on the topic, educating South African citizens about this form of crime.

Human Trafficking of Young Women and Girls for Sexual Exploitation in South Africa 89

UNODC, 2007). Some of the members of these syndicates were filmed by a crew of the local television programme Special Assignment while the syndicates were trafficking children from Durban to Bloemfontein and Johannesburg in 2004. Some of these criminals have since been caught by the SAPS. The conditions within which the trafficked children were held was described by one of the investigators as 'deplorable, not fit for a pig and downright

Although human trafficking occurs for other purposes in this country, sexual exploitation is the most frequently reported reason. Human trafficking for sexual exploitation occurs within a context of high levels of contact crimes (interpersonal violent crimes occurring between persons who are known to each other). As illustrated in Figure 1 below, for the period from 2009 to 2010, the SAPS recorded approximately 2.1 million criminal cases: 31.9%

Of these contact crimes, sexual violence comprised of 10.1% (see Figure 2, below). Although the details have not been released for the period 2009/2010, in the period 2008/2009, prostitution and other sexually exploitative acts accounted for 15.3% of the total number of

shameful' (UNODC, 2007).

of these cases were contact crimes (Sigsworth, 2008).

**Figure 1.** Crime figures for 2009/2010 ([70])

sexual offence cases.

Internal trafficking also has historical origins dating back to the late nineteenth and early twentieth century. At the turn of the century, a criminal leader called Nongoloza Mathebula (1867-1948) and his gang abducted and kidnapped women and boys from neighbouring areas to the mine compounds and kept them as sex slaves in the wake of the discovery of sexually transmitted diseases among prostitutes selling their bodies to mine workers (Van Onselen, 1998).

When the political struggle was at its highest (during the 1980s until 1990) and into the early 1990s, 'jack-rollers' kidnapped and abducted young women and girls who appeared to be superior and were less appealing to men from lower socio-economic backgrounds. The targeted victims led quiet lives and had been seriously pursuing educational goals. They were also physically attractive. The jack-rollers would confine them in secluded residences where the victims were repeatedly raped and physically assaulted (Mokwena, 1991). These practices were not considered human trafficking at the time. However, South Africa has defined these practices as criminal since becoming a signatory to United Nations Human Rights-oriented legislation. Such practices are now classified as trafficking for sexual exploitation in Part 6 Section 71 (1-2) b of the Criminal Law (Sexual Offences and Related Matters Act, Act (32 of 2007), as amended.

Internal trafficking is the most commonly reported form of human trafficking in South Africa. Human trafficking research reports produced in this country have revealed evidence of children being trafficked from poor socio-economic areas such as rural areas and farms in the Eastern Cape and KwaZulu-Natal to developed parts of the country, such as urban areas in the Western Cape and Gauteng (Bermudez, 2008; Molo Songololo, 2005). Another research report has identified case studies of teenagers recruited and transported under false pretences to work as prostitutes in hidden brothels across South Africa (Unicef, 2003; UNODC, 2007). In between these research reports, newspapers, television documentaries, workshops, seminars and conferences have provided evidence of the prevalence of internal trafficking. A criminal investigator aligned with the Organised Crime Unit of the SAPS in Port Elizabeth has also exposed organised Nigerian syndicates trafficking children from city centres to city centres across South Africa (Van der Watt, 2009). Furthermore, children as young as ten are being kidnapped and abducted by organised criminal gangs who first feed them drugs in preparation for work as prostitutes (Chetty, 2009; Molo Songololo, 2005; UNODC, 2007). Some of the members of these syndicates were filmed by a crew of the local television programme Special Assignment while the syndicates were trafficking children from Durban to Bloemfontein and Johannesburg in 2004. Some of these criminals have since been caught by the SAPS. The conditions within which the trafficked children were held was described by one of the investigators as 'deplorable, not fit for a pig and downright shameful' (UNODC, 2007).

Although human trafficking occurs for other purposes in this country, sexual exploitation is the most frequently reported reason. Human trafficking for sexual exploitation occurs within a context of high levels of contact crimes (interpersonal violent crimes occurring between persons who are known to each other). As illustrated in Figure 1 below, for the period from 2009 to 2010, the SAPS recorded approximately 2.1 million criminal cases: 31.9% of these cases were contact crimes (Sigsworth, 2008).

88 Child Abuse and Neglect – A Multidimensional Approach

South African citizens about this form of crime.

Matters Act, Act (32 of 2007), as amended.

Onselen, 1998).

(SAPS) raids on brothels.  These Asian women were brought into the country under false pretences – they were told they would be working in high-end restaurants where they could mingle with and marry rich men. When they arrived in South Africa, they became entangled in debt bondage and their passports were taken from them (Reuters, 1998). Since then, academic institutions and civil organisations have increasingly been reporting on the subject of internal and external human trafficking for sexual exploitation. Furthermore, government and non-governmental organisations (NGOs) are raising awareness on the topic, educating

Internal trafficking also has historical origins dating back to the late nineteenth and early twentieth century. At the turn of the century, a criminal leader called Nongoloza Mathebula (1867-1948) and his gang abducted and kidnapped women and boys from neighbouring areas to the mine compounds and kept them as sex slaves in the wake of the discovery of sexually transmitted diseases among prostitutes selling their bodies to mine workers (Van

When the political struggle was at its highest (during the 1980s until 1990) and into the early 1990s, 'jack-rollers' kidnapped and abducted young women and girls who appeared to be superior and were less appealing to men from lower socio-economic backgrounds. The targeted victims led quiet lives and had been seriously pursuing educational goals. They were also physically attractive. The jack-rollers would confine them in secluded residences where the victims were repeatedly raped and physically assaulted (Mokwena, 1991). These practices were not considered human trafficking at the time. However, South Africa has defined these practices as criminal since becoming a signatory to United Nations Human Rights-oriented legislation. Such practices are now classified as trafficking for sexual exploitation in Part 6 Section 71 (1-2) b of the Criminal Law (Sexual Offences and Related

Internal trafficking is the most commonly reported form of human trafficking in South Africa. Human trafficking research reports produced in this country have revealed evidence of children being trafficked from poor socio-economic areas such as rural areas and farms in the Eastern Cape and KwaZulu-Natal to developed parts of the country, such as urban areas in the Western Cape and Gauteng (Bermudez, 2008; Molo Songololo, 2005). Another research report has identified case studies of teenagers recruited and transported under false pretences to work as prostitutes in hidden brothels across South Africa (Unicef, 2003; UNODC, 2007). In between these research reports, newspapers, television documentaries, workshops, seminars and conferences have provided evidence of the prevalence of internal trafficking. A criminal investigator aligned with the Organised Crime Unit of the SAPS in Port Elizabeth has also exposed organised Nigerian syndicates trafficking children from city centres to city centres across South Africa (Van der Watt, 2009). Furthermore, children as young as ten are being kidnapped and abducted by organised criminal gangs who first feed them drugs in preparation for work as prostitutes (Chetty, 2009; Molo Songololo, 2005;

Of these contact crimes, sexual violence comprised of 10.1% (see Figure 2, below). Although the details have not been released for the period 2009/2010, in the period 2008/2009, prostitution and other sexually exploitative acts accounted for 15.3% of the total number of sexual offence cases.

