*3.2. Insufficient Accountability, Governance, and Financing Respectively Contribute to Sub-Optimal Person-Centredness*

At an institutional level, our findings indicated that the health systems faced multiple design and implementation constraints to fully delivering pro-equity or people-centered immunization and PHC services. Strategies to improve equity by aligning service design and delivery to the needs and preferences of those at greatest risk of access barriers—such as vaccination in communities (e.g., outreach or mobile vaccination services), expanded clinic hours, and community mobilization activities—existed in policy and facilities' operational plans and budgets, but were sub-optimally implemented. The lack of person-centeredness was most acute for caregivers and communities that were geographically inaccessible, socially excluded, or faced financial access barriers. For example, many caregivers decided not to seek vaccination services because of the long, difficult, or unsafe walks to health centers, as well as long wait-times once there, and this was exacerbated among low-income women and those who were socially isolated. Planned outreach vaccination sessions are meant to overcome these barriers, but a theme across all three countries was dissatisfaction with the low frequency of these services or not knowing when they would occur. When community-based or outreach services were implemented, they were implemented in communities close to the health facility, as health workers faced their own challenges—financial or logistical—in reaching remote communities.

Respondents in all countries described insufficient or poorly planned and managed immunization and PHC budgets, which led to insufficient operational funds to implement these strategies. Triangulation of data across multiple levels of the health system identified the root causes of weak governance and accountability, insufficient and fragmented financial resources, and weak leadership and management capability. Poor resource generation, allocation, and management, thus, most affected communities that already faced access barriers to immunization services. In Mozambique and Nigeria, national policies supporting integrated health services were sub-optimally implemented due to insufficient and fragmented finances stemming from weak governance. In all countries there was a recognition that certain remote or migrant communities were missed entirely with health and social services, and that no mechanism existed to identify these communities and link them to services.

Current or previous experience with vaccine stockouts weakened caregivers' trust in vaccination services. Many zero-dose children in the DRC were unvaccinated due to an ongoing shortage of BCG vaccines; the likelihood of a caregiver returning again after a missed opportunity for vaccination depended on the intersection of other barriers. Sub-optimal health worker motivation and performance was an important barrier to vaccination in all countries, ranging from absenteeism that led to missed opportunities for vaccination, to disrespectful care, to poor clinical quality of care. Caregiver reports of service quality varied across interviewees, but we noted that mothers of under-vaccinated children were likely to report poor service experience as a reason for not returning for additional doses. This included perceptions that sub-optimal clinical quality resulted in common side effects, such as swelling or sores at the vaccination site. As noted above, health workers themselves experienced institutional inequality and disempowerment. Despite these conditions, and as noted elsewhere, many health workers and other health system staff noted their commitment and intrinsic motivation to their roles [26].

#### *3.3. Local Solutions Address Power Imbalances*

Local co-creation workshops succeeded in reconceptualizing the problem of no immunization and under-immunization among participants, by presenting challenges from caregivers' or healthcare workers' perspectives. The exercise challenged each participant to empathize with caregivers and healthcare workers by better understanding the barriers they face in getting children vaccinated. By facilitating group discussions with caregivers and health workers, it allowed all community and health system participants in the workshop to work together to identify how they were responsible in supporting caregivers to overcome barriers. It was a new experience for all participants to be brought into a workshop where district, health facility, community leaders, and caregivers were invited as equals. In the DRC and Mozambique, district and provincial stakeholders expressed that the workshops were enlightening, and their perspectives changed about mothers related to the barriers they face and their agency in overcoming them.

Community-level participants from all countries expressed excitement at how they could support caregivers in getting their children to the health center. Solutions that emerged from the workshop included forming walking groups of caregivers to travel together to health facilities (Mozambique), husbands helping with transport (Mozambique) or childcare (Nigeria), and championship by community and religious leaders, who themselves are supported with training and information (DRC and Mozambique). These solutions suggest that participants were motivated by feelings of social cohesion. All co-creation workshops also proposed better implementation of existing solutions, such as outreach vaccination. Health system participants often uncovered new knowledge about financing challenges between levels of the health system that inhibited their ability to better support healthcare workers in adhering to their facility's immunization goals or implement outreach activities. Multiple solutions reflected ideas of people-centered care and improved service experience, such as joint planning for outreach services across health programs to better reach remote communities, integrated delivery of all child health services at facilities, reducing waiting times, and expanded service hours.

#### **4. Discussion**

The drivers of vaccination, identified through this study, are consistent with other studies, but we provide a new way of reconceptualizing them through HCD and intersectional lenses. Viewed through a caregivers' perspective, each individual has a unique set of social, institutional, and structural circumstances that intersect and interact to constrain or enable her options and outcomes. As Crenshaw argued when she proposed the intersectionality theory [27], it is limiting to group caregivers into binary categories, such as race or gender or to attribute a single characteristic—such as religion, education, or wealth—to explain immunization inequalities. A complete understanding of the drivers of inequality requires analyzing the joint influence of multiple factors related to the individual, as well as the health system and greater structural context. Our study used qualitative interviews guided by an HCD mindset to identify the lived experiences, challenges, and needs of caregivers of un- and under-vaccinated children. Presentation of their stories in communitylevel workshops built empathy and enabled co-design of locally relevant solutions that addressed the needs and preferences of caregivers. Some of the solutions were novel to the researchers, such as community walking groups, but many were in fact the improved implementation of existing strategies, such as outreach vaccination. As a project with the goal of overcoming entrenched obstacles to immunization equity, the resulting solutions guided our choice of activities and their design, with a focus on strengthening the local capacity for gender integration, strengthening community partnerships, and addressing root causes of sub-optimal service experience.

Our empirical data demonstrated the lack of person-centeredness or alignment of immunization programs with client needs, particularly for caregivers and communities facing multiple intersecting vulnerabilities.

Despite the many pro-equity strategies that exist and are budgeted and planned for [28], very few were actually implemented due to financial resource constraints at the operational level stemming from weak accountability and governance. We note that strategies to reach zero-dose children likely cost more, and that at the operational level, vaccinating individuals and communities at a higher risk of morbidity and mortality should be prioritized [29]. With the increased global investment in pro-equity strategies to reach zero-dose children and missed communities, we note the importance of also strengthening accountability for implementation and stronger health system governance and management.

Another root cause of the lack of people-centeredness stems from the way in which power structures are entrenched in health systems. On an interpersonal level, this can result in inconvenient or disrespectful services, but on an institutional level, results in weak accountability and insufficient resources to improve access, quality and experience. We saw evidence that stakeholders at operational and community levels were interested in and committed to taking actions to support caregivers to access vaccination, ensure the implementation of outreach vaccination services, and improve the overall convenience of services. Will they succeed? We believe this is the level where efforts to reorient PHC around user needs can have the most traction, although tangible pathways towards improved empathy and person-centeredness exist also at planning, policy and funding levels. Policies and programs can invest in or encourage approaches that are gender responsive, people-centered, integrate HCD and intersectional lenses, and explicitly address institutional and structural root causes. For example, tools for operational planning, such as integrated microplans, can be revised to ensure identification of the barriers and needs of the hardest-to-reach, and can engage caregivers and communities in the identification of solutions. Technical partners, such as our project, can catalyze the engagement of nontraditional partners to fill resource gaps needed to implement pro-equity strategies (e.g., local businesses) and ensure accurate sharing of information from trusted voices (e.g., religious leaders). Policymakers and external funders can support efforts to integrate the delivery of all PHC services for improved efficiency and client satisfaction, address human resource motivation, and improve management skills.
