Integrated delivery of health services with routine immunization: a fifty-year perspective towards strengthening primary health care in ESA countries

¹WHO Inter-Country Support Team office for East and Southern Africa, Harare, Zimbabwe

^&Corresponding author
Daudi Manyanga, WHO Inter-Country Support Team office for East and Southern Africa, Harare, Zimbabwe

Introduction    

The Expanded Programme on Immunization (EPI) was launched by the World Health Organization (WHO) in 1974 as a vertical initiative aimed at increasing coverage of key childhood vaccines. It was built on the global success of the smallpox eradication campaign, which concluded with the disease being declared eradicated in 1980 [1,2]. In its early years, EPI operated as a standalone program with dedicated infrastructure, funding, and personnel focused on delivering vaccines for diseases such as tuberculosis (BCG), poliomyelitis (OPV), diphtheria, pertussis, tetanus (DPT), and measles [3,4]. While this vertical approach helped rapidly increase immunization coverage, it also highlighted the need for integration with broader health systems to ensure sustainability and equity. The program was designed top-down and operated parallel to general health services due to the technical requirements of dedicated logistics, cold chain systems, and management. EPI´s initial design also adopted mass campaign strategies used during smallpox eradication [5].

The integration of EPI with other health services began in the early 1980s, notably with the launch of UNICEF´s GOBI strategy in 1982 [6]. GOBI-Growth monitoring, Oral rehydration therapy, Breastfeeding, and Immunization were a cornerstone of the Child Survival Revolution, promoting simple, cost-effective interventions to reduce child mortality. This marked one of the first major efforts to combine immunization with other child survival strategies, transitioning EPI from a purely vertical program to a more integrated approach within primary health care (PHC). This shift was driven by evidence from many developing countries showing persistently low vaccination coverage [7]. By the mid-1980s, the integrated model gained momentum and significantly improved child health outcomes [2]. For example, global DTP3 coverage rose from around 20% in 1980 to over 60% by 1990, largely due to the combined efforts of EPI and child survival initiatives. This integration laid the foundation for later strategies such as the Integrated Management of Childhood Illness (IMCI) and Reaching Every District (RED), which emphasized linking immunization with broader health system strengthening [8-10]. These approaches improved efficiency, accessibility, and community trust, especially in low-resource settings, and demonstrated that immunization could serve as a gateway for delivering other essential health services. The GOBI strategy was expanded in the mid-1980s to GOBI-FFF, adding Family Planning, Female Literacy, and Food Supplementation [11]. This expansion reflected a growing recognition that child survival depends not only on direct health interventions but also on broader social determinants. UNICEF and other stakeholders promoted this integrated approach as part of the Child Survival Revolution, aiming to reduce child mortality through low-cost, high-impact strategies [12,13]. However, by the early 2000s, health systems faced challenges in implementing diagonal integration, which combines vertical (disease-specific) and horizontal (system-wide) approaches [14-16]. Disease-specific programs, such as those for polio and measles, often operated in silos, diverting resources from routine services and creating fragmentation. Health workers were frequently overburdened during mass campaigns, leading to burnout and reduced quality of care. Training efforts were often reactive and narrowly focused, resulting in gaps in broader competencies needed for integrated service delivery. Surveillance systems concentrated on specific diseases, missing opportunities to strengthen comprehensive health information platforms [17]. Additionally, political and funding priorities favored short-term, measurable outcomes, making it difficult to sustain integrated approaches. These challenges underscore the need for more resilient and flexible health systems capable of addressing both routine and emergency needs.

In the East and Southern Africa (ESA) sub-region, where health systems face challenges such as limited resources, workforce shortages, and high disease burdens, integration of EPI with other services is particularly critical [18]. It enhances efficiency, reduces missed opportunities for care, and strengthens the continuum of services for children and caregivers. Moreover, integrated service delivery aligns with WHO´s health systems strengthening approach and supports countries in achieving Sustainable Development Goals (SDGs), especially those related to child health, maternal health, and equity [19]. The transition from vertical immunization programs to integrated service delivery is a key focus of the Immunization Agenda 2030, endorsed by the World Health Assembly in 2020. This agenda positions immunization as a fundamental aspect of PHC and a driver of Universal Health Coverage (UHC). It advocates for a synergistic model in which immunization strengthens health systems and vice versa, moving beyond co-location of services to holistic, system-wide integration. In ESA, where health systems face ongoing challenges such as high disease burden, inequitable coverage, and limited resources, integration is vital for sustainability. Bundling services such as combining immunization with nutrition screening, vitamin A supplementation, and maternal health counseling optimizes each contact with the health system, minimizing missed opportunities and improving efficiency and equity. The Global Vaccine Action Plan (GVAP, 2012-2020) laid the foundation for the Immunization Agenda 2030 by emphasizing the need for immunization programs to operate within robust health systems. GVAP´s Strategic Objective 4 called for strong immunization systems within multisectoral health efforts, linking immunization to broader health system strengthening and the UHC agenda. Although GVAP´s coverage targets were not fully met, it successfully shifted global perspectives toward integrated, system-based approaches. The implementation of Immunization Agenda 2030 involves integration across life stages and health system functions for example, administering tetanus toxoid during antenatal care, bundling child health services with EPI visits, and aligning HPV vaccination with school health programs. Integration also strengthens supply chains, workforce capacity, and data systems, leveraging immunization infrastructure to support broader health goals. This strategic alignment reinforces WHO´s commitment to equity, resilience, and universal access to essential health services. The integrated delivery of EPI has become both a strategic imperative and a practical necessity for building resilient, people-centred health systems in ESA countries. This subregion continues to experience the highest burden of zero-dose children, those who have not received even a single dose of the diphtheria-tetanus-pertussis (DTP1) vaccine.