Human Trafficking of Young Women and Girls for Sexual Exploitation in South Africa 91

citizens, for example. As a result, some had their possessions stolen or burned by South African citizens. The insecurity felt by refugee women and girls on arrival in South Africa (Chetty, 2009; Minnaar, 2009, Mutongwizo, 2009; Palmary, 2005; Prince, 2009) aggravates the problem. They tend to rely on fellow citizens for economic opportunities instead of assimilating into and seeking help from South African citizens (Malapa, 2008). However, fellow citizens do not always provide legitimate economic opportunities. There is some evidence that some immigrants recruit fellow nationals for prostitution (Martens, 2003;

In this chapter, the problem statement relating to human trafficking is addressed. Concepts such as 'human trafficking', 'sexual exploitation', 'child trafficking' and 'girl' are defined. A distinction is made between voluntary and involuntary prostitution. A theoretical framework to elucidate the vulnerability of young women and girls to human trafficking is also provided, particularly within the socio-economic and socio-cultural context within which human trafficking in South Africa occurs. South African responses to human trafficking are identified, taking into account the fact that the relevant legislation has not yet been passed into law, because certain social and legal politics are preventing the rapid processing of this law. A strategy or policy that could effectively reduce the human trafficking of young women and girls for sexual exploitation in South Africa is proposed.

The purpose of writing this chapter is to illustrate the plight of victims of human trafficking for involuntary prostitution. Given this plight, it is important to research and write about human trafficking for sexual exploitation over other forms of human trafficking. Matters of particular concern are the age of victims of human trafficking for sexual exploitation, the increasing numbers of sex trafficking victims, socio-cultural factors contributing to the crime, the context within which human trafficking for involuntary prostitution occurs, the limited South African responses to human trafficking, as well as the politics of legal reform hindering the promulgation of the Prevention and Combating of Trafficking in Persons Bill.

Human traffickers recruit, kidnap and abduct young girls between the ages of 11 and 17 (Dyantyi & Pritz, 2009; Muller & Holley, 2009; UNICEF, 2003; Van der Watt, 2009). When these girls encounter human traffickers who make lucrative offers, or promise them economic prosperity, or when these girls are kidnapped and abducted, they are usually alone, without a capable guardian (Lutya, 2010b). The traffickers target this age bracket because of a client preference for younger girls – such clients believe that younger girls are compliant and docile, and therefore more likely to comply with their sexual demands (Bernat & Zhilina, 2010; Bernant & Winkeler, 2010; UNICEF 2003). In addition, the increasing number of HIV/Aids infections has popularized the socio-cultural myth of the virgin cure: some HIV/Aids infected men believe that sexual intercourse with a virgin will

O'Connor, 2009; SALRC, 2004).

**1.1. Aim of the book chapter**

**2. Problem statement**

Despite high levels of contact crimes, especially sexual violence against women and children, the South African criminal justice system has been ineffective in its approach to sexually violent crimes affecting women and girls. Only approximately 5% of reported and prosecuted sexual violence cases receive a custodial sentence (Sigsworth, 2008). Regardless of the large amount of research and scholarly work on human trafficking, there is currently still no specific law to prosecute the crime in the country – South Africa literally does not have a crime called human trafficking. Parts of existing legislation are used to prosecute to human trafficking activities (SALRC, 2008; Stuurman, 2009). However, there are some sections from the Criminal Law (Sexual Offences and Related Matters) Amendment Act (32 of 2007) and the Children's Act (Act 38 of 2005) reserved only for the sexual exploitation of trafficked women and children. Part six of the Criminal Law (Sexual Offences and Related Matters) Amendment Act (32 of 2007) is reserved to prosecute trafficking in persons for sexual purposes. Chapter 18 of the Children's Act 38 of 2005 is reserved to prosecute trafficking in children.

South Africa is a hotbed for human trafficking for a variety of other state-related factors. It is a source, transit and destination country for human trafficking (Le Roux, 2009b; SALRC, 2008; Stuurman, 2009; UNICEF, 2003). It is reputed among neighbouring countries to be economically advanced and therefore may be seen as potentially offering golden opportunities to poor immigrants. Since South Africa opened its borders to foreign citizens from neighbouring countries such as Zimbabwe, Lesotho, Mozambique and Namibia in 1994, a large number of documented and undocumented immigrants have entered the country as refugees, asylum seekers and tourists (Irish, 2005). On arrival in South Africa, many of these immigrants experienced xenophobia from the local population, which creates feelings of insecurity and fear. They have been accused of stealing jobs from South African citizens, for example. As a result, some had their possessions stolen or burned by South African citizens. The insecurity felt by refugee women and girls on arrival in South Africa (Chetty, 2009; Minnaar, 2009, Mutongwizo, 2009; Palmary, 2005; Prince, 2009) aggravates the problem. They tend to rely on fellow citizens for economic opportunities instead of assimilating into and seeking help from South African citizens (Malapa, 2008). However, fellow citizens do not always provide legitimate economic opportunities. There is some evidence that some immigrants recruit fellow nationals for prostitution (Martens, 2003; O'Connor, 2009; SALRC, 2004).

## **1.1. Aim of the book chapter**

90 Child Abuse and Neglect – A Multidimensional Approach

**Figure 2.** Contact crimes for 2009/2010 (70)

children.

