Project – Assessment of Health-System Barriers to Routine Childhood Immunization and Their Implications for Vaccine Coverage Among Under-Five Children in Selected Primary Health Centres in Okene LGA

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Routine childhood immunization is one of the most important and cost-effective public health interventions for preventing childhood morbidity, disability and mortality from vaccine-preventable diseases. Vaccination protects children against infectious diseases by stimulating the development of specific immunity before exposure to the disease-causing organisms. Childhood vaccines have contributed substantially to reductions in deaths and complications associated with diseases such as measles, poliomyelitis, diphtheria, pertussis, tetanus, tuberculosis and hepatitis B. However, the public health benefits of immunization depend on the ability of health systems to make vaccines continuously available, accessible and acceptable to the populations that need them.

The effectiveness of routine immunization is therefore closely related to the strength and functionality of the health system through which vaccines are delivered. Immunization is not simply the physical administration of a vaccine; it involves a chain of interconnected activities, including vaccine forecasting and procurement, financing, storage, transportation, cold-chain maintenance, distribution, trained personnel, service delivery, supervision, monitoring, recording and community mobilization. A weakness at any point in this chain can reduce the ability of health facilities to provide vaccination services consistently and can ultimately affect vaccine coverage.

Globally, immunization programmes have made substantial progress, but inequities in vaccination coverage remain a major public health concern. Children living in disadvantaged communities are more likely to miss routine vaccinations because of socioeconomic difficulties, geographical barriers, weak health systems and limited access to quality healthcare services. In Nigeria, these challenges are particularly important because the country has historically experienced low and uneven routine immunization coverage. Adeloye et al. (2017), in a systematic review and meta-analysis, found substantial geographical and socioeconomic variations in childhood immunization coverage in Nigeria and identified several individual and contextual factors associated with vaccination uptake.

Nigeria’s immunization programme has evolved considerably since the introduction of the Expanded Programme on Immunization in 1978. The programme was subsequently integrated into the country’s primary healthcare system, with routine childhood vaccination becoming an important component of services provided at primary healthcare facilities. Nevertheless, the existence of a national immunization programme has not eliminated disparities in coverage. Ogunniyi (2024) reported that Nigeria continued to experience major challenges in routine immunization, including weaknesses in programme implementation and low national coverage.

The health-system environment in which routine immunization services are delivered is particularly important. Health facilities require adequate numbers of trained health workers to conduct vaccination sessions, maintain records, educate caregivers, manage vaccines and monitor children who fail to return for subsequent doses. Shortages of personnel may result in reduced service hours, overcrowding, long waiting times and inadequate opportunities for caregiver education. Eboreime, Abimbola and Bozzani (2015) found that human resources and commodities at routine immunization service delivery points in Nigeria were generally insufficient, emphasizing the importance of adequate health-system resources for effective immunization services.

The availability of vaccines and other commodities is another critical component of the immunization system. Vaccines are biological products that require appropriate storage and temperature control throughout the supply chain. Interruptions in vaccine supply, inadequate cold-chain equipment or failures in vaccine distribution can prevent health facilities from providing scheduled vaccination services. When caregivers repeatedly visit a facility and vaccines are unavailable, they may postpone vaccination, lose confidence in the service or fail to return altogether.

Health-system accountability also plays an important role in determining immunization performance. Erchick et al. (2017), examining Nigeria’s routine immunization system from the perspectives of officials at national, state, local government and health-facility levels, identified challenges involving vaccine availability, financing, logistics, human resources and data management. The researchers also reported delays in funding, inadequate supervision, unclear responsibilities and limited decision-making authority at lower levels of the system. These findings demonstrate that poor immunization performance can result from structural and organizational weaknesses rather than caregiver behaviour alone.

Financing is another important health-system determinant. Routine immunization requires financial resources for vaccine transportation, cold-chain maintenance, outreach activities, supervision, health-worker training, community mobilization and data management. Delays or inadequacies in financing can therefore disrupt activities at the facility level. Erchick et al. (2017) identified delayed funding and unclear accountability as important barriers to effective routine immunization service delivery in Nigeria.

