Project – Evaluation of Primary Healthcare Service Delivery and Its Effect on Routine Immunization Coverage Among Children Under Five Years in Selected Local Government Areas of Northern Nigeria
CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
Primary healthcare (PHC) is widely recognized as the foundation of an effective and equitable health system because it provides the first level of contact between individuals, families, communities, and healthcare providers. The Alma-Ata Declaration of 1978 emphasized that primary healthcare should be accessible, community-oriented, affordable, and based on active participation of individuals and communities in health decision-making (World Health Organization [WHO], 1978). In recent years, global health policy has continued to emphasize the strengthening of PHC systems as a pathway toward achieving universal health coverage, improving population health outcomes, and reducing inequalities in access to essential health services (WHO & UNICEF, 2018). A strong PHC system provides preventive, promotive, and curative services, including maternal and child healthcare, disease prevention, health education, and routine immunization.
Routine immunization is one of the most successful and cost-effective public health interventions for reducing childhood morbidity and mortality. Vaccines protect children against several infectious diseases, including measles, poliomyelitis, tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, and other vaccine-preventable diseases (WHO, 2023). Globally, immunization programmes have contributed significantly to increased child survival, preventing millions of deaths annually and reducing the burden of infectious diseases (Gavi, the Vaccine Alliance, 2021). However, despite remarkable global progress, millions of children, particularly those living in low- and middle-income countries, remain incompletely vaccinated or completely unvaccinated due to barriers related to health system weaknesses, socioeconomic conditions, geographical accessibility, and caregiver perceptions (Sato, 2019; UNICEF, 2023).
In developing countries, especially those in sub-Saharan Africa, the effectiveness of routine immunization programmes depends largely on the capacity and performance of primary healthcare systems. PHC facilities serve as the main delivery points for childhood vaccination services by providing vaccine administration, caregiver education, immunization monitoring, community mobilization, and follow-up of children who miss scheduled vaccines (Oleribe et al., 2019). Therefore, deficiencies in PHC service delivery can directly affect immunization outcomes by limiting access, reducing service reliability, and weakening community confidence in vaccination programmes.
Nigeria continues to experience significant challenges in achieving optimal routine immunization coverage despite being one of the countries with extensive immunization programmes in Africa. The country introduced the Expanded Programme on Immunization (EPI) in 1978 and later strengthened immunization activities through the establishment of the National Primary Health Care Development Agency (NPHCDA). These initiatives have improved vaccine availability and programme coordination; however, childhood immunization coverage remains uneven across regions, with Northern Nigeria recording some of the lowest vaccination indicators (National Bureau of Statistics [NBS] & UNICEF, 2022).
According to the Nigeria Multiple Indicator Cluster Survey/National Immunization Coverage Survey (MICS/NICS), many Nigerian children still fail to receive all recommended routine vaccines, and a considerable proportion of children remain zero-dose children who have received no basic vaccines at all (NBS & UNICEF, 2022). These gaps demonstrate that vaccine availability alone is insufficient to guarantee immunization success. Rather, effective immunization requires a functional PHC system capable of delivering accessible, acceptable, and high-quality health services.
Northern Nigeria faces unique challenges that affect PHC performance and childhood immunization coverage. Several studies have identified socioeconomic disadvantage, poverty, low maternal education, cultural beliefs, insecurity, inadequate health infrastructure, shortage of healthcare workers, and geographical barriers as important factors influencing healthcare utilization and vaccination uptake in the region (Antai, 2019; Babalola, 2021). Many rural communities in Northern Nigeria are characterized by dispersed settlements and limited access to healthcare facilities, making routine contact with PHC services difficult for caregivers and children.
The quality of primary healthcare service delivery is a major determinant of immunization coverage. Effective PHC services require adequate healthcare workers, functional infrastructure, reliable vaccine supply chains, effective cold-chain systems, community outreach activities, and good communication between healthcare providers and caregivers (WHO, 2020). Where these components are weak, immunization services may become irregular, resulting in missed vaccination opportunities and incomplete immunization among children.
