Urban settings do not ensure access to services: findings from the immunisation programme in Kampala Uganda

Abstract

BackgroundPrevious studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda.MethodsMixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Survey data underwent descriptive statistical analysis. Latent content analysis was used for qualitative data.ResultsOf the 821 respondents in the survey, 96% (785/821) were mothers with a mean age of 26 years (95% CI 24–27). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents (24%, 95% CI 21–27). This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3–6 hours before receipt of services although this was more common at public facilities. Only 33% (95% CI 30–37) of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% (95% CI 27–34) of the survey respondents utilised these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. Charges ranged from US$ 0.2 to US$4 and these were more commonly reported at private (70%, 95% CI 65–76) than at public (58%, 95% CI 54–63) facilities. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities.ConclusionsComplex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, governments should strengthen health systems to cater for increasing urban populations.

Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: applying a structural equation model

“…Similar studies assessing the quality of service in public clinics in South Africa showed that the clinics were easily accessible and services were of acceptable quality [38], but the time spent by patients at the clinic to complete the services was very long [38, 39]. These findings suggest that public health services in many resource-constrained LMICs are characterised by long waiting periods [40–42], which could be a consequence of operational challenges such as performance of multiple tasks and work overload of health workers [18]. In addition to staff shortage which was reported by operational managers and patients in the qualitative component [43] of the broader mixed methods study, patients who missed previous clinic appointments were being made to wait in the queues during subsequent visits until nurses had attended to patients who were on the appointment list for that day [43].…”

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa

“…Barriers to access have been primarily researched for rural settings, but are equally relevant for those hard to reach in urban settings. 73 Lack of financial protection is a significant financial barrier to access and can lead to catastrophic health expenditures. Available data for eight sub-Saharan countries (Ghana, Kenya, Malawi, Niger, Senegal, Uganda, Tanzania, and Zambia) suggest that more than a quarter of the population may be further pushed into poverty by OOP payments on health services.…”

Reasons for defaulting from childhood immunization program: a qualitative study from Hadiya zone, Southern Ethiopia

“…These include caregiver literacy and employment [7–11], geographic location [7, 8, 12, 13], maternal utilization of other health services and place of childbirth [7, 14], safety concerns, and misconceptions about vaccines [15, 16]. Lack of awareness in the form of poor understanding of benefits, dosing and schedules [10, 12, 14, 17, 18], is also among the commonly reported reasons for defaulting from the program.…”

“…A few studies also identified household income, child illness [19, 20], poor male partner involvement [15], and large family size [16] to be associated with defaulting. Incomplete immunization is also commonly linked to weaknesses in the health systems, such as the lack of vaccines during vaccination sessions [17] and poor geographic access and long distance from the sites [7, 8, 12, 15, 21], including in urban settings [13]. Poor service arrangements with long waiting time [13, 15], inconvenient schedules [16], unwelcoming health care environment [16, 19], and not holding sessions as planned [22] were also mentioned.…”

“…Incomplete immunization is also commonly linked to weaknesses in the health systems, such as the lack of vaccines during vaccination sessions [17] and poor geographic access and long distance from the sites [7, 8, 12, 15, 21], including in urban settings [13]. Poor service arrangements with long waiting time [13, 15], inconvenient schedules [16], unwelcoming health care environment [16, 19], and not holding sessions as planned [22] were also mentioned. Also, the lack of organized outreach services and functional defaulter tracing mechanisms have also been cited as contributing to incomplete immunization [22].…”