The physical accessibility of health facilities also influences vaccination coverage. A facility may offer routine immunization, but if it is located far from communities, poorly connected by transportation or difficult to reach because of financial constraints, caregivers may not be able to utilize the service consistently. Eboreime et al. (2015) demonstrated that supply-side differences, including the distribution of vaccination service delivery points, are relevant to access to routine immunization in Nigeria.

In addition to fixed health facilities, outreach and mobile vaccination services can help overcome geographical barriers. Outreach services are particularly useful for communities where households are located far from primary health centres. However, outreach activities require adequate personnel, transportation, vaccines, fuel, cold-chain capacity, planning and funding. When these resources are unavailable, communities that depend on outreach services may experience reduced access to routine immunization.

The organization of immunization sessions can also influence coverage. Caregivers may be unable to attend facilities if vaccination sessions are scheduled on inconvenient days or at times that conflict with work and household responsibilities. Long waiting times may further discourage attendance. These challenges can contribute to missed opportunities for vaccination, particularly among caregivers who depend on daily income or have several children to care for.

Health workers constitute an essential link between the health system and caregivers. Their knowledge, communication skills, attitudes and workload can influence the quality of immunization services. Health workers are responsible not only for administering vaccines but also for explaining vaccine benefits, informing caregivers about possible minor reactions, identifying children who have missed doses and encouraging caregivers to return for subsequent appointments. Poor communication or unfriendly interactions can weaken caregivers’ trust in health services.

Community engagement is another health-system function that can influence immunization coverage. Immunization programmes require cooperation from community leaders, religious leaders, women’s groups and other influential community structures. Community mobilization can improve awareness of vaccination schedules and encourage caregivers to use available services. The 2024 scoping review by Mohammed et al. found that health literacy, maternal education and community-leader influence were among important facilitators of immunization in Nigeria, while logistical, socioeconomic, cultural and systemic healthcare deficiencies were identified as barriers.

The health system must also have effective mechanisms for identifying children who miss vaccination appointments. Accurate recording and reporting allow health workers to determine which children have received particular vaccines and which children have dropped out of the immunization schedule. Weak data systems can make it difficult for facilities to identify defaulters and plan appropriate follow-up interventions. Erchick et al. (2017) specifically identified data management as one of the components of Nigeria’s routine immunization system affected by accountability challenges.

The relationship between health-system performance and vaccination coverage is evident from research conducted in different parts of Nigeria. Gunnala et al. (2016), using district-level cluster surveys across northern Nigeria, demonstrated substantial variation in routine vaccination coverage between districts. Their findings highlighted the importance of operational-level information for identifying areas requiring immunization programme improvement.

Health-system barriers can also interact with caregiver-level barriers. For example, a caregiver who is already uncertain about vaccination may become even less willing to return after experiencing vaccine stock-outs or prolonged waiting periods. Conversely, reliable service delivery can reinforce caregivers’ confidence and encourage continued use of immunization services. Thus, vaccine uptake is shaped by the interaction between demand-side and supply-side factors.

Evidence from Lagos and other parts of Nigeria shows that interventions directed at the health-system level can improve immunization completion. Brown et al. (2016), in a randomized controlled trial conducted in primary healthcare centres in Ibadan, evaluated cellphone reminder/recall and health-provider training interventions. The study found substantially higher immunization completion among children whose caregivers received cellphone reminders compared with the control group, demonstrating the potential value of organized follow-up systems within primary healthcare.

Similarly, the evaluation of a multi-partner intervention across six northern Nigerian states by Dougherty et al. (2024) demonstrates that coordinated interventions can strengthen routine immunization performance. The study highlights the importance of partnerships and system-level approaches to improving routine vaccination coverage in areas with persistent immunization challenges.

