One of the biggest health deficits across Africa is the currently unacceptably low levels of immunisation. These are exposing millions, especially children and other vulnerable groups, to deadly diseases that are preventable with vaccines. What are the causes of this fatal shortfall, and how can it be overcome? Jamila Versi talks to three experts on the subject.

A mother travels down difficult roads to bring her sick child to a health centre. The journey might have taken hours. When she gets there, it is a Tuesday. Had she been there on a Wednesday, she could have gotten the DPT (diphtheria, pertussis [whooping cough] and tetanus) vaccine as well. But the journey is long, and it’s not a trek she’ll be able to replicate the day after.

For Dr Chigozie Edson Utazi, Associate Professor in Spatial Data Science at Southampton University (UK), who uses geospatial modelling to look at vaccination coverage specifically around zero-dose children, this is a very concrete example of some of the challenges around immunisation.

Vaccines generally have to be kept within a strict cold chain, moving through refrigerators and temperature-controlled boxes until the point when they are administered. In places where electricity is unreliable, or where health facilities are far away from central storage points, this can mean that vaccines are only available on particular days.

This is only one example of why looking at low vaccine rates only through the lens of ‘vaccine hesitancy’ – mistrust of vaccines, often described as one of the main reasons for under-vaccination across the continent – can miss a much bigger story.

Across conversations with political anthropologist Dr Luisa Enria, an Associate Professor in Global Health and Development at LSHTM (UK), and Utazi and Gavi’s Chief Country Delivery Officer, Thabani Maphosa, what becomes clear is that there is rarely one reason why a child is unvaccinated.

Mistrust and misinformation can play a role, but so can poverty, conflict, geography, staffing, infrastructure and whether a vaccine is actually available when somebody reaches a clinic.

Sometimes, what looks like vaccine refusal has very little to do with the vaccine itself.

Looking a little further than ‘hesitancy’

For the last fifteen years, Enria has been working in Sierra Leone, looking at community experiences, epidemic preparedness and interventions during humanitarian emergencies. She worked on vaccine trials during the West African Ebola outbreak (2014-16), and more recently, has undertaken research on vaccine confidence in Northern Nigeria, and has contributed to the response to the current Ebola outbreak in DRC.

Her work asks us to take a closer look at how the language of ‘vaccine hesitancy’ is being used.

Misunderstandings and mistrust

There are, of course, long histories of mistrust around vaccination on the continent. In Cameroon in 1990, an anti-tetanus vaccination campaign was halted amid fears that it would make young girls infertile.

Ebola vaccine trials in Ghana were suspended in 2015 following accusations that researchers were infecting participants with Ebola. And in northern Nigeria, a boycott of the polio vaccine in 2003-2004 was driven partly by beliefs that it contained contraceptives that would render children infertile.

But, Enria argues, unless there is a real understanding of how those ideas came about, simply labelling them misinformation is not particularly useful.

“You can’t really control the epidemic without a full understanding of the social dynamics of the affected communities,” she says. Often, “everything is sort of being dubbed as resistance or misinformation”, when people may actually have quite rational concerns based on what they have seen happen in their communities or through previous experiences with healthcare.

The issue with narratives of vaccine refusal, she argues, “is that it really puts the responsibility and blame on the individual, and very often mothers, because it’s often childhood vaccination.”

Her work has instead tried to “flip the lens a little bit” and look at the trustworthiness of the health system itself.

And sometimes, the reasons for low uptake are incredibly simple.

During research with community health workers in the borderlands of Sierra Leone, Enria came across communities where vaccination teams were arriving on the same day residents travelled across the border to go to the market.

“People were saying things like, well, you come and vaccinate at the same time as we go to the market across the border. So we’re not there. Thus, it’s a whole web of factors, but it’s easier just to label it under vaccine hesitancy.”

There are similar issues around getting vaccines to remote areas. Healthcare workers may not have fuel or money to travel out to communities. People may move backwards and forwards across borders, making it difficult to even calculate population figures accurately. And mistrust of the health service can itself come from bad experiences with healthcare.

Enria points out that health workers in precarious health systems are often extremely underfunded and overworked. Some may not have been paid for months. That can translate into frustration or rudeness towards patients, which can then affect whether somebody wants to come back.

The problem that gets described as ‘mistrust’ can itself have much more structural causes.

One way of dealing with that has, in Sierra Leone, been to create two-way meetings between health workers and communities, sometimes described as ‘peace meetings’. Community members can explain why they are unhappy with the quality of care or why they are worried about vaccines, while health workers can explain the circumstances they themselves are working under.

During the recent Ebola vaccine trials, people’s concern about how much blood researchers were taking from them was addressed by simply holding up large water bottles and visually showing how small the amount of blood being removed actually was.

It sounds basic, but that is partly Enria’s point. If you listen closely enough to what somebody is actually worried about, the response can be much more specific.