Despite high levels of contact crimes, especially sexual violence against women and children, the South African criminal justice system has been ineffective in its approach to sexually violent crimes affecting women and girls. Only approximately 5% of reported and prosecuted sexual violence cases receive a custodial sentence (Sigsworth, 2008). Regardless of the large amount of research and scholarly work on human trafficking, there is currently still no specific law to prosecute the crime in the country – South Africa literally does not have a crime called human trafficking. Parts of existing legislation are used to prosecute to human trafficking activities (SALRC, 2008; Stuurman, 2009). However, there are some sections from the Criminal Law (Sexual Offences and Related Matters) Amendment Act (32 of 2007) and the Children's Act (Act 38 of 2005) reserved only for the sexual exploitation of trafficked women and children. Part six of the Criminal Law (Sexual Offences and Related Matters) Amendment Act (32 of 2007) is reserved to prosecute trafficking in persons for sexual purposes. Chapter 18 of the Children's Act 38 of 2005 is reserved to prosecute trafficking in

South Africa is a hotbed for human trafficking for a variety of other state-related factors. It is a source, transit and destination country for human trafficking (Le Roux, 2009b; SALRC, 2008; Stuurman, 2009; UNICEF, 2003). It is reputed among neighbouring countries to be economically advanced and therefore may be seen as potentially offering golden opportunities to poor immigrants. Since South Africa opened its borders to foreign citizens from neighbouring countries such as Zimbabwe, Lesotho, Mozambique and Namibia in 1994, a large number of documented and undocumented immigrants have entered the country as refugees, asylum seekers and tourists (Irish, 2005). On arrival in South Africa, many of these immigrants experienced xenophobia from the local population, which creates feelings of insecurity and fear. They have been accused of stealing jobs from South African In this chapter, the problem statement relating to human trafficking is addressed. Concepts such as 'human trafficking', 'sexual exploitation', 'child trafficking' and 'girl' are defined. A distinction is made between voluntary and involuntary prostitution. A theoretical framework to elucidate the vulnerability of young women and girls to human trafficking is also provided, particularly within the socio-economic and socio-cultural context within which human trafficking in South Africa occurs. South African responses to human trafficking are identified, taking into account the fact that the relevant legislation has not yet been passed into law, because certain social and legal politics are preventing the rapid processing of this law. A strategy or policy that could effectively reduce the human trafficking of young women and girls for sexual exploitation in South Africa is proposed.

## **2. Problem statement**

The purpose of writing this chapter is to illustrate the plight of victims of human trafficking for involuntary prostitution. Given this plight, it is important to research and write about human trafficking for sexual exploitation over other forms of human trafficking. Matters of particular concern are the age of victims of human trafficking for sexual exploitation, the increasing numbers of sex trafficking victims, socio-cultural factors contributing to the crime, the context within which human trafficking for involuntary prostitution occurs, the limited South African responses to human trafficking, as well as the politics of legal reform hindering the promulgation of the Prevention and Combating of Trafficking in Persons Bill.

Human traffickers recruit, kidnap and abduct young girls between the ages of 11 and 17 (Dyantyi & Pritz, 2009; Muller & Holley, 2009; UNICEF, 2003; Van der Watt, 2009). When these girls encounter human traffickers who make lucrative offers, or promise them economic prosperity, or when these girls are kidnapped and abducted, they are usually alone, without a capable guardian (Lutya, 2010b). The traffickers target this age bracket because of a client preference for younger girls – such clients believe that younger girls are compliant and docile, and therefore more likely to comply with their sexual demands (Bernat & Zhilina, 2010; Bernant & Winkeler, 2010; UNICEF 2003). In addition, the increasing number of HIV/Aids infections has popularized the socio-cultural myth of the virgin cure: some HIV/Aids infected men believe that sexual intercourse with a virgin will

cure them of the disease (Dyantyi & Pritz, 2009; Fitzgibbon, 2003; Gould, 2008). The United Nations estimates that 79% of all trafficked victims are moved for the purposes of sexual exploitation (Tshwane Alliance for Street Children, 2009; Tyakume, 2009). Most of these victims are recruited, abducted or kidnapped from socio-economically deprived areas and are then moved to economically developed parts of the country (Bermudez, 2008; Bernat & Zhilina, 2010; Bernat & Winkeler, 2010; Molo Songololo, 2005).

Human Trafficking of Young Women and Girls for Sexual Exploitation in South Africa 93

Fick, 2009). For instance, a holiday visit of a child which turns into exploitation could be seen as human trafficking, instead of as a vulnerable situation that could lead to human trafficking if the child was to be removed under false pretences. Human trafficking has not yet occurred. The child has not yet been recruited, transferred, harboured, deceived or intentionally bought for exploitation, even when the child has been abused sexually, physically and emotionally by the relatives. The act of victimising the child becomes a spontaneous act during the period of stay at the relatives' home, but cannot be prosecuted

According to the Prevention and Combating of Trafficking in Person Bill (2010), sexual exploitation implies the commission of any sexual offences against the victim of human trafficking.  The various ways in which a person could be misused through sex are forced marriage, sex work, forced pregnancy for the purpose of selling the child, as well as personal gratification. Forced marriage and personal gratification are acts that occur within private homes, and that are often perpetrated towards young women and girls who have not been recruited, transported, sold, supplied, procured through deceit, fraud or debt bondage – the essential components of the South African definition of human trafficking. It seems that a clear distinction between a human trafficking victim and a child who has been forced into a marriage is lacking, as well as between a human trafficking victim and a young

There needs to be legal and social criteria that can be used by social services and criminal justice authorities to identify victims of human trafficking. Currently, the Prevention and Combating of Trafficking in Persons Bill does not provide clear guidelines pertaining to the victims of human trafficking. Sections 11 and 12 refer to professionals that could assist in the identification, referral and reporting of a victim of trafficking, but these sections fail to describe the characteristics of the victim. A list of factors have been presented by SALRC (2008) describing the circumstances within which a victim could be experiencing when encountered by professionals. It might be best if the Bill requires that all these factors should be present at the time of identification, namely sexual violence, confinement, forcing drugs on the victim, threats by family members, and mental as well as sexual health related problems, to name just a few. However, these factors could be present in a person who has not been trafficked. Legally speaking, to be defined as a victim of human trafficking a person should have experienced crimes vital in the definition of human trafficking, at least social dislocation, and should be unfamiliar with the environment within which she was or

According to section 1 of the Children's Act (Act 38 of 2005) child trafficking for sexual exploitation means the recruitment, transportation, receipt, harbouring, and transfer of

woman or a girl who is sexually exploited by a member of her family.

as trafficking.

is confined.