Recent evidence further emphasizes that health-system barriers in Nigeria are multidimensional. Mohammed et al. (2024), in a scoping review of barriers and facilitators to routine immunization in Nigeria, identified systemic healthcare deficiencies alongside logistical, socioeconomic and cultural barriers. Importantly, the review found regional differences in the factors affecting immunization, indicating that interventions should be adapted to local circumstances rather than applying one uniform strategy nationwide.

The implications of health-system barriers are considerable because low vaccine coverage leaves children vulnerable to vaccine-preventable diseases. When vaccination services are interrupted, inaccessible or unreliable, children may miss opportunities to receive vaccines within the recommended period. This can lead to incomplete immunization, delayed protection and accumulation of susceptible children within communities.

The issue is particularly important for children under five because this age group is the primary target of routine childhood immunization programmes. Vaccines administered during infancy and early childhood are intended to provide protection during a period when children may be especially vulnerable to severe infectious diseases. Consequently, failures in routine immunization services can have immediate consequences for child health.

The distinction between vaccination coverage and effective immunization service delivery is also important. A health facility may report that vaccines are being administered, while some children in its catchment population remain unvaccinated because they cannot consistently access the service. Assessment of health-system barriers therefore requires consideration of what happens within the facility as well as how services reach the surrounding community.

Okene Local Government Area in Kogi State provides an important setting for examining these issues. As in many Nigerian communities, primary health centres represent an important point of contact between households and the formal healthcare system. The effectiveness of routine immunization within these facilities depends on adequate staffing, vaccine availability, cold-chain functionality, financing, service organization, supervision, record keeping and community engagement.

Assessing health-system barriers at the level of selected primary health centres is therefore valuable because facility-level weaknesses may be hidden by broader national or state-level vaccination statistics. For example, aggregate coverage figures may not reveal whether a particular facility experiences frequent vaccine stock-outs, inadequate staffing, irregular outreach services, poor cold-chain functionality or insufficient supervision.

There is consequently a need for empirical research that examines the specific health-system barriers affecting routine childhood immunization in selected primary health centres in Okene LGA. Understanding these barriers can help distinguish between problems related to vaccine demand and problems resulting from the organization and delivery of immunization services.

The present study therefore focuses on the assessment of health-system barriers to routine childhood immunization and their implications for vaccine coverage among under-five children in selected primary health centres in Okene LGA. The study will examine factors such as availability of vaccines and commodities, staffing, cold-chain facilities, accessibility, financing, health-worker practices, service organization, supervision, record keeping and outreach activities. The findings are expected to provide evidence that can support improvements in routine immunization service delivery and contribute to higher vaccination coverage among children under five.

1.2 Statement of the Problem

Routine childhood immunization remains one of the most effective interventions for preventing vaccine-preventable diseases among children under five. However, the availability of vaccines does not necessarily guarantee that children receive them. Effective vaccination requires a functional health system capable of ensuring continuous vaccine availability, adequate staffing, reliable cold-chain systems, accessible service points, appropriate financing, effective supervision and proper monitoring.

Nigeria continues to experience challenges in achieving uniformly high routine immunization coverage. Adeloye et al. (2017) identified considerable variation in childhood immunization coverage across Nigeria and reported multiple determinants associated with vaccination uptake. More recent evidence continues to demonstrate persistent weaknesses in Nigeria’s routine immunization programme. Ogunniyi (2024) reported that national routine immunization coverage remained inadequate and identified several programme-level challenges affecting immunization performance.

A major problem is the inadequate availability of essential health-system resources. Routine immunization requires sufficient vaccines, syringes and safety boxes, functional cold-chain equipment, transportation and trained health workers. Eboreime et al. (2015) found that human resources and commodities at routine immunization delivery points in Nigeria were generally insufficient. Such shortages can cause cancelled sessions, delayed vaccination and missed opportunities for children to receive recommended vaccines.

Vaccine stock-outs represent another important concern. When caregivers arrive at a health facility and discover that the required vaccine is unavailable, they may be asked to return on another day. Repeated unsuccessful visits can impose additional transportation and opportunity costs on families and may eventually discourage caregivers from returning. Thus, vaccine availability is directly connected with the reliability and credibility of routine immunization services.

