The Ghana Expanded Programme on Immunization and the Global Vaccine Action Plan set a 90% immunization target at national level and 80% at district level by the year 2020(19). However, the findings of this study shows that full immunization coverage is still below target at 72.6% in 2018. Aside failure to meet target levels, full immunization coverage declined between 2014 and 2018 suggesting the inability of the immunization delivery system to sustain gains made from previous years.
Immunization coverage relating to socioeconomic, geographic, maternal, child, and place of birth characteristics also changed between the two survey years. For example, high coverage was observed among the poor in 2014 but coverage was highest among the rich in 2018. Similar variations were observed among rural and urban residents.
It is worth noting that, there are discrepancies in the estimates of full immunization coverage for Ghana as reported by other studies. Budu et al. estimated full immunization coverage to be 95.2% in 2014 which contradicts the findings of this paper. Several factors account for these variations as outline in this document(29).
The findings of this study highlight the changing dynamics in child immunization coverage reported by related studies in Ghana. Asuman et al found high immunization coverage among children whose mothers are resident in rural areas in 2008(10) while Budu et al. found high coverage to be associated with urban residents in 2014 (30). High immunization coverage related to rural residence have been found in the Gambia which contradict the popular notion that rural residence was associated with low immunization coverage(31, 32).
Yawson et al. using a bottle neck analysis identified challenges affecting the EPI which could explain the decline in full immunization coverage observed in 2018(33). These challenges included limited number of fixed and outreach sites which may be preventing some mothers from accessing immunization for their children, difficulty reaching some communities due to unavailability of vehicles and motorable roads, inadequate cold chain system leading to the destruction of viable vaccines, vaccine stock out due to budgetary and procurement delays and fear of mothers on the safety of multiple vaccines. All these factors could directly or indirectly cause missed opportunities in immunization.
4.1 Equity Impact
This study found maternal age, hospital delivery and child possession of a health card were strongly associated with full immunization coverage (one dose of BCG, three doses of DPT-HepB-Hib, four doses of polio (including the birth dose), three doses of pneumococcal vaccine; two doses of rotavirus vaccine; one dose of measles-containing vaccine and one dose of Yellow Fever) after adjusting for background characteristics.
4.1.1 Maternal age
Maternal age is said to be the most important factor associated with immunization coverage (34). This support evidence from related studies showing that immunisation coverage among pre-school children increased by 16% among children whose mothers were between 17–26 years (34). Other studies indicated that children of younger mothers, especially teenage mothers are at an increased risk of under immunization (34–36) because of cultural discrimination and lower incomes. The age of a mother directly affects her maturity and receptivity to health information. Therefore, the older a mother is, the higher the probability she will take her child for immunization.
4.1.2 Hospital delivery
Maternal and child health are interrelated the reason health interventions are organised to serve both mother and child concurrently. This also explains why maternal healthcare utilisation has a direct impact on a child's health outcomes. A Benin study identified a strong association between full immunization and antenatal care, skilled attendance at birth and postnatal care check-ups (37). Similar evidence was found in India (38, 39), in Lao (40), in Ethiopia (41) and among East African countries (42). Maternal healthcare utilisation is a determinant of childhood immunization among SSA countries (43). Children born in health facilities have greater chances of owning a child welfare card. This card serves as a form of commitment and a reminder for mothers to present their children for immunizations. Children born in health facilities would receive their first immunization and then subsequent vaccines.
Ghana over the years implemented strategic policies aimed to bridge the gap of inequalities in healthcare access and increase utilisation. Notable policies implemented to achieve this mandate included the introduction of the National Health Insurance Scheme (NHIS) and the free maternal health services for pregnant women eliminating financial burden on pregnant women. The implementation of the Community Health Planning and Services(CHPS) (44) and the training of more community Health Nurses and Midwives increased access to skilled delivery in rural areas. Also, the provision of alternative use and integration of Traditional Birth Attendants into mainstream healthcare increased skilled delivery across the country.
Despite growing efforts to increase access to health facilities, access to essential health services is still a challenge. Many communities are faced with a lack of an adequate transport system preventing them from accessing health facilities. Also, due to a lack of motorised vehicles and inaccessible routes, health care workers are unable to provide services to families living in hard-to-reach areas. Therefore, to ensure children are vaccinated and go on to complete immunization, access to health care facilities must be central in planning. Adopting community-based programs is key to successful vaccination programs and will help in eliminating inequalities.