**3.3. Child trafficking**

**3.2. Sexual exploitation**

Currently, South Africa does not have the means to distinguish between voluntary and involuntary prostitution. Public hearings are still being conducted by the South African Law Reform Commission to debate a suitable approach to prostitution. The country will have to decide whether to legalize or regulate, continue to criminalize or abolish prostitution.

If they cannot be rescued by the police or are not reported missing by family members, victims of sex trafficking cannot be identified easily (SALRC, 2008). They are often assumed to be just another group of morally depraved girls searching for 'easy money' (Bernat & Zhilina, 2010; Bernat & Winkeler, 2010). During the transportation process, if they are questioned by the authorities, human traffickers falsely identify victims as relatives (Bernat & Zhilina, 2010; Bernat & Winkeler, 2010). Even though they could be offered help by strangers, victims of sexual exploitation find it difficult to just leave their captors. They are consistently threatened with violence or may have been physically assaulted by human traffickers (Delport, Koen & MacKay, 2007; UNICEF, 2003; Van der Watt, 2009).

Although South Africa has made significant progress with regard to the prevention, protection, prosecution and partnerships to respond to human trafficking, there are still a number of ambiguities and gaps in the knowledge of human trafficking in South Africa. Furthermore, the politics of legal reform are hindering the promulgation of the Prevention and Combating of Trafficking in Persons Bill.

## **3. Definition of concepts**

## **3.1. Human trafficking**

The Prevention and Combating of Trafficking in Persons Bill (2009) defines human trafficking to include the recruitment, sale, supply, procurement, transportation, transfer, harbouring, disposal, or receipt of persons or the adoption of a child facilitated or secured through legal or illegal means within and across the borders of the Republic by means of threat, force, intimidation or other forms of coercion, abduction, kidnapping, fraud, deception, debt bondage, abuse of power, or the giving or receiving of payment in order to achieve the consent of the other or by abusing vulnerability for the purpose of exploitation.

There is, however, still some confusion with regard to the definition of human trafficking. Ambiguity arises from the inclusion of the word 'exploitation', with little explanation or an inadequate explanation of what constitutes 'exploitation' (Gould & Fick, 2008). Consequently, it is easy to include any exploitative situation under the umbrella of human trafficking. The broadness of the definition of exploitation could mean that a common sense interpretation of exploitation is used to describe a human trafficking situation (Gould & Fick, 2009). For instance, a holiday visit of a child which turns into exploitation could be seen as human trafficking, instead of as a vulnerable situation that could lead to human trafficking if the child was to be removed under false pretences. Human trafficking has not yet occurred. The child has not yet been recruited, transferred, harboured, deceived or intentionally bought for exploitation, even when the child has been abused sexually, physically and emotionally by the relatives. The act of victimising the child becomes a spontaneous act during the period of stay at the relatives' home, but cannot be prosecuted as trafficking.

## **3.2. Sexual exploitation**

92 Child Abuse and Neglect – A Multidimensional Approach

and Combating of Trafficking in Persons Bill.

**3. Definition of concepts**

**3.1. Human trafficking**

Zhilina, 2010; Bernat & Winkeler, 2010; Molo Songololo, 2005).

cure them of the disease (Dyantyi & Pritz, 2009; Fitzgibbon, 2003; Gould, 2008). The United Nations estimates that 79% of all trafficked victims are moved for the purposes of sexual exploitation (Tshwane Alliance for Street Children, 2009; Tyakume, 2009). Most of these victims are recruited, abducted or kidnapped from socio-economically deprived areas and are then moved to economically developed parts of the country (Bermudez, 2008; Bernat &

Currently, South Africa does not have the means to distinguish between voluntary and involuntary prostitution. Public hearings are still being conducted by the South African Law Reform Commission to debate a suitable approach to prostitution. The country will have to

If they cannot be rescued by the police or are not reported missing by family members, victims of sex trafficking cannot be identified easily (SALRC, 2008). They are often assumed to be just another group of morally depraved girls searching for 'easy money' (Bernat & Zhilina, 2010; Bernat & Winkeler, 2010). During the transportation process, if they are questioned by the authorities, human traffickers falsely identify victims as relatives (Bernat & Zhilina, 2010; Bernat & Winkeler, 2010). Even though they could be offered help by strangers, victims of sexual exploitation find it difficult to just leave their captors. They are consistently threatened with violence or may have been physically assaulted by human

Although South Africa has made significant progress with regard to the prevention, protection, prosecution and partnerships to respond to human trafficking, there are still a number of ambiguities and gaps in the knowledge of human trafficking in South Africa. Furthermore, the politics of legal reform are hindering the promulgation of the Prevention

The Prevention and Combating of Trafficking in Persons Bill (2009) defines human trafficking to include the recruitment, sale, supply, procurement, transportation, transfer, harbouring, disposal, or receipt of persons or the adoption of a child facilitated or secured through legal or illegal means within and across the borders of the Republic by means of threat, force, intimidation or other forms of coercion, abduction, kidnapping, fraud, deception, debt bondage, abuse of power, or the giving or receiving of payment in order to achieve the consent of the other or by abusing vulnerability for the purpose of exploitation.

There is, however, still some confusion with regard to the definition of human trafficking. Ambiguity arises from the inclusion of the word 'exploitation', with little explanation or an inadequate explanation of what constitutes 'exploitation' (Gould & Fick, 2008). Consequently, it is easy to include any exploitative situation under the umbrella of human trafficking. The broadness of the definition of exploitation could mean that a common sense interpretation of exploitation is used to describe a human trafficking situation (Gould &

decide whether to legalize or regulate, continue to criminalize or abolish prostitution.

traffickers (Delport, Koen & MacKay, 2007; UNICEF, 2003; Van der Watt, 2009).

According to the Prevention and Combating of Trafficking in Person Bill (2010), sexual exploitation implies the commission of any sexual offences against the victim of human trafficking.  The various ways in which a person could be misused through sex are forced marriage, sex work, forced pregnancy for the purpose of selling the child, as well as personal gratification. Forced marriage and personal gratification are acts that occur within private homes, and that are often perpetrated towards young women and girls who have not been recruited, transported, sold, supplied, procured through deceit, fraud or debt bondage – the essential components of the South African definition of human trafficking. It seems that a clear distinction between a human trafficking victim and a child who has been forced into a marriage is lacking, as well as between a human trafficking victim and a young woman or a girl who is sexually exploited by a member of her family.

