Systemic analysis of bottlenecks in routine EPI coverage vaccination among children aged 0–23 months in the health areas of the Mumbunda Health District: a cross-sectional mixed-methods study

Vaccines are one of the most powerful tools humanity has developed to protect children from deadly diseases. Since the global effort to immunize children began in the 1970s, millions of lives have been saved. Yet, in many places, the promise of a vaccine does not always reach the child who needs it. This gap between the plan and the reality often happens not because the vaccines are missing, but because the local systems meant to deliver them are strained. In the Democratic Republic of Congo, a country with vast challenges in healthcare delivery, officials have long noticed a strange contradiction. Official records sometimes show that vaccination rates are incredibly high, even exceeding the total number of children in a district. However, when researchers ask families directly, they find that many children have missed their shots. This disconnect suggests that the numbers on paper do not tell the whole story about who is actually being protected.

To understand why this happens, a team of researchers from the University of Lubumbashi and the local health district decided to look closely at the Mumbunda Health District in the city of Lubumbashi. They wanted to move beyond simple statistics and understand the daily realities of the nurses and health workers who try to vaccinate children every day. They focused on children between birth and two years old, a critical window for protection. The researchers used a two-part approach: they gathered data from nearly fifty health workers across dozens of clinics to see the big picture, and then they sat down for long, detailed conversations with seven key leaders to understand the reasons behind the numbers. Their goal was to find the specific points where the system gets stuck, or "bottlenecks," and to trace those problems back to their roots.

The study revealed that the system is not failing because of a single missing piece, but because of deep cracks in how the local health system is managed and funded. The researchers found that the most severe problems lie in two areas: stewardship and financing. Stewardship, in this context, refers to the leadership and organization required to keep the program running smoothly. It involves making sure data is recorded correctly, plans are shared with everyone, and that different parts of the system talk to each other. The study found that this leadership function was severely weakened. In many clinics, the forms used to record vaccinations were not being kept or filed properly. Some health workers admitted they took photos of the forms with their phones because they could not afford paper to photocopy them. In other cases, the detailed plans for how to reach every child were created at the main health center but never shared with the smaller, satellite clinics that actually do the work. This meant that the people on the front lines were often working without a clear map or the necessary information to do their jobs effectively.

The second major bottleneck was money, or more specifically, the lack of reliable funding for daily operations. While the vaccines themselves are often provided for free by the government or international partners, the cost of running the clinics is not always covered. The researchers found that health workers frequently had to use their own personal money to pay for fuel to transport vaccines, for phone calls to coordinate with other clinics, or even for the transport of the vaccines themselves. In some areas, the budget for vaccination activities existed on paper but the money never actually arrived at the local level. This created a situation where health workers were expected to deliver a free service but were forced to find their own resources to make it happen. Sometimes, to cover these costs, clinics would charge small fees for related services, like weighing a child, which could discourage poor families from coming. This financial strain meant that even when a clinic had the vaccines, it might not have the means to run a session or reach children in remote neighborhoods.

Beyond leadership and money, the study also highlighted issues with the physical resources and the people who deliver the care. The researchers found that the cold chain—the system of refrigerators needed to keep vaccines from spoiling—was fragile. Some clinics did not have approved refrigerators and had to store vaccines in neighbors' fridges or rely on unreliable power sources. If the electricity failed or the fridge broke, the vaccines could be lost. Similarly, the staff were often overworked and under-trained. In some clinics, only one or two people knew how to run a vaccination session, so if they were sick or on leave, the service stopped. Training was also inconsistent; some workers had been trained years ago, while others had only received a brief briefing that day. This lack of consistent expertise made the system vulnerable to small disruptions.

Despite these challenges, the study found that the actual act of giving a vaccine was often done well when the opportunity arose. The technical quality of the service was generally good, and the health workers were dedicated. However, the system was so fragile that it could not guarantee that every child would get that opportunity. The researchers observed that children often missed their shots not because they refused the vaccine, but because they could not get to the clinic due to rain, distance, or because the clinic was closed. Sometimes, a family would bring a child for a check-up, but the clinic would not have the vaccine that day, and the family would not return. The study also noted that community health workers, who are vital for finding children who have missed shots, were often volunteers with little support, making their work difficult to sustain.

The most striking finding of the research was how these different problems connected to create the paradox of high official numbers but low real-world coverage. Because the data recording was inconsistent and the plans were not shared, the main health office received reports that looked good on paper but did not reflect the reality on the ground. The high administrative numbers were a result of a system that was good at counting doses when things went smoothly, but bad at ensuring those doses reached every child. The researchers concluded that simply counting vaccines is not enough. To truly protect children, the system needs to fix the leadership and funding gaps first. This means ensuring that local leaders have the resources to manage their clinics, that plans are shared with everyone involved, and that the people delivering the vaccines are not forced to pay for their own work. Without these changes, the gap between the official numbers and the reality of unvaccinated children will likely continue.

The study does not claim to have solved the problem, but it provides a clear picture of where the system is breaking down. It suggests that the solution lies in strengthening the local management of health districts and ensuring that funding reaches the people who need it most. By focusing on these foundational issues, rather than just trying to push more vaccines out the door, health officials can begin to build a system that actually reaches every child. The work of these researchers offers a roadmap for understanding why a system can look successful on paper while failing in practice, and points the way toward making immunization programs that are both reliable and fair.