Routine childhood immunization remains a core public health intervention, but coverage gaps persist in low- and middle-income countries. This exploratory qualitative study aimed to identify health system barriers, opportunities and best practices affecting delivery of routine childhood vaccination in marginalized Ethiopian settings—specifically urban slums and pastoralist regions—by capturing perspectives of frontline healthcare workers and program managers.
The research focused on five regions—Addis Ababa, Oromia, Gambella, Afar and Somali—selected for high numbers of zero-dose and under-immunized children. The study used Human-Centered Design (HCD) and the World Health Organization’s Behavioral and Social Drivers (BeSD) frameworks to inform data collection and interpretation.
An exploratory qualitative approach was used between November and December 2023. Regions included both urban slum contexts and pastoralist areas to reflect differing marginalization drivers. Purposive, criterion-based sampling targeted individuals with direct immunization program experience at facility and woreda levels.
In total, 39 key informant interviews (KIIs) were completed. Participants comprised 5 RMNCH directors, 5 Woreda EPI officers, 5 EPI focal persons, 14 healthcare workers (HCWs), and 10 health extension workers (HEWs). Selection continued until thematic saturation was reached.
Interview guides were developed after literature review and adapted using HCD and BeSD frameworks to probe service delivery barriers and facilitators in context. Tools were translated into local languages and consent procedures followed local standards as reported.
Transcripts were analyzed using Open Code software (version 4.03). Thematic analysis combined deductive and inductive coding. Trustworthiness measures included inter-coder reliability checks and daily debriefings among the research team.
Participants identified multiple persistent health system constraints affecting routine immunization delivery in the study settings. Prominent barriers included:
Inconsistent vaccine supply leading to interrupted services and missed opportunities for vaccination.
Limited cold-chain capacity at facility and outreach levels, constraining the ability to store and transport vaccines reliably.
Insufficient financing and resource allocation, which affected logistics, outreach frequency, and the capacity to sustain services.
High workloads for available staff and human resource shortages, particularly in remote or densely populated informal settlements.
Operational challenges in reaching target populations caused by mobility, scattered settlements, and poor infrastructure in pastoralist and urban slum areas.
These system-level issues were reported to contribute to under-immunisation and missed vaccination appointments among children in marginalized communities.
The study emphasized how context-specific drivers compound system-level barriers. Urban slums were described as high-density informal settlements with limited or absent public services, complicating routine service access and outreach planning. Pastoralist areas were characterized by high population mobility, remote locations, and poor infrastructure, which hinder routine cold-chain maintenance and scheduled immunization activities.
Socio-cultural elements noted by participants included low health literacy in some communities and pockets of vaccine hesitancy, which interact with logistical barriers to reduce uptake.
Despite challenges, respondents identified several promising practices and facilitators that improved service reach or uptake:
Community engagement and involvement of local community structures to identify and mobilize caregivers, schedule outreach, and build trust.
Use of mobile teams to reach remote or highly mobile populations, adapting service delivery to community movement patterns.
Inclusion of the private sector where available to extend service points and increase convenience for caregivers.
Local innovations and adaptive planning by health workers that matched outreach timing to community routines.
These strategies were described as demonstrating notable successes in specific contexts within the study regions.
Health workers and managers proposed several strategies to strengthen delivery of routine childhood vaccination in marginalized settings. Key recommendations included:
Strengthening vaccine supply chains and logistics to reduce stockouts and ensure reliable availability at facility and outreach levels.
Expanding and maintaining cold-chain capacity suitable for outreach in remote and mobile contexts.
Increasing human resources, reducing staff workload, and enhancing provider training and supervision to improve service quality and outreach effectiveness.
Enhancing community awareness and tailored demand-generation activities using participatory approaches that reflect local context and needs.
Formalizing and scaling best practices such as mobile teams, community-based planning, and partnerships with local structures and private providers.
The study concluded that persistent health system challenges—supply, cold chain, financing, workforce and access—continue to impede equitable delivery of routine childhood vaccination in urban slums and pastoralist regions of Ethiopia. At the same time, existing best practices such as community engagement, mobile outreach and local partnerships can inform tailored strategies.
Authors emphasized that strengthening health system capacity alongside empathetic, participatory approaches rooted in HCD and behavioral insights is essential to close equity gaps and increase vaccine coverage among under-immunized children in marginalized settings.
Note: The source provides qualitative findings and stakeholder perspectives; quantitative coverage estimates, cost data, or specific outcome metrics beyond the reported themes were not reported in the source.