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Introduction The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019. Methods We identified Nepal as an exemplar in the delivery of early childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results The following success factors emerged: 1) Codification of health as a human right, along with other vaccine-specific legislation, ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage. Conclusion This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.

IntroductionThe essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies prove effective at driving coverage is not well-established. To address this gap, we identified critical success factors associated with advancing key policies and programs that may have led to the substantial changes in routine childhood immunization coverage in Zambia between 2000 and 2018.MethodsWe conducted mixed-methods research based on an evidence-based conceptual framework of core vaccine system requirements. Additional facilitators and barriers were explored at the national and subnational levels in Zambia. We conducted a thematic analysis grounded in implementation science frameworks to determine the critical success factors for improved vaccine coverage.ResultsThe following success factors emerged: 1) the Inter-agency Coordinating Committee was strengthened for long-term engagement which, complemented by the Zambia Immunization Technical Advisory Group, is valued by the government and integrated into national-level decision-making; 2) the Ministry of Health improved the coordination of data collection and review for informed decision-making across all levels; 3) Regional multi-actor committees identified development priorities, strategies, and funding, and iteratively adjusted policies to account for facilitators, barriers, and lessons learned; 4) Vaccine messaging was disseminated through multiple channels, including the media and community leaders, increasing trust in the government by community members; 5) The Zambia Ministry of Health and Churches Health Association of Zambia formalized a long-term organizational relationship to leverage the strengths of faith-based organizations; and 6) Neighborhood Health Committees spearheaded community-driven strategies via community action planning and ultimately strengthened the link between communities and health facilities.ConclusionBroader health systems strengthening and strong partnerships between various levels of the government, communities, and external organizations were critical factors that accelerated vaccine coverage in Zambia. These partnerships were leveraged to strengthen the overall health system and healthcare governance.HighlightsThis paper describes how policies and programs contributed to improved vaccine coverage in ZambiaCommunication, coordination, and collaboration between implementing levels were imperativeAdjacent successes in health systems strengthening and governance were leveragedPolicies in Zambia include flexibility in implementation for tailored approaches in each district

Literature examining the functionality of Inter-agency Coordinating Committees (ICCs) is limited and outdated. We employed a qualitative study design to investigate the critical factors for improvements in routine immunization coverage for children under 1 year of age in Zambia from 2000-2018. Key informants identified the Zambian ICC as a success factor for improvements in vaccine programming. This article begins to fill the existing gap in literature by illustrating how Zambia bolstered its ICC for long-term functionality, expanded ICC membership and scope beyond Gavi requirements, and distinguished a complementary structure for the Zambian Immunization Technical Advisory Group (ZITAG). This study was nested within the Exemplars in Vaccine Delivery Project, part of the Exemplars in Global Health Program. Findings from this paper may contribute to decision-making processes, long-term engagement, membership, and mandates for ICCs in other countries.