To put this vision into practice, countries must prioritize key factors from a health systems perspective, ensuring alignment with WHO policies and the Immunization Agenda 2030 framework. These factors have been selected for their potential to reinforce the foundations of PHC, facilitate seamless service integration, and address the comprehensive health needs of children and caregivers. They also reflect WHO´s life-course immunization approach, promoting vaccination from infancy through old age, ensuring continuity of care, and maximizing health system interactions. A top priority is enhancing workforce competency through multi-skilling, enabling health workers to deliver immunization services alongside other essential interventions such as nutrition screening and family planning counseling, in line with WHO´s guidance on optimizing the health workforce for UHC [8,20]. Leveraging the EPI cold chain for other temperature-sensitive commodities such as antibiotics and oxytocin aligns with WHO´s Effective Vaccine Management (EVM) framework and improves supply chain efficiency.

Implementing digital health information systems, including integrated electronic registries, is vital for tracking immunization, child growth, and maternal health. This supports data-driven decision-making and aligns with WHO´s Digital Health Resolution (WHA71.7) [21]. Community engagement strategies that build trust and generate demand for integrated services are also crucial, as emphasized in WHO´s framework for community health [22,23]. Financing models should evolve toward pooled funding mechanisms that support bundled service delivery rather than siloed programs, consistent with WHO´s UHC financing guidance. At the point of care, co-locating services such as immunization, vitamin A supplementation, deworming, and growth monitoring enhances efficiency and convenience. Additionally, equity-focused monitoring and outreach are essential for identifying and reaching zero-dose children and underserved populations, reinforcing the core principle of the Immunization Agenda 2030 to “leave no one behind.” Together, these strategies form a comprehensive, policy-aligned roadmap for transforming immunization into a platform for broader health system strengthening across the ESA subregion. We published this paper to highlight a critical need in ESA, where health systems struggle with the highest rate of zero-dose children, those who have not received a single dose of the DTP1 vaccine. This issue underscores systemic inequities and missed opportunities for care. The evolution of EPI illustrates the potential of immunization as a platform for broader health service delivery.

The goal is to provide evidence for integrated service delivery, drawing on global health strategies such as GOBI, IMCI, and RED, which demonstrate that bundling services like immunization, nutrition, maternal health, and disease surveillance can enhance efficiency and build community trust. However, challenges such as siloed programming and fragmented data systems persist. This paper outlines how these barriers can be addressed through alignment with WHO policies, including the Effective Vaccine Management initiative and the Digital Health Resolution. It also aligns with the Immunization Agenda 2030, which promotes immunization as a key component of PHC and UHC, emphasizing a life-course approach and equity principles, particularly relevant in ESA countries.

Methods     

Study design: we conducted a descriptive mixed-method secondary analysis using both quantitative and qualitative approaches to evaluate the integration of health services with routine immunization in the East and Southern Africa (ESA) subregion. This study utilized data collected through the electronic WHO-UNICEF Joint Reporting Form (eJRF), focusing on indicators related to service integration scheduled alongside routine immunization delivery and health system interactions. No new primary data were collected; instead, we systematically reviewed and analysed country-reported data to assess trends and contextual factors influencing integrated service delivery. The analysis included 20 ESA countries: Botswana, Comoros, Eritrea, Eswatini, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Tanzania, Uganda, Zambia, and Zimbabwe. The quantitative component aimed to identify statistical trends in the integration of various services such as nutrition (breastfeeding, vitamin A, and micronutrient supplementation), growth monitoring, deworming, HIV/AIDS, and maternal health with routine immunization. Data were analysed using Microsoft Excel to evaluate patterns of integrated service delivery and identify gaps in implementation. The qualitative component examined systemic and contextual factors affecting the integration of services with immunization, including workforce capacity, infrastructure, data systems, and community engagement. This analysis provided insights into the broader environment in which immunization services are delivered and how integration is operationalized across different settings. These insights were primarily drawn from literature reviews and reports, such as external comprehensive EPI programme reviews. We selected a six-year period (2018-2024) for our analysis, as earlier data were not available. This study aims to generate evidence to inform strategies for strengthening integrated service delivery and optimizing immunization platforms as entry points for broader health interventions in the ESA subregion.