Human-resource shortages can similarly affect vaccination coverage. Where health facilities have too few trained immunization personnel, health workers may be overwhelmed by large numbers of clients and other primary healthcare responsibilities. This may reduce the amount of time available for vaccination, counselling, record keeping, defaulter tracing and community outreach.

Weak supervision and accountability can further reduce health-system performance. Erchick et al. (2017) reported accountability problems involving vaccine availability, financing, logistics, human resources and data management in Nigeria’s routine immunization system. They also identified delayed funding, insufficient supervision and unclear roles among different levels of government as important challenges.

Poor data management presents another problem because health facilities need accurate records to monitor vaccination performance. Without reliable records, health workers may be unable to identify children who have missed doses, determine dropout rates or accurately estimate the number of children requiring vaccination. Consequently, weaknesses in data management can affect both service planning and the measurement of vaccine coverage.

Geographical and financial accessibility may also affect coverage. Even when vaccination services are technically available, caregivers may not use them if health facilities are too far away or transportation is expensive. The distribution of service delivery points and availability of resources therefore remain important components of routine immunization performance (Eboreime et al., 2015).

Another problem is the organization of vaccination services. Inconvenient clinic schedules, long waiting times and irregular outreach sessions can make it difficult for caregivers to obtain vaccines when required. These service-delivery barriers may be particularly problematic for caregivers who have employment, trading, farming or household responsibilities.

The consequences of these health-system weaknesses extend beyond individual children. Low vaccination coverage creates a larger population of susceptible children and increases the possibility of outbreaks of vaccine-preventable diseases. Mohammed et al. (2024) emphasized that systemic healthcare deficiencies, logistical challenges and socioeconomic factors continue to affect routine immunization in Nigeria and that regional differences require context-specific interventions.

Despite the importance of health-system factors, there is insufficient localized evidence on the specific barriers affecting routine childhood immunization at primary health-centre level in Okene LGA. National and state-level statistics can indicate the overall level of vaccination coverage but may not reveal facility-specific problems such as vaccine stock-outs, inadequate staffing, cold-chain failures, poor supervision, irregular outreach or inadequate record keeping.

Without adequate information about these barriers, interventions may focus disproportionately on caregivers and communities while insufficient attention is given to supply-side weaknesses. This could limit the effectiveness of immunization improvement programmes because caregivers cannot receive vaccines that are unavailable or services that are inaccessible.

The problem, therefore, is that health-system barriers may be contributing to inadequate routine childhood immunization coverage among under-five children in Okene LGA, but the extent and nature of these barriers at selected primary health centres are not sufficiently documented. It is therefore necessary to examine the health-system factors affecting immunization service delivery and determine their implications for vaccine coverage.

Consequently, this study will assess health-system barriers to routine childhood immunization and examine their implications for vaccine coverage among under-five children in selected primary health centres in Okene LGA. The findings are expected to provide evidence for strengthening vaccine supply, human resources, cold-chain systems, service accessibility, supervision, data management and other components of routine immunization delivery.

1.3 Objectives of the Study

1.3.1 General Objective

The general objective of this study is to assess health-system barriers to routine childhood immunization and their implications for vaccine coverage among under-five children in selected primary health centres in Okene LGA.

1.3.2 Specific Objectives

The specific objectives are to:

1. assess the level of routine childhood immunization coverage among under-five children attending selected primary health centres in Okene LGA;
2. determine the availability of vaccines, immunization commodities and functional cold-chain equipment in selected primary health centres;
3. assess the adequacy and availability of health workers providing routine childhood immunization services;
4. identify health-system factors, including financing, supervision, service organization, record keeping and outreach activities, that constitute barriers to routine childhood immunization.