There needs to be legal and social criteria that can be used by social services and criminal justice authorities to identify victims of human trafficking. Currently, the Prevention and Combating of Trafficking in Persons Bill does not provide clear guidelines pertaining to the victims of human trafficking. Sections 11 and 12 refer to professionals that could assist in the identification, referral and reporting of a victim of trafficking, but these sections fail to describe the characteristics of the victim. A list of factors have been presented by SALRC (2008) describing the circumstances within which a victim could be experiencing when encountered by professionals. It might be best if the Bill requires that all these factors should be present at the time of identification, namely sexual violence, confinement, forcing drugs on the victim, threats by family members, and mental as well as sexual health related problems, to name just a few. However, these factors could be present in a person who has not been trafficked. Legally speaking, to be defined as a victim of human trafficking a person should have experienced crimes vital in the definition of human trafficking, at least social dislocation, and should be unfamiliar with the environment within which she was or is confined.

### **3.3. Child trafficking**

According to section 1 of the Children's Act (Act 38 of 2005) child trafficking for sexual exploitation means the recruitment, transportation, receipt, harbouring, and transfer of children through deceit, fraud, abduction and kidnapping for the purpose of sexual exploitation due to a position of vulnerability. In relation to children, section 1 of the Children's Act (Act 38 of 2005) states that commercial sexual exploitation implies the procurement of a child to perform sexual activities for financial or other rewards including acts of prostitution or pornography, irrespective of the person using or receiving the reward. Human Trafficking of Young Women and Girls for Sexual Exploitation in South Africa 95

money from the customer for her own gain. By contrast, involuntary prostitution refers to any sex work that is performed indoors or outdoors where the prostitute works under the supervision and monitoring of another person. The money obtained from selling sex is taken by the monitor or supervisor (pimp). The difference between these two concepts is that a voluntary prostitute exercises agency by deciding on the job, area and type of client to serve, whilst an involuntary prostitute is forced to do the work in a chosen area and to serve

There are three theoretical attributes which can be used to explain human trafficking for the sexual exploitation of young women and girls in South Africa: victim vulnerability, victim precipitation, as well as the victim-criminal relationship (Daems, 2005; Nettlebeck, Wilson, Potter & Perry, 2000). These attributes should be present and stabilise in a victim's life for a long time (Nettlebeck et.al 2000). Victim vulnerability pertains to the presence of factors, contextual and situational, in a victim's life that could make the victim more vulnerable to victimisation (Clark, 2005). It could be the victim's lifestyle; personal characteristics or the amount of time the victim spends or interacts with the offender (UNICEF, 2003; UNODC, 2007). Secondly, a victim's words, actions and behaviour may precipitate the offender's actively and passively victimising her (UNODC, 2007). In the context of human trafficking for sexual exploitation victim precipitation thus occurs when the victim accepts recruitment, travels with a chaperone and allows herself to be transported with or without the documentation required by immigration officials. In addition, the lack of a reasonable solution to socio-economic challenges facing her, the potential victim may seek help from traffickers. Eventually, the time spent by the victim in the company of human traffickers

Victim vulnerability is best explained when a person is surrounded by factors that could result in victimisation. It is attributed to a variety of internal and external factors that are multidimensional, such as their age and lack of maturity, which affects young women and girls more than adults, whilst socio-economic factors create potential victimisation for both children and adults (Clark, 2005). Many young South African women and girls spend a significant amount of free time in entertainment establishments that sell liquor (shebeens, nightclubs and bars), abusing intoxicating substances such as drugs and alcohol, engaging in risky sexual behaviour, as well as participating in criminal activities (Gould, 2005; Gould & Fick, 2008 ). These lifestyles place them within close proximity to human traffickers. Closeness to human traffickers of potential victims may not result in actual victimisation: some young girls do not accept offers from strangers. The contextual situation within which girls entertain themselves, coupled with their immaturity and the absence of a capable guardian, may make it easier for traffickers to recruit them successfully. Eccentric behaviours by a potential victim do not necessarily create vulnerability to victimisation, but poor control of feelings, inadequate social skills and confrontational responses to problematic situations may increase vulnerability to victimisation (Nettlebeck et al 2000).

may provide traffickers with opportunities for the victimisation of girls.

clients preferred by the supervisor or monitor.

**4. Theoretical framework**

## **3.4. Girl**

According to the South African Constitution (108 of 1996), a girl is any female person, daughter, or young woman under the age of 18. This person may still be residing with her parents, in a hostel or heading a household. Girls as young as seven are abducted, kidnapped or misled by traffickers to accept offers that promise to yield financial incentives.  Firstly, young girls are perceived as disease-free and therefore possess the potential to attract more customers/clients/users than older women. The International Labour Organization reports that the high incidence of HIV/Aids infections among young women has propelled users of sex workers to select girls' more than young women. This preference has led to many young South African girls' being recruited, abducted and kidnapped for sexual exploitation (Lutya, 2010a). Some girls have been abducted and kidnapped on their way to school, running an errand for their parents or venturing outside with friends (Lutya, 2010a). Secondly, the desire to own the latest labels and technological gadgets pushes some girls into pursuing their materialistic hopes. If they are offered a job, such girls may accept the job with little or no scrutiny in the hope of generating an income in order to reach this materialistic goal (Lutya, 2010a). It is possible that the need to achieve the patriarchally approved gendered notion of femininity, defined by aesthetics – fancy clothes, make-up, groomed hair and nails – as well as the desire to fit in and receive external confirmation (Russell & Tyler, 2002) may drive some girls to accept dubious jobs from traffickers. Gender and consumption could be ways in which some girls define who they are in relation to boys and society: that means they become feminine through consumer culture, a behaviour society expects of young women and girls (Russell & Tyler, 2002). In essence, any person under the age of 18 is vulnerable to human trafficking in three ways: legally (if the person is financially inadequately equipped to reside independently and in pursuit of financial independence), socially (if the person is in need of social affirmation) and individually (if the person hopes to obtain affirmation of her physical aesthetic attributes).