Variables: the variables used in this study were derived from the electronic WHO-UNICEF Joint Reporting Form (eJRF) and focused on services reported as integrated and scheduled during routine vaccination contacts in the public sector for children aged 0-11 months and 12-23 months. These variables included vitamin A supplementation, growth monitoring, referral services (for both child and caregiver), deworming treatment, micronutrient supplementation, family planning for caregivers, and health education on breastfeeding, water, sanitation, and hygiene (WASH), HIV/AIDS services, malaria preventive treatment, and bed net distribution. In total, 21 indicators were analyzed across age groups and service categories.

Data source: we collected data on the integration of health services with routine immunization from 20 ESA countries, covering the years 2018 to 2024. This data was obtained using the electronic WHO-UNICEF Joint Reporting Form (eJRF) and is publicly accessible, having been routinely reviewed and validated by the WHO and UNICEF secretariats. While the Expanded Programme on Immunization was established earlier in some countries, such as South Africa before 1975, in others by 1990, and in South Sudan in 2011, relevant data on integrated service delivery were only available starting from 2018. Consequently, we utilized secondary data from 2014 onwards, which was retrieved from the WHO-UNICEF Joint Reporting Form repository. No primary data were collected for this analysis, and any information outside the study period or from other sources was excluded.

Results     

We observed that several services are scheduled and integrated with routine vaccinations in the public sector across the Eastern and Southern Africa (ESA) sub-region. The reported services include vitamin A supplementation, growth monitoring, referrals for children and caregivers, deworming treatment, micronutrient supplementation, family planning for caregivers, and health education on breastfeeding, water, sanitation, hygiene, HIV/AIDS services, and malaria prevention and distribution, among others. We assessed 21 eJRF indicators related to integrated service delivery with routine immunization in the public sector across ESA countries. The most integrated service was growth monitoring for children aged 0-11 months, with an average score of 91%, followed by growth monitoring for 12-23 months (89%), breastfeeding education for 0-11 months (87%), and referrals for 0-11 months (86%). Countries that consistently implemented over 80% of these services included Tanzania, Zambia, Eritrea, and Namibia. In contrast, South Sudan, Seychelles, Madagascar, and Mozambique scored below 50%, indicating significant gaps in integration and the need for improved coordination and reporting.

As shown in Table 1, the package of services that integrates vitamin A supplementation, growth monitoring, and referral services during routine vaccination contacts has been fully implemented in the public sectors of Botswana, Ethiopia, Lesotho, South Africa, Tanzania, and Zambia. We noted that the average rate of vitamin A supplementation for children aged 0-11 months was 2% higher than for those aged 12-23 months across the sub-region. Mauritius, Seychelles, and South Sudan reported no integration of these services. Rwanda reported integration only in 2023 for the 0-11-month age group. Uganda's performance was suboptimal only provided services to children aged 0-11 months until 2020, when it expanded to include both age groups. Mozambique and Zimbabwe had years without reporting on whether the services were included. Growth monitoring was well-implemented in most countries, except in Madagascar, where the service was not included until 2020, and in South Sudan until 2022. In other countries, suboptimal performance was primarily due to a lack of reporting rather than a clear indication that the service was not integrated with routine vaccination. Referral services for sick children or caregivers were reported to be practiced in most countries during the study period. Exceptions included Malawi, which did not report this practice until 2019, and South Sudan in 2022.

During the study period, we observed that most ESA countries successfully integrated family planning services with routine vaccination. Botswana, Ethiopia, Lesotho, Mauritius, and Tanzania achieved a perfect integration rate of 100% (Table 2). In contrast, South Sudan did not provide these services, while Comoros and Uganda showed the least integration. Regarding deworming services, these were not scheduled along with routine immunizations for children aged 0-11 months in Botswana, Ethiopia, Rwanda, Mauritius, Seychelles, and South Sudan. While Madagascar and Tanzania initially integrated deworming, they discontinued it in 2022 and 2020, respectively. For the older age group (12-23 months), most countries integrated deworming, with Ethiopia, Mauritius, and South Sudan as the exceptions. Notably, Rwanda offered integrated deworming for this age group only in 2021. Data on micronutrient supplementation for the subregion were limited to the years 2022-2024. As of this period, micronutrient supplementation was not scheduled alongside routine immunizations in Botswana, Ethiopia, Madagascar, Seychelles, South Sudan, Tanzania, and Zimbabwe. In contrast, Eritrea, Malawi, Lesotho, Namibia, and Zambia reported full integration of micronutrient supplementation with routine vaccination for both age groups (0-11 months and 12-23 months) within their public health services.