1.4 Research Questions

1. What is the level of routine childhood immunization coverage among under-five children attending selected primary health centres in Okene LGA?
2. To what extent are vaccines, immunization commodities and functional cold-chain equipment available in the selected primary health centres?
3. Are there adequate health workers available to provide routine childhood immunization services in the selected facilities?
4. What health-system factors constitute barriers to routine childhood immunization in the selected primary health centres?

1.5 Research Hypothesis

H₀: There is no significant relationship between health-system barriers and routine childhood immunization coverage among under-five children in selected primary health centres in Okene LGA.

1.6 Significance of the Study

The study will be significant to the Kogi State Ministry of Health and primary healthcare authorities because it will provide evidence on the health-system weaknesses that may affect routine childhood immunization coverage in Okene LGA. The findings may support evidence-based planning and resource allocation.

The study will benefit primary healthcare facility managers by identifying facility-level problems relating to vaccine availability, staffing, cold-chain equipment, service organization, supervision and record keeping. Such information may assist managers in prioritizing areas requiring improvement.

The study will also be useful to immunization health workers. Understanding the operational barriers affecting service delivery may help health workers and supervisors develop strategies for reducing missed opportunities, improving client flow, strengthening follow-up and increasing immunization coverage.

The findings may benefit caregivers and communities indirectly through improvements in the quality, reliability and accessibility of routine immunization services. A stronger health system can make vaccination services more predictable and convenient for caregivers.

The study will be valuable to non-governmental organizations and development partners working in immunization and child health. The findings may assist such organizations in designing interventions targeting specific supply-side gaps rather than relying exclusively on general immunization campaigns.

The study will also contribute to academic literature by providing localized evidence concerning health-system barriers to routine childhood immunization in Okene LGA. It may serve as a reference for researchers undertaking related studies in Kogi State and other parts of Nigeria.

1.7 Scope of the Study

The study will focus on health-system barriers affecting routine childhood immunization and their implications for vaccine coverage among under-five children attending selected primary health centres in Okene Local Government Area, Kogi State.

The study will examine vaccine and commodity availability, cold-chain functionality, health-worker availability, accessibility of services, financing, supervision, record keeping, service organization and outreach activities. It will also assess routine immunization coverage among eligible children attending the selected facilities.

Geographically, the study will be restricted to selected primary health centres in Okene LGA. It will not cover every health facility in Kogi State. Consequently, findings will primarily reflect the conditions and experiences within the selected facilities and their catchment communities.

1.8 Operational Definition of Terms

Health-System Barriers: Conditions within the organization, financing, management and delivery of healthcare services that hinder effective provision and utilization of routine childhood immunization.

Routine Childhood Immunization: The regular provision of recommended vaccines to children according to the national immunization schedule through fixed, outreach and other approved service-delivery platforms.

Vaccine Coverage: The proportion of eligible children in a defined population who have received specified recommended vaccines.

Under-Five Children: Children who are below five completed years of age.

Primary Health Centre: A health facility that provides essential primary healthcare services, including routine childhood immunization, maternal and child health services and health promotion.

Vaccine Stock-Out: A situation in which a health facility has no available supply of a particular vaccine when it is required for routine immunization.

Cold Chain: The system of equipment, procedures and processes used to store and transport vaccines within the required temperature range from the point of manufacture to the point of administration.

Health Worker: A trained healthcare professional involved in providing immunization or related primary healthcare services.

Accessibility: The extent to which caregivers can physically, financially and organizationally reach and utilize routine immunization services.

Immunization Dropout: A situation in which a child starts the vaccination schedule but fails to return for one or more subsequent recommended vaccine doses.

Outreach Immunization: Immunization services provided outside the fixed health facility to reach communities or populations that have difficulty accessing routine services.

Health-System Strengthening: Efforts aimed at improving the organization, resources, management, financing and performance of the health system to enhance health-service delivery and outcomes.

Project – Assessment of Health-System Barriers to Routine Childhood Immunization and Their Implications for Vaccine Coverage Among Under-Five Children in Selected Primary Health Centres in Okene LGA