#### **3.5. Difference between voluntary and involuntary prostitution**

A prostitute is working on a voluntary basis if her decision to perform sex work has not been influenced, forced on her or coerced by anyone. She is working as a prostitute involuntarily if another person has forced, confined and manipulated her to work as a prostitute. In this paper, the term 'voluntary prostitution' pertains to any work that is performed by a prostitute, either indoors or outdoors, where the prostitute obtains the money from the customer for her own gain. By contrast, involuntary prostitution refers to any sex work that is performed indoors or outdoors where the prostitute works under the supervision and monitoring of another person. The money obtained from selling sex is taken by the monitor or supervisor (pimp). The difference between these two concepts is that a voluntary prostitute exercises agency by deciding on the job, area and type of client to serve, whilst an involuntary prostitute is forced to do the work in a chosen area and to serve clients preferred by the supervisor or monitor.


*Article* **Modeling and Experiment of the Critical Depth of Cut at the Ductile–Brittle Transition for a 4H-SiC Single Crystal**

#### **Peng Chai, Shujuan Li \* and Yan Li \***

School of Mechanical and Precision Instrument Engineering, Xi an University of Technology, No. 5 South Jinhua Road, Xi'an 710048, Shaanxi, China<EMAIL_ADDRESS>**\*** Correspondence<EMAIL_ADDRESS>(S.L<EMAIL_ADDRESS>(Y.L.)

Received: 19 April 2019; Accepted: 5 June 2019; Published: 7 June 2019

**Abstract:** In this paper, a theoretical model of the critical depth of cut of nanoscratching on a 4H-SiC single crystal with a Berkovich indenter is proposed, and a series of scratch tests in a nanomechanical test system was performed. Through nanoindentation experimentation on fused quartz, the Berkovich indenter nose radius was indirectly confirmed using least squares. The range of critical depths of cut at the ductile–brittle transition was obtained by SEM observation, and the size of cracks was amplified with increasing scratching depth. The theoretical result of the critical depth of cut at the ductile–brittle transition for a 4H-SiC single crystal is 91.7 nm, which is close to the first obvious pop-in point of the relation curve between tangential force and lateral displacement. Repeated experimental results show good consistency and good agreement with other references.

**Keywords:** 4H-SiC; critical depth of cut; Berkovich indenter; cleavage strength; nanoscratching


**Acknowledgements**

I do acknowledge the technical guidance of my colleagues in the Faculty of Health Sciences of Uganda Martyrs' University. In a special way I appreciate Ms. Scovia Mbabazi, the former Associate Dean and Mr. Mathias Lwenge, the current Associate Dean at the faculty.


**2. Materials and Methods**

### *2.1. Trial Design*

In this case report, a ten-year-old girl with right hemiparesis following ischemic stroke caused by probable primary central nervous system angioitis was enrolled to undergo 10 sessions of RMT with Gloreha Sinfonia.

The aim of this study was to provide an account of the efficacy of RMT using Gloreha Sinfonia in terms of improvements in the range of motion, spasticity, force modulation capability and functionality of the hemiplegic hand in pediatric stroke patients. This paper was organized according to CARE guidelines [20]. Figure 1 presents the timeline.

#### **Figure 1.** Timeline.

#### *2.2. Participant*

A nine-year and eleven-month-old girl on 24 March 2020, who apparently was in a state of full wellbeing, fell to the ground and lost consciousness after feeling a severe headache while she was playing with her brother; then, she had generalized hypertonus, trismus and emission of noises for about 10 min with apparent resolution. When the ambulance arrived, the little girl had regained consciousness and was able to carry out simple orders with her 4 limbs. When she arrived in the Umberto I ER, her speech appeared fluid and there were no evident cranial nerve deficits. Later, the girl complained of headaches again, and she had a reduced ability to move on the right side, deviation of the buccal rim and dysarthria. She underwent brain MRI in urgency, which highlighted "ischemic acute lesion in the left Rolandic area". Her parents reported a history of mild and sporadic headache in the previous days. Transferred for competence to the ER of the Pediatric Hospital Bambino Gesù of Rome, the girl appeared alert, oriented and responsive to verbal stimulus. The right side was compromised, with deviation of the buccal rim and a deficit of tone and strength that was greater in the upper limb than in the lower limb; moreover, she had difficulty in trunk control in sitting positions and had no problems with dysphagia and desaturation. She started low molecular weight heparin, as per the hematological prescription and according to Pediatric Stroke Guidelines [8]. As soon as possible, the child was transferred to the Department of Neurology of the same hospital to complete the investigations planned for this case. During neurological hospitalization, the girl underwent another brain MRI, which confirmed recent ischemic lesions. In particular, they were in the territory of the left Middle Cerebral Artery (MCA) with greater extension compared to the first MRI examination, associated with a reduction in the left Internal Carotid Artery (ICA) caliber and left M1 and Al flow profile irregularities (left MCA and Anterior Cerebral Artery—ACA—arteritis). The baby was subjected to ultrasound of the neck vessels, evaluation and cardiological examinations, immuno-infectious examinations, thrombophilia screening, trace oligoclonal bands and platelet aggregation tests. In consideration of the exclusion of secondary causes and of vasculitis alterations in other parts of the body, the diagnostic suspicion of primary CNS angiitis was conducted, for which, to complete the diagnosis, and further in-depth examinations were carried out according to the national protocol for primary vasculitis [8]. By 27 March 2020 to 4 April 2020, the child had also started treatment with intravenous cortisone. In a short period of time, the child showed an improvement in clinical conditions, in particular in dysarthria and in the ability to make minimal movements with the right lower limbs. Upon discharge from neurology, she was prescribed aspirin, heparin suspension and cortisone scaling. On 4 April 2020, the child was transferred to the Pediatric Neurorehabilitation Department of the same hospital located in Palidoro (near Rome) to begin an intensive neuro-motor rehabilitative treatment. She was admitted to Bambino Gesù Rehab Department from 4 April 2020 to 12 June 2020.

Therefore, after 15 days from the stroke onset, she began intensive rehabilitation treatment consisting of 5 sessions/week of neuro-motor therapy, 2 sessions/week of speech therapy and 1 session/week of occupational therapy. In addition to conventional motor treatments, she performed robotic motor training for the upper limb (Mit Manus). The proposals were recognition activities of different textures, heights and shapes to stimulate the sensitivity of the right upper limb, activate the intrinsic muscles of the hand, and to improve the pronation–supination of the forearm and coordination of the two upper limbs in simple gestures of daily life. At the last MRI examinations on 10 April and 19 May 2020, respectively, there was a reduction in the known ischemic lesions in the left hemisphere and a reduction in the size of ICA, the M1/M2 sections of the MCA and the A1 section of the ACA. Upon discharge, the condition of the child improved overall, reached a moderate static and dynamic control of the trunk and started ambulatory training with the help of an ankle-foot orthosis, but right hemiparesis and dysarthria persisted.