During the study period, integrated health education sessions including topics such as breastfeeding and water, sanitation, and hygiene (WASH) were fully implemented (100%) in Botswana, Lesotho, Mauritius, Tanzania, and Zambia within the ESA subregion. In contrast, countries that demonstrated lower average implementation scores for integrated health education included South Sudan (29%), Mozambique (50%), Comoros (57%), and Madagascar (57%). Among the components of the health education package, breastfeeding for young infants (ages 0-11 months) received relatively higher scores compared to other topics (Table 3). We also note that, HIV/AIDS services for both age groups were reported to be fully integrated with routine vaccinations (100%) in Botswana, Ethiopia, Lesotho, Mauritius, South Africa, Tanzania, and Zambia (Table 4). However, the integration of HIV/AIDS services with routine vaccinations was not reported in Comoros, Madagascar, Malawi, and South Sudan. Madagascar and Tanzania reported that malaria preventive treatment for children aged 0-11 months and 12-23 months was scheduled alongside routine immunization. In contrast, this service was not reported in Botswana, Lesotho, Mauritius, Mozambique, Seychelles, South Sudan, and Zambia. The distribution of insecticide-treated bed nets was scheduled with routine immunization in Eritrea, Ethiopia, and Tanzania, but was not reported at all in Lesotho, Malawi, Mozambique, and Seychelles. Overall, Ethiopia and Tanzania had higher mean scores for integrating HIV/AIDS and malaria program interventions with routine immunization in the public sector. In contrast, integration was less likely to occur in South Sudan, Seychelles, Malawi, Madagascar, and Mozambique.

Discussion     

Several essential health services are integrated with routine vaccinations in the East and Southern Africa subregion. These include vitamin A supplementation, growth monitoring, referrals, deworming treatment, micronutrient supplementation, family planning, and health education on breastfeeding, hygiene, and disease prevention. This integration supports WHO´s Immunization Agenda 2030, aiming to enhance primary health care and advance universal health coverage. Countries like Botswana, Ethiopia, Lesotho, South Africa, Tanzania, and Zambia have fully implemented these services, with vitamin A coverage for children aged 0 to 11 months being 2% higher than for those aged 12 to 23 months. However, Mauritius, Seychelles, and South Sudan reported no integration, while Rwanda began integrating services for the younger age group in 2023. Uganda expanded its services to both age groups in 2020. Given the high incidence and mortality associated with measles infection in South Sudan, targeted support may be necessary to strengthen the integration of essential health services and improve their uptake among children aged 0-11 months and 12-23 months. There were gaps in reporting from Mozambique and Zimbabwe, leaving uncertainty about their service integration.

Growth monitoring showed good implementation overall, with Madagascar starting in 2020 and South Sudan reporting only in 2022. Referral services for sick children and caregivers were common, but Malawi and South Sudan reported these services later than other countries. These findings highlight both progress and challenges in integrated service delivery. WHO advocates for this approach to improve efficiency and health outcomes. Countries with strong integration demonstrate their potential, while others may benefit from better monitoring, policy alignment, and capacity-building to ensure equitable service delivery. We also observed that most countries in the ESA subregion have made commendable progress in integrating family planning services with routine immunization. Several have achieved full integration, reflecting strong alignment with the strategies promoted by the WHO and other immunization stakeholders that emphasize comprehensive primary health care. However, disparities still exist, particularly in countries like South Sudan, Comoros, and Uganda, where integration is limited or absent, likely due to reporting or systemic challenges.

The integration of deworming services is inconsistent, especially for infants under one year old. Some countries have even discontinued previously established programs, indicating a need for renewed policy focus and resource allocation. Although integration of these services is more common for children aged 12 to 23 months, gaps persist. Micronutrient supplementation has the least integration across the subregion, with only a few countries consistently offering it alongside immunization. This situation highlights missed opportunities to address child malnutrition and improve developmental outcomes. To ensure equitable and effective service delivery across ESA countries, it is essential to strengthen coordination between immunization and other child health survival services, improve data systems, and enhance community engagement. The integration of health education and disease prevention with routine immunization in the ESA subregion shows promising progress, particularly in Botswana, Lesotho, Mauritius, Tanzania, and Zambia, where breastfeeding and WASH education have been fully implemented. This aligns with WHO´s Immunization Agenda 2030, which promotes using immunization platforms for broader health services. However, South Sudan, Mozambique, Comoros, and Madagascar reported lower implementation scores, highlighting coverage gaps. In addition, breastfeeding education for infants aged 0-11 months received higher scores, indicating strong prioritization. In terms of