Healthcare worker availability and performance are particularly important in routine immunization programmes. Healthcare workers are responsible for administering vaccines, educating caregivers, maintaining immunization records, identifying missed children, and conducting community mobilization activities. However, shortages of trained personnel, inadequate motivation, and excessive workload have been reported as challenges affecting PHC service delivery in Nigeria (Oleribe et al., 2019). Inadequate staffing may reduce the frequency of immunization sessions and limit the ability of health facilities to conduct outreach services.
Accessibility of PHC facilities also influences childhood vaccination behaviour. Families living far from health centres may experience transportation difficulties, financial costs, and time constraints that discourage regular utilization of immunization services. Studies have shown that distance to healthcare facilities is significantly associated with childhood vaccination status, with children living farther from health facilities being less likely to complete recommended immunization schedules (Sato, 2019). Consequently, strengthening outreach services and community-based approaches remains essential for reaching children in hard-to-access communities.
Another important factor affecting immunization coverage is the quality of interaction between healthcare providers and caregivers. Vaccine acceptance is influenced by trust, communication, respect, and caregivers’ understanding of immunization benefits. Poor communication, negative experiences at health facilities, misinformation, and inadequate health education may contribute to vaccine hesitancy and incomplete vaccination (Larson et al., 2018). Therefore, PHC service delivery must incorporate effective health education and community engagement alongside vaccine provision.
The Nigerian government has implemented several initiatives aimed at strengthening PHC services, including the Basic Health Care Provision Fund (BHCPF), PHC revitalization programmes, and immunization improvement strategies. These interventions seek to improve healthcare financing, increase access to essential services, and strengthen service delivery at the community level (Federal Ministry of Health [FMoH], 2019). Nevertheless, challenges remain regarding implementation effectiveness, accountability, human resource availability, and equitable distribution of resources across Local Government Areas.
Local Government Areas represent important operational units for PHC implementation in Nigeria. The performance of PHC facilities at the LGA level directly influences the availability, accessibility, and quality of immunization services delivered to communities. Differences in PHC infrastructure, staffing, management practices, and community participation may explain variations in immunization coverage among different areas.
Although previous studies have examined determinants of childhood immunization in Nigeria, many have focused primarily on caregiver characteristics such as maternal education, socioeconomic status, and cultural beliefs. Limited attention has been given to evaluating how the broader PHC service delivery environment affects routine immunization coverage, especially among children under five years in selected Local Government Areas of Northern Nigeria. Understanding this relationship is important for developing interventions that address health system weaknesses rather than focusing only on individual behavioural factors.
Therefore, this study seeks to evaluate primary healthcare service delivery and its effect on routine immunization coverage among children under five years in selected Local Government Areas of Northern Nigeria. The study will assess key PHC service delivery components, including healthcare accessibility, availability of health workers, quality of immunization services, outreach activities, and facility readiness, and determine their influence on routine childhood immunization coverage.
1.2 Statement of the Problem
Routine immunization remains one of the most effective strategies for preventing childhood morbidity and mortality; however, Nigeria continues to experience significant challenges in achieving adequate immunization coverage among children under five years. Despite decades of government commitment, international support, and the availability of vaccines through the Expanded Programme on Immunization (EPI), many Nigerian children still fail to receive the complete schedule of recommended childhood vaccines (National Bureau of Statistics [NBS] & UNICEF, 2022). The persistence of low immunization coverage suggests that the challenge is not only related to vaccine availability but also reflects weaknesses in healthcare delivery systems, particularly at the primary healthcare level where most routine immunization services are provided.
Primary healthcare facilities are expected to serve as the foundation for childhood immunization delivery by ensuring accessibility, vaccine availability, caregiver education, disease prevention, community mobilization, and monitoring of immunization outcomes. However, many primary healthcare centres in Nigeria face persistent challenges, including inadequate infrastructure, insufficient healthcare personnel, irregular vaccine supply, weak cold-chain systems, limited outreach activities, and poor community engagement (Oleribe et al., 2019). These challenges reduce the ability of PHC facilities to provide consistent and reliable immunization services, particularly in rural and underserved communities.