Her team has also used what they call ‘mapping power’ – looking at who is actually influential within a community, rather than simply approaching whoever has the most formal authority.

In one example in Sierra Leone, researchers went to male chiefs before finding that a group of female chiefs did not feel represented by them. So, the strategy had to change. It might mean speaking to market traders, teachers or somebody with no formal position at all, but who is influential locally.

The work, I point out, sounds long and quite expensive. “Well, it’s less money than it takes to cure an outbreak,” says Enria. “My concern is that it’s often seen as ‘a nice to have’, the social science – but actually, it’s pretty essential, and it’s preventative.”

Where are the zero-dose children?

Utazi’s work looks at a different side of the same question. He uses geospatial and spatio-temporal modelling to look at vaccination coverage and zero-dose children. In very simple terms, the work is trying to answer: if we know there are millions of children who are not being vaccinated, where exactly are they?

Zero-dose generally refers to children who have not received the first dose of the diphtheria-tetanus-pertussis vaccine. A child usually receives the vaccine at 6 weeks old, so the DTP vaccine functions as a sign of whether a child is accessing vaccination services at all.

National vaccination figures can hide huge inequalities. A country might have an 80% vaccination rate, Utazi explains, but “that coverage would not be 80% everywhere”.

One area may be doing extremely well while another is doing badly. Even within the same state, an urban centre might have very different coverage levels from rural areas.

“So, this is actually what we are interested in when we do geospatial analysis,” he says. “We want to know how the indicator of interest varies.”

His work takes household survey data and combines it with satellite-derived information and other geographic data to estimate vaccination coverage at lower administrative levels, closer to where programmes are actually being planned and implemented.

Eventually, the information literally becomes a map that is able to give more specific and detailed understandings of the coverage. And that becomes important when looking at zero-dose children.

Nigeria had around 2.2m zero-dose children in 2025, according to figures Utazi cited from WHO and UNICEF.

But saying there are 2.2m children nationally is not enough if you are actually trying to reach them – “You want to know exactly where to find them,” he says. Geospatial modelling offers a way to help show where the resources are actually needed. Utazi calls this “precision public health” – essentially, using limited resources more precisely.

One of the things his research has also shown is that zero-dose status is usually not just about vaccination. “Zero dose actually is a marker of broader deprivation,” he says.

Zero-dose children are more likely to be found in remote rural areas, conflict-affected communities and among the urban poor. Poverty, maternal education and unemployment can all influence whether a child is vaccinated.

“So, it’s not just a failure of the immunisation programme,” he says, but “a combination of several social, economic [and] demographic factors.”

He gives the example of a mother waking up in the morning without knowing where the family’s next meal is going to come from. “The last thing they’re going to think about,” he says, “is taking their child to a health facility to get vaccinated. So, poverty is a huge, huge, huge factor.”

Thinking holistically

Nigeria also shows another issue: vaccination campaigns can increase coverage temporarily, but they cannot necessarily compensate for a routine health system that is not working.

Utazi describes a persistent north-south divide in vaccination coverage, with parts of northern Nigeria, which has also been impacted by political instability as well as higher birth rates, continuing to have much lower rates than areas in the south.

Vaccination campaigns may raise coverage, but if the routine immunisation programme is still struggling, the gains can disappear very quickly. “If the routine immunisation programme is not functioning properly… you just get back to square one,” he says.

Conflict makes all of this significantly harder. Health workers may not be able to travel to health facilities safely. Supply chains can be disrupted. Parents may not feel safe leaving home. Families can be displaced into camps or temporary settlements where normal vaccination services are not available.

“If these services are not available there,” Utazi says, “the children that you have in those environments would never get vaccinated.”

He argues that vaccination programmes therefore cannot always work in isolation. If another programme is already reaching vulnerable children to deal with malnutrition, for example, that could also become an opportunity to vaccinate. “We’re thinking of sort of a more holistic approach,” he says.

Rather than making a family travel separately for every service, different health interventions could be coordinated.

Healthcare volunteer injecting a dose of intramuscular vaccine during an international prevention campaign in rural Africa

Systems and communication

For Thabani Maphosa, a lot of these issues come down to systems. As the Chief Country Delivery Officer of GAVI, the Vaccine Alliance, he oversees the organisation’s work with countries globally. He describes three things as sitting at the heart of GAVI’s work: equity, systems and sustainability.

Equity includes reaching zero-dose children. But “systems are what really enable our work”, he says. Sustainability is then about countries increasingly taking ownership of their immunisation programmes through domestic financing, political will and stronger health systems.

He describes GAVI’s model as a partnership rather than a charity model, with the aim being for countries to gradually take more responsibility for their own vaccination programmes.

Looking specifically at Africa, one of the first challenges Maphosa points to is demographic. GAVI has partnered with 41 of Africa’s 54 countries, where child populations are also growing extremely quickly. “As we look into the future, Africa is actually squarely the continent where GAVI is going to be,” he says. “Africa is actually the unfinished business.”

