Our study highlights the health system barriers that affect measles vaccination coverage including inconsistent vaccine stocks, inadequate cold chain storage, missed opportunities for community outreach, lack of dedicated transportation and relatively low prioritization of immunization activates among staff. Overall, these findings suggest an urgent need to better organize and resource vaccination activities in order to achieve set vaccination targets in rural areas of Uganda.
Vaccine stock outs were reported as one of the primary barriers to effective delivery of immunization services in the study area. Stock outs occur when vaccine supplies are depleted either arising from an unexpectedly high number of recipients or the orders underestimate the eligible underlying population. Many times, the children affected by stock outs are those who are already underserved due to distance to health facility. Vaccine stock outs have an established impact on immunization outputs as the children who are expected to get such vaccines at such slated times often miss out waiting for the delivery and distribution of the vaccines . Some of the challenge of vaccine stock outs could also be due to the small amount of storage capacity that some facilities have, including at the district level, which is responsible for distribution of the vaccine. Another factor contributing to the vaccine stock outs could be the delays by the national supply system through the National Medical Stores (NMS) to supply vaccines. This impediment could also be coupled with the inefficiant management at both the facility and the District Local Government where requisitions could take long to reach NMS culminating into delays. Regardless of the source, caregivers experience frustration after traveling long distances only to be told that the vaccine is not available. Such experiences may also contribute to lower enthusiasm for future care seeking due to lack of trust in the vaccine supply.
In addition, the UNEPI policy of unpreserved vaccine which must be discarded at the end of the session or 6 h after reconstitution, should be modified so as to optimize this vaccine’s availability, such that vials can in practice be opened whenever an eligible child presents. This policy has direct contribution of vaccination practice at health facility level for example, the ordering of vaccine in 5-dose rather than 10-dose vials increases the health workers’ hesitation to open a vial for fear of being blamed for wastage, thereby reducing missed opportunities and raising timely coverage. These health workers tend to request caretakers to either wait for others or to go and come back on a particular where they anticipate more numbers of children to be vaccinated such that the opened vials serve more children. This is a common phenomenon in low- and middle-income countries which have limited budget allocation for vaccines but also low technological access that limits the planning and prediction of such supplies . This study findings are in line with other studies conducted at Mulago National Referral Hospital, Uganda that showed that majority of the new borns miss immunization due to vaccine stock outs [18, 19]. This calls for budget increase for EPI activities at the district health offices, and proper planning by stakeholders like national medical stores (NMS), ministry of health and district health department to minimise the occurrence of stock outs .
The above factors outlined issues of vaccine supply. However, barriers also exist among the health care workers themselves, ranging from description of burn out, increased workloads, and inconsistencies in pay. Low prioritization of vaccine services among health care workers was one of the reported barriers in our study. Multiple health care workers reported having lost their motivation to work, while those that were working were the ones that needed the money despite being burned out. We note that this study was conducted during the first wave of the novel coronavirus pandemic, which may have exacerbated these issues. During this period health workers stretched their routine activities to support COVID-19 response. For example, some staff were redeployed to other health facilities that needed additional support. With some staff leaving due to burn out, the staff who have stayed are more reliant on pay to stay engaged. The sign of exhaustion among health workers was realized as many participants kept pointing out their frustrations arising from non-payments due to delays in release of Primary Health Care (PHC) funds. Although increased funding would be helpful, other non-financial incentives and improvements should also be explored. Staff performance could be motivated by promotions, further studies, more capacity building sessions. Our findings are in line with other studies done in Uganda that showed that health workers’ attitude is critical for better immunization activities [20, 21]. The district leadership and management of BHC should explore various non-financial motivation mechanisms for their staff such that there is continuity of service delivery even in absence of PHC funds. Furthermore, there is need to draw out a clear work schedule for the health facility staff spelling out when they will be working in the EPI Section.
The absence of transport during the time when the district reported measles outbreak  was reported as a hindrance to increasing the accessibility of immunization activities. Movement of health workers from their respective health facilities to different outreach sites was difficult. Participants reported negotiating credit with local private transport companies including commercial motorcycle drivers, while awaiting the release of PHC funds for use as a refund. According to Ministry of Health EPI guidelines, the transportation of vaccines from the district vaccine store to lower health facilities is the mandate of the district health office which can be achieved if transport means and fuel is availed through PHC funds . Our study revealed that this transportation of vaccines was affected due to lack of available transport facilities. This could be possible due to technical delays in the release of PHC funds which affects the fuelling of available vehicles. Transportation challenges could also be associated with diversion of EPI vehicles—commonly referred to as “GAVI vehicles”—for other administrative duties in the district hence affecting the immunization activities. Uganda being a low-income country, resources such as vehicles are shared by the district leaders depending on the priority demand at a particular time.
The rugged terrain of the area greatly limits the accessibility of some villages. Many caregivers cannot climb to high terrain areas where the outreach sites are located which greatly contributes to children missing their scheduled vaccinations thus increases the numbers of unvaccinated thus increases the chances of measles outbreaks. This finding is in line with other studies conducted in Uganda where it was clearly noted that physical barriers like hilly/mountainous geographical locations and road terrain greatly limited the accessibility of services for children under 5 years [13, 20, 21, 23]. This calls for geographical context planning for immunization services to cater for such difficulties such that outreach sites could be located in such places where critical need is known.
The findings showed that less attention was given by health workers to tracking the missed opportunities for measles immunization even when children were taken to the health facilities for other services. Health workers are few and the idea of tracking the vaccination status of children during routine service provision is not taken as a priority. In the same vein, there are no specific reminders to different caretakers on their scheduled dates although the community health workers normally remind many caretakers in totality on the need to go for health services in various health facilities. In addition, caretakers and caregivers forget to bring their eligible children for the measles vaccination at 9 months. This could be attributed to inconsistencies in the payment of staff for immunization activities, which (as reported by various stakeholders) results in less prioritization of those immunization activities. This poor remuneration of these health workers could also explain why many of them were reported to have lost interest in EPI activities leaving this to the community health workers (locally referred to as Village Health Teams) who may not be technical enough to track the missed children. Furthermore, the health workers also asserted that their large workload reduces their ability to concentrations on tracking children who miss particular vaccines, including the measles vaccine. This study finding is in agreement with previous studies done in similar regions (e.g., Hoima district) that showed that staff overload affected the attention to immunization activities which contributed to measles outbreak . There should also be deliberate efforts to identify the children who missed the vaccination through review of health facility records, follow up of caregivers of children who are due for MRV leveraging local leaders and public communication (i.e., radio) to remind the caregivers about the need to complete the vaccination for their children. Furthermore, reminding caregivers of the importance of maintaining immunization cards may prove useful, as these cards show the dates for subsequent visits.
Our study has a number of strengths. We interviewed the staff who are directly involved in the provision of measles vaccination services which helped to understand real issues they face. We also targeted both the stakeholders in management positions and those of the implementing staff which, which method gave a broad picture to the perceived barriers. The study also employed two methods (e.g., KIIs and FGD) that helped to deeply explore the subject matter. Lastly, we captured ideas and potential solutions to improve measles vaccination coverage that stakeholders can utilize. However, this study also had limitations including the relatively small number of interviews and FGDs, which was primarily due to the fact this was a graduate student research project with a modest budget. We also interviewed only one VHT who was already involved in other activities at BHC and his views many have not be representative of other VHTs in communities. We also did not interview caregivers so our results reflect only those of the service providers, rather than the end-users. Lastly, we did not interview the Ministry of Health and NMS staff who could expand on issues related to vaccination supplies and budget allocation for the district.