Northern Nigeria continues to record some of the lowest childhood immunization indicators in the country. Several studies have linked poor immunization outcomes in the region to multiple interacting factors, including poverty, low maternal education, cultural perceptions, religious concerns, insecurity, limited access to health facilities, and inadequate health system capacity (Antai, 2019; Babalola, 2021). Many rural communities in Northern Nigeria are characterized by geographical barriers, dispersed settlements, and limited transportation options, which make access to routine healthcare services difficult for caregivers and children.
One major concern is the limited accessibility and utilization of primary healthcare services. Although PHC facilities exist across many Local Government Areas, their physical availability does not always translate into effective service utilization. Some communities experience long distances to healthcare facilities, irregular immunization sessions, inadequate healthcare worker presence, and poor communication regarding vaccination schedules. These factors may result in missed opportunities for vaccination and contribute to incomplete immunization among children under five years (Sato, 2019).
Another significant problem is the inadequate availability and distribution of healthcare workers. Effective immunization programmes depend on skilled and motivated health personnel who can administer vaccines, maintain accurate records, provide health education, and conduct community outreach activities. However, shortages of healthcare workers, particularly in rural PHC facilities, continue to affect the quality and continuity of immunization services in Nigeria (Oleribe et al., 2019). Where healthcare workers are insufficient or overburdened, immunization sessions may become irregular, reducing caregiver confidence and participation.
Furthermore, weaknesses in PHC infrastructure and logistics remain major barriers to effective immunization coverage. Routine immunization requires functional cold-chain equipment, reliable electricity, vaccine storage systems, essential supplies, and proper record management. Inadequate infrastructure can lead to vaccine wastage, service interruptions, and reduced community trust in healthcare facilities (WHO, 2020). Although programmes such as the Basic Health Care Provision Fund (BHCPF) and PHC revitalization initiatives have attempted to address these challenges, variations in implementation continue to affect service quality across different Local Government Areas (Federal Ministry of Health [FMoH], 2019).
Community engagement and health communication also represent critical gaps affecting immunization uptake. Many caregivers require continuous information regarding the importance of vaccination, vaccine schedules, and the dangers of vaccine-preventable diseases. Where PHC facilities have limited community outreach programmes, caregivers may lack adequate knowledge or motivation to complete immunization schedules. Evidence suggests that effective communication between healthcare providers and communities improves vaccine confidence and reduces hesitancy (Larson et al., 2018).
Despite the recognized importance of PHC in improving immunization outcomes, limited empirical evidence exists regarding the extent to which specific components of PHC service delivery influence routine immunization coverage among children under five years in selected Local Government Areas of Northern Nigeria. Existing studies have largely focused on individual-level factors such as maternal education, household characteristics, and vaccine attitudes, while giving less attention to health system factors including service accessibility, facility readiness, staffing levels, outreach activities, and quality of immunization services.
This gap in knowledge creates difficulties for policymakers, healthcare managers, and development partners attempting to design effective strategies for improving childhood vaccination coverage. Without adequate understanding of how PHC service delivery affects immunization outcomes, interventions may continue to address symptoms rather than underlying health system challenges.
Therefore, the problem of this study is the persistent inadequate routine immunization coverage among children under five years in Northern Nigeria despite continued investment in primary healthcare services and immunization programmes. This study seeks to evaluate primary healthcare service delivery and determine its effect on routine immunization coverage among children under five years in selected Local Government Areas of Northern Nigeria.
1.3 Aim of the Study
The main aim of this study is to evaluate primary healthcare service delivery and determine its effect on routine immunization coverage among children under five years in selected Local Government Areas of Northern Nigeria.
1.4 Objectives of the Study
The specific objectives of the study are to:
- Assess the level of primary healthcare service delivery in selected Local Government Areas of Northern Nigeria.