The HPV (human papillomavirus) vaccine, which protects against high-risk virus strains that cause cervical, throat, and other cancers, as well as genital warts, is a good example of tackling both structural and community challenges.

Previously, the HPV vaccines required two doses – but now, it only requires one, a “game changer”, says Maphosa. In a conflict setting, reaching somebody once might be possible. Reaching them again months later may not be. “If we reach a girl once, we know she’s protected,” he says.

It has also changed the way vaccination teams think about what they do when they have access to a community. “When we have a moment to tackle them, how do we bank up services so that we reach them once?” he asks. “Because we don’t know when we are actually going to reach them next.”

From a community perspective, he highlights that the HPV vaccine, when introduced, was critiqued by churches in Kenya out of fears that it encouraged young women to have an early sexual debut.

It took understanding what they saw as the issue to work with and educate the church, by saying, “If we really do miss this opportunity, do you actually want to live in communities where you have missed the window of protection for these women and it catches up with you as cancer?”

It is crucial when talking to communities, he argues, that the argument is tailored the right way. “I never want to stand on a pedestal. You never want to judge another person for not understanding. You want to be caring and compassionate and attuned to understanding each other to form a conversation.”

Immunisation despite conflict

Maphosa also argues, however, that conflict is not always the be-all and end-all to vaccination, as presumed. Sudan is one of the examples he comes back to. Before the current conflict, there was high vaccination coverage in Sudan. When the conflict began, coverage fell dramatically.

But even while the fighting continued, it began to recover. Maphosa says one of the reasons was that humanitarian partners were able to work across conflict lines and reach places that the government could not.

At some points, vaccines could not even travel through Sudan to reach other parts of the country. Instead, they had to go through neighbouring Chad and then cross back into conflict-affected areas. That required humanitarian organisations, the Sudanese government and the Chadian authorities to work together.

The government’s position on this, argues Maphosa, is the only reason the vaccination coverage was successful.

“The adults may have their problems,” he says, “but when it comes to health, the virus is the enemy, and we should make sure that the children are protected regardless of where they are.”

He says Sudan saw a 32% improvement in vaccination coverage over two years, despite the conflict continuing. It also shows why vaccination cannot always be looked at neatly within national borders. Disease does not stop at a border, and neither do displaced populations.

“If we really don’t operate with a transnational approach,” Maphosa says, “we will always be fighting alone and fighting alone is a weak position. We must fight together.”

Fridge-less vaccines

If factors such as poverty and accessibility, as well as miscommunication and mistrust between health workers and communities, offer challenges for vaccination, all the experts are very optimistic about the potential of StablevaX and microarray patches to help ensure immunisation. StablevaX – which would allow vaccines to be stored and transported without needing to be a part of the refrigerator ‘cold-chain’ – has undergone a successful trial.

Utazi describes maintaining the cold chain as one of the greatest practical difficulties for vaccination programmes in low-resource environments. Vaccines have to remain at particular temperatures while they are being stored and transported. But there are places where electricity is unreliable, or where health facilities are far away from the places where vaccines can safely be stored. ( See page 50. )

“I’ve walked behind healthcare workers all over Sierra Leone who’ve opened fridges and said, yup, the fridge temperature is off, we have to throw out the vaccines,” says Enria.

With a solution like StablevaX, the mother who arrives with the sick child at the distant health centre would be able to vaccinate their child, rather than experiencing a “missed opportunity for vaccination”.

In fact, Maphosa says, it’s not only about the cold chain: “We do need innovation that actually takes us both outside the cold chain, but also reduces the touch points that we need.” With the introduction of more accessible vaccines – or, in the case of micro-array patches, immunisation that doesn’t require needles – vaccination could be distributed far more easily and be much more accessible.

Local manufacturing

There is one final issue sitting further up the chain: manufacturing. The Covid-19 pandemic exposed just how dependent much of the continent remains on vaccine production elsewhere.

Maphosa points to Gavi’s Africa Vaccine Manufacturing Accelerator, a $1.2bn initiative aimed at supporting local and regional vaccine manufacturing. He describes it as one of the lessons of the “vaccine nationalism” seen during Covid, as African countries found themselves in a weaker position when wealthy countries competed for limited supplies.

The hope is that in another pandemic, Africa has more of the infrastructure it needs “to also step up and produce and defend its own population. If manufacturing capacity is distributed more evenly,” he says, “I think that’s going to do vaccination programmes around the world a huge favour.”

A closer look at immunisation challenges across Africa reveals just how many factors mitigate against successful vaccination outcomes – whether that might be misinformation, difficult roads, conflict, insufficient healthcare workers, or expired vaccines – and just how different expertise from across all fields is required to tackle immunisation holistically. But, as the saying goes, understanding the problem is halfway to solving it.

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