4.1.3 Socioeconomic status of household
This study did not find socioeconomic status to be a predictor of complete immunization. In Ghana, routine vaccines are provided free without direct out of pocket cost at the point of use. Also political efforts have been made to reach rural and poor population groups through the Community Based Health and Planning services(CHPS) initiative and also the use of drones to deliver vaccines to inaccessible areas (45). Though this study did not find socio-economic status to be a determinant of full immunization, socioeconomic related inequalities were observed in our primary outcome variable (FIC) and in OPV0. This support related evidence reporting socioeconomic inequalities in child immunisation coverage among urban poor residents in Ghana (11). Income related inequalities have been reported in many EPI in low and middle income countries (32, 46) (47). Bridging income related inequality is a key benchmark in achieving Universal Health Coverage (UHC).
4.4 Missed Opportunities
Missed opportunities for vaccination occur when a child has contact with the health system but fail to complete their immunization. Immunization dropout rate is a good measure of missed opportunities and for determining access and utilisation of immunization services. The WHO recommends immunization systems to limit immunization dropout rate to less than 10%. (24, 25).
This study estimated Ghana immunization dropout rate for penta1 to measles to be 10.4% in 2018 a little above the WHO recommended dropout rate of 10%. Immunization dropout rates are used to estimate continuity of use, client satisfaction and capacity of the system to deliver a series of vaccination services(22). The frequent shortage of vaccines in the EPI could cause many children to miss out on their immunization. Also, attitude of health professionals who provide immunization services, services delays are all reason that could influence immunization dropouts. It is imperative for the government to address procurement and budgetary constraints to avoid vaccine shortages while improving areas that ensure client satisfaction. The sporadic outbreak of measles and Yellow Fever in Northern Ghana could be attributed to missed opportunities in immunization(12)). This would increase the burden of child morbidity and mortality especially where greater cause of child mortality in Ghana is attributed to vaccine preventable diseases.
4.4 Gavi support for Ghana
Ghana exceeded Gavi’s eligibility threshold and entered transition in 2013 (5). However, due to unstable economic conditions, Ghana’s domestic resources are unable to fully fund the national immunization services hence the continual reliance on Gavi. This transitional period is marred with challenges as competing government expenditure and public service bureaucracy mitigate the prompt release of funds to procure vaccines. Ghana has among the highest vaccine wastage for a country dependent on donor support compared to other countries (48). This partly explains the shortage of vaccines experienced in recent times (49) (14).
4.5 Limitation and future direction
Firstly, this study is subject to recall bias because the DHS and the MICS employs recall of vaccination history by mothers during the data collection process. The goal standard is to use a written record of vaccination status on the child record card or any available vaccination record card. Also, other forms of bias could be introduced during the data collection period like social desirability bias as a mother who defaults on her child immunization may report on complete immunization to appear a responsible parent before the interviewer. Secondly, we estimated crude immunization coverage without taking into consideration timeliness of completing immunization coverage.
It is important for interventions to be designed with a focus on equity. There is a need for the government to continue to invest in women empowerment as women have the traditional role of caring for children while involving men to play supportive roles.
Also, as Ghana has rapidly urbanised, immunization services need to re-strategize and map out the location of urban poor children who are at risk of missing out on immunization. The continual existence of under-immunised or unvaccinated children retards progress in achieving herd immunity needed to interrupt the transmission of vaccine-preventable diseases.
Good record keeping should be strengthened to ensure that children who default on their scheduled immunization are traced. Good health worker attitudes should be promoted to improve the quality of immunization services.
Since Ghana transitioned into a middle-income country, support for vaccination has declined. Ghana needs to conduct economic analysis of new vaccination programs to help allocate limited resources in the context of budgetary constraints. This analysis should include cost impact, direct benefits, and health system consequences. It is imperative for the government and relevant stakeholders to continue to advocate for child health services alongside strong political commitment. Considerable resources and financing should be dedicated to immunization services; if not, hard-earned achievements will be lost when Ghana finally takes its exit as a beneficiary of GAVI.
Lastly, for Ghana to achieve universal and equitable access to childhood immunization, there should be a continual monitoring of immunization coverage since the direction and sources of inequality keep changing. Ghana has consistently measured its coverage using penta3 as a proxy indicator which does not take into consideration other antigens in the EPI. A better indicator to measure the performance of an EPI is the complete immunization. This should be incorporated into the national immunization strategic plan.