- Examine the availability and adequacy of healthcare resources, including healthcare workers, infrastructure, vaccine supply, and equipment in primary healthcare facilities.
- Determine the level of routine immunization coverage among children under five years in selected Local Government Areas.
- Examine the relationship between primary healthcare service delivery and routine immunization coverage among children under five years.
- Identify the challenges affecting effective primary healthcare service delivery for routine immunization programmes.
1.5 Research Questions
The study will answer the following research questions:
- What is the level of primary healthcare service delivery in selected Local Government Areas of Northern Nigeria?
- To what extent are healthcare resources such as personnel, infrastructure, vaccines, and equipment available in primary healthcare facilities?
- What is the level of routine immunization coverage among children under five years in the selected Local Government Areas?
- What relationship exists between primary healthcare service delivery and routine immunization coverage among children under five years?
- What challenges affect effective primary healthcare service delivery for routine immunization programmes?
1.6 Research Hypothesis
The following null hypothesis will be tested at 0.05 level of significance:
H₀: There is no significant relationship between primary healthcare service delivery and routine immunization coverage among children under five years in selected Local Government Areas of Northern Nigeria.
1.7 Significance of the Study
The study is significant because it provides evidence on the relationship between primary healthcare service delivery and childhood immunization outcomes. The findings will be useful to government agencies, healthcare providers, researchers, and community stakeholders involved in improving child health services.
Government and Health Policy Makers
The findings will assist policymakers at federal, state, and local government levels in understanding how PHC service delivery factors influence immunization coverage. The evidence generated may guide decisions concerning PHC strengthening, healthcare financing, workforce planning, vaccine logistics, and immunization policies. The study will support efforts aimed at achieving universal health coverage and improving child survival outcomes.
Primary Healthcare Administrators and Health Workers
The study will provide useful information to PHC managers and healthcare workers regarding areas requiring improvement in immunization service delivery. Understanding the influence of staffing, accessibility, infrastructure, and community engagement will help healthcare providers develop more effective strategies for reaching children who are not fully immunized.
Local Government Health Authorities
Since Local Government Areas are responsible for implementing many PHC activities, the findings will assist local health authorities in identifying service delivery gaps and developing targeted interventions to improve routine immunization performance within their jurisdictions.
Parents and Caregivers
The study will indirectly benefit caregivers by promoting improved immunization services, increased awareness, and better access to vaccination opportunities. Improved PHC performance can increase caregiver confidence and encourage timely completion of childhood vaccination schedules.
Researchers and Academic Institutions
The study will contribute to existing literature on primary healthcare systems and immunization coverage in Nigeria. It will serve as a reference source for students, researchers, and scholars interested in public health, epidemiology, healthcare management, and child health interventions.
1.8 Scope of the Study
This study focuses on the evaluation of primary healthcare service delivery and its effect on routine immunization coverage among children under five years in selected Local Government Areas of Northern Nigeria.
The study is designed to examine the extent to which primary healthcare service delivery influences childhood immunization outcomes. It specifically focuses on key components of PHC service delivery, including availability of healthcare personnel, accessibility of PHC facilities, availability of vaccines and immunization equipment, quality of immunization services, healthcare worker performance, outreach activities, community mobilization, and caregiver health education.
The study population comprises healthcare workers involved in routine immunization services and caregivers of children under five years attending selected primary healthcare facilities in the selected Local Government Areas. The study will assess caregivers’ experiences with PHC services, their children’s immunization status, and factors influencing completion of routine immunization schedules.
Geographically, the study is restricted to selected Local Government Areas in Northern Nigeria. The choice of Northern Nigeria is based on the continued challenges associated with childhood immunization coverage in the region, where health system limitations, socioeconomic inequalities, and access barriers contribute to poor vaccination outcomes (NBS & UNICEF, 2022).
The study is limited to routine childhood immunization services provided through primary healthcare facilities. It does not cover vaccination programmes targeting adolescents, adults, emergency vaccination campaigns, or special outbreak response immunization activities.
Conceptually, the study is limited to examining the relationship between the independent variable (primary healthcare service delivery) and the dependent variable (routine immunization coverage among children under five years). Primary healthcare service delivery is assessed through indicators such as healthcare accessibility, availability of healthcare workers, facility readiness, vaccine availability, outreach services, and quality of healthcare interactions, while immunization coverage is assessed through vaccination completion status and receipt of recommended childhood vaccines.
1.9 Limitations of the Study
Although adequate measures will be taken to ensure the reliability and validity of the findings, the study may experience certain limitations.
First, the study may be affected by recall bias among caregivers. Some caregivers may have difficulty accurately remembering vaccination dates, missed appointments, or specific healthcare experiences, particularly when immunization records are unavailable. To reduce this limitation, respondents will be encouraged to provide information using available child immunization cards where possible.
Second, the study may encounter geographical accessibility challenges due to the rural nature of some selected communities in Northern Nigeria. Poor road networks, transportation difficulties, and distance between communities may affect the ease of reaching some respondents and healthcare facilities.
Third, the study may be influenced by social desirability bias, where healthcare workers or caregivers provide responses they believe are socially acceptable rather than their actual experiences or practices. Confidentiality and anonymity will therefore be emphasized during data collection to encourage honest responses.
Fourth, variations in healthcare resources, administrative practices, and community characteristics across different Local Government Areas may limit the extent to which findings can be generalized to all areas of Northern Nigeria.
Finally, the cross-sectional nature of the study may limit the ability to establish long-term causal relationships between PHC service delivery and immunization coverage. However, the study will provide valuable evidence regarding associations between healthcare delivery factors and childhood vaccination outcomes.
1.10 Operational Definition of Terms
Primary Healthcare (PHC)
Primary healthcare refers to essential healthcare services that are accessible to individuals and communities through their first contact with the health system. In this study, PHC refers specifically to community-based healthcare facilities responsible for providing preventive, promotive, and basic curative services, including routine childhood immunization.
Primary Healthcare Service Delivery
This refers to the processes and activities through which PHC facilities provide healthcare services to communities. In this study, it includes healthcare accessibility, availability of health workers, vaccine supply, facility infrastructure, outreach services, health education, and quality of immunization services.
Routine Immunization
Routine immunization refers to the regular administration of recommended vaccines to children according to the national immunization schedule without being part of emergency vaccination campaigns or outbreak response activities.
Immunization Coverage
Immunization coverage refers to the proportion of eligible children who receive recommended vaccines within a specified population and period. In this study, it refers to the percentage of under-five children who have received appropriate routine vaccines according to the national immunization schedule.
Under-Five Children
Under-five children refer to children who are below five years of age and are eligible to receive routine childhood immunization services.
Vaccine-Preventable Diseases
These are infectious diseases that can be prevented through vaccination, including measles, tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, and hepatitis B.
Healthcare Workers
Healthcare workers refer to trained personnel involved in providing healthcare services at primary healthcare facilities. In this study, they include nurses, community health extension workers (CHEWs), environmental health officers, and other personnel involved in immunization activities.
Healthcare Accessibility
Healthcare accessibility refers to the ease with which individuals can obtain healthcare services. In this study, it includes geographical distance, transportation availability, service availability, and affordability of accessing PHC immunization services.
Healthcare Facility Readiness
Healthcare facility readiness refers to the ability of a PHC facility to provide effective immunization services based on availability of essential infrastructure, equipment, vaccines, cold-chain systems, and trained personnel.
Immunization Uptake
Immunization uptake refers to the acceptance and utilization of vaccination services by caregivers for their children. It includes initiation and completion of recommended vaccine doses.
Community Outreach Services
Community outreach services refer to immunization activities conducted outside healthcare facilities to reach populations who may experience barriers accessing routine PHC services. These include mobile vaccination sessions, household mobilization, and community awareness programmes.
Project – Evaluation of Primary Healthcare Service Delivery and Its Effect on Routine Immunization Coverage Among Children Under Five Years in Selected Local Government Areas of Northern Nigeria
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