Followed a period of non-in-patient rehabilitation at the Fondazione Santa Lucia in Rome, there she performed a neuro-motor rehabilitative treatment of 180 days, 4 times a week, including speech therapy and occupational therapy as well.

After 180 days of treatment and with respect for the recovery of the right upper limb, the girl was able to perform movements against gravity flexo-extension and abduction– adduction of the shoulder with extended elbow and spinal compensation. In addition, she was able to perform movements against gravity elbow flexo-extension, while hinting at muscle recruitment at the level of the wrist and hand extensor muscles and first finger opponent. However, the girl was able to find strategies to solve practical problems of daily life and involving the right upper limb in base activities.

In January 2021, the child began, in association with the conventional treatment and in progress at the Fondazione Santa Lucia, a treatment with the Gloreha robotic glove for the right upper limb at the Campus Bio-Medico University. The objective of the robotic treatment was to recover the movements of extension of the fingers and wrist and improve hand-wrist bending and manual dexterity movements. The use of Gloreha aimed also at recovering the sensory skills of the hand, improving its muscle tone and functionality. Moreover, the use of non-immersive virtual reality through interactive video games had the objective of stimulating cognitive abilities, such as attention, visual-spatial analysis, working memory and executive functions as well.


**3. Mobile money and digital payments versus financial inclusion**

Payments refer to the various ways to transfer money. Advances in payment technology influence household choice of payment methods [8]. Consequently, it is instructive to review how switching between payment types affects financial inclusion of households and ultimately, their welfare. On the one hand, mobile money enables users of mobile phones to deposit, withdraw, and transfer money without having a bank account. Mobile money services are provided by telecommunication companies in conjunction with commercial banks through a network of licenses agents. Mobile money services provide various services including but not limited to making deposits into a virtual wallet, which can be used to make payments for purchases, receipt of remittances, person-to-person payments, person-to-government payments, making saving as well as borrowing. Mobile money is available to individuals with bank accounts as well as those without bank accounts. The provision of financial services to those without bank accounts has helped to financially include individuals who previously lacked access to bank services in Africa. Conversely, digital payments allow households to pay digitally instead of via traditional means such as cash or cheque. They include the use of credit cards, credit cards, e-wallets, and mobile phones.

The Digital Revolution, which started in the 1980s and is ongoing, refers to the advancement of technology from analog electronic and mechanical devices to the digital technology available today. The digital revolution has enabled more persons and firms to access the internet, mobile phones as well as other digital services, which are automated and are controlled by the customer of the service, for example, as an "app" on a mobile phone or tablet PC. The interesting question from the perspective of the global agenda is how the digital revolution can enable to attainment of the sustainable development goals? One potential answer is digital financial inclusion. Digital financial inclusion involves the deployment of the cost-saving digital means to reach currently financially excluded and underserved populations with a range of formal financial services suited to their needs that are responsibly delivered at a cost affordable to customers and sustainable for providers. Inclusive digital financial services include online accounts, mobile money services, electronic payments, combinations of insurance and credit as well as FinTech applications that reach individuals and firms, which were hitherto excluded. If digital financial inclusion is provided through a well-regulated ecosystem, it has the potential to enable economic growth and launch countries on to a trajectory to the realization of sustainable development goals [9].

Digital finance and financial inclusion have several benefits to financial services users, digital finance providers, governments, and the economy. The digital finance issues presented by Ozili [10] are relevant for the ongoing debate and country-level projects directed at greater financial inclusion via digital finance in developing and emerging economies. Digital finance and financial inclusion have the potential to work better for individuals, businesses as well as governments.

Although financial inclusion has a central role in efforts toward global economic empowerment, financial inclusion has been deemed the soft side of financial services. This is because it has received limited or no attention from regulatory, policy as well as financial perspective. A major segment of world's population that is economically disadvantaged is either financially excluded or financially underserved [11]. Financial inclusion helps low-income households to get access to basic financial services such as savings, credit, and insurance, improving their financial self-control, thereby promoting economic growth, which is crucial for the realization of development. Therefore, financial services not only foster economic development but also reduce poverty and income inequality. The lack of financial inclusion is a root cause of other social ills in low-income regions of the world, for instance, intergenerational poverty,

lack of food security as well as civil unrest. Financial exclusion is an integral part of social exclusion. Therefore, the financially excluded individuals and firms are socially dependent upon their social networks.


**1. Introduction**

The expansion of routine immunization is heralded as a global success story [1], enabling greater survival and improved child health worldwide [2]. Nevertheless, an estimated 25 million children were un- or under-vaccinated in 2021 [3], with many facing compounding barriers in vaccine access, availability, and demand. The ongoing COVID-19 pandemic has contributed to at least some of today's gaps in childhood vaccination [3], with estimates of under-one children without any doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) rising from 10% prevalence in 2019 to 14% in 2021 [3]. Communities with high levels of unvaccinated or "zero-dose children" often face myriad vulnerabilities [4–7], such as residing in highly remote areas or informal settlements in cities [7–9]; being affected by displacement and/or prolonged conflict or unrest [7,8]; longstanding poverty and/or societal neglect [4]; or some constellation of these factors. Subsequently,

**Citation:** Fullman, N.; Correa, G.C.; Ikilezi, G.; Phillips, D.E.; Reynolds, H.W. Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children. *Vaccines* **2023**, *11*, 647. https://doi.org/10.3390/ vaccines11030647

Academic Editors: Ahmad Reza Hosseinpoor, M. Carolina Danovaro, Devaki Nambiar, Aaron Wallace and Hope Johnson

Received: 2 February 2023 Revised: 9 March 2023 Accepted: 10 March 2023 Published: 14 March 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

optimally identifying where and how to better reach zero-dose children will likely require a combination of context-specific strategies and broader investments to address persisting structural challenges.

Over the last few years, a growing body of research has sought to assess characteristics of zero-dose children and their families or households, as well as potential drivers of high zero-dose prevalence at different geographic levels [4–8,10–17]. Past work has found that zero-dose children experience a higher odds of missing or lacking access to other types of primary care services [6,11,12], while their mothers were more likely to have no antenatal care visits and not deliver at a health facility [11,12]. Lower levels of household wealth, educational attainment, and measures of women's empowerment also have been associated with higher levels of zero-dose children [4,10,16,17]. Gender-based inequalities, which span from differential rates of immunization by infant gender and gender-related barriers related to who can seek or provide vaccination services [16,18], emphasize the complex yet crucial role that gender plays in a country and/or community [19]. Prior studies have found ethnic disparities [15], as well as differences by religious affiliation [13,20], among children who have received no doses of DTP, though the exact nature of these relationships varied by country. Quantifying these risk factors and determinants of zero-dose children can provide critical program inputs, spanning from identifying key barriers to service access [7,18] to honing in on what sociocultural forces may be negatively affecting vaccine sentiments and trust [18–20]. However, exclusively focusing on zero-dose risk profiles and factors associated with higher rates of unvaccinated children may miss important lessons around successful approaches to addressing inequalities in childhood immunization. Accordingly, also understanding what has worked to improve childhood vaccination can inform program and policy adaptations tailored for reaching zero-dose children.

Positive outlier, or so-called 'positive deviance', methodologies have been used at the unit or organizational level in healthcare settings [21–23], as well as for more populationlevel contexts [24–28], to generate or strengthen the evidence base around what works to improve key health priorities. While the exact approaches toward this type of research and synthesis vary, they usually espouse a shared premise: knowledge and implementation strategies around achieving success or progress exist from places or contexts where such success or progress have been previously attained [21]. As a result, identifying and then examining what contributes to exceptional performance or progress can offer actionable insights into what policies and practice could be adapted for similar impact elsewhere. For instance, the *Good Health at Low Cost* case studies first in 1985 [26] and then in 2013 [27], sought to synthesize how and why countries or regions achieved substantial advances in several health indicators compared to their peers with similar income and demographic profiles; in 2018, the World Bank took a similar approach for understanding rapid progress on universal health coverage measures and facilitating shared learning opportunities across countries [28]. In 2016, the Global Burden of Disease study developed analyses to compare country-level performance on various health metrics relative to changes in sociodemographic development [29–31]; such findings emphasized that important health program and policy lessons could be learned from countries where achievements exceeded expected levels or trends on the basis of sociodemographic improvements alone. Lastly, the Exemplars in Global Health (EGH) program has sought to synthesize key lessons and strategies used by countries that attained exceptional progress in health—exemplars through mixed-methods research and engagement with partners [32–35]. As highlighted by past and current work on positive outliers, such analyses can foster opportunities for cross-country learning and exchange around successful policy or programmatic approaches for a given health challenge. With more learning agendas and priority-setting around zero-dose children for both national and global initiatives (e.g., Immunization Agenda 2030 [IA2030] [36] and Gavi 5.0 [37]), adopting a positive outlier lens toward country progress in reducing zero-dose children could further inform key immunization program and policy efforts.

With this study, we develop a novel approach for identifying positive outliers in reducing zero-dose children over time. This analysis currently takes a geographic focus, one of many important dimensions of inequality, by comparing patterns in both national and subnational declines in the percentage of under-one children with no doses of DTP (no-DTP) from 2000 to 2019 among 56 low- and lower-middle-income countries (LMICs). Based on this approach, identified 'exemplar' countries or subnational locations that substantially reduced zero-dose children could be targeted for further examination into the policy or program factors behind such gains.

### **2. Materials and Methods**

## *2.1. Data*

We used estimates of DTP1 among children under 1 year of age at the national and second administrative levels from the Institute for Health Metrics and Evaluation (IHME). The methods used to estimate DTP1 at different geospatial resolutions are detailed elsewhere [38]; in brief, DTP1 coverage estimates were derived from georeferenced household surveys and modeled using Bayesian geostatistical methods for 106 countries at the first and second administrative levels from 2000 to 2019. We opted to use these spatially modelled estimates over alternative sources (e.g., administrative data) to maximize both the potential number of countries included and comparability of estimates across locations. We subtracted DTP1 estimates from 100% to reflect the percentage of under-one children with no doses of DTP, or no-DTP prevalence—a commonly used indicator for zero-dose children [10,36].

For this analysis, we focused on 56 LMICs (Table 1). These countries were selected on the following criteria: (1) designation of low- or lower-middle income for fiscal year 2020 by the World Bank [39] or having received support from Gavi, the Vaccine Alliance as of 2018 [40]; (2) availability of both national and subnational no-DTP estimates at the second administrative level from 2000 to 2019; (3) not being classified as a post-transition middle-income country by Gavi and inclusion as part of Gavi's zero-dose segmentation country groups [41]. Supplementary Table S1 includes the full list of initially considered countries and those excluded from the current analysis.

**Table 1.** Included countries for identifying potential exemplars in reducing zero-dose children. \* Gavi-supported indicates that the country received Gavi support as of 2018 or had a dedicated country hub page. \*\* Countries with national and subnational DTP1 estimates (for both first and second administrative units) as modeled by the Institute for Health Metrics and Evaluation. Supplementary Table S1 provides the list of initial countries considered but excluded due to not meeting inclusion criteria.

#### **Table 1.** *Cont.*

**Table 1.** *Cont.*


**Acknowledgements**

We wish to thank NIMPE and Phu Yen Provincial Health leadership and staff for planning executing the work described in Vietnam (especially Professor Duong Thanh Tran, Dung Viet Dang and Thinh Duc Ngo). Drs. Nam Dinh Nguyen, Tuong Trinh Dinh, Global Fund, Hanoi, Vietnam provided technical support, data analysis and illustration preparation. Dr. Hung Pham, Consortium for Health Action, Savage, MN, USA and Hanoi, Vietnam provided project leadership and coordination. Dr. Gerard Kelly, Research School of Population Health, Canberra, Australia for geographic information system (GIS) planning and support. We also would like to thank Michael MacDonald for critical review of this chapter. We thank Ms. Tuyen Pham for providing illustration editing for this chapter. This work was supported in part by funding from the US Department of Defense. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of Defense, nor the US or Vietnamese Government. Much of this work was inspired by the late Alan Magill (former Director of Malaria, Bill & Melinda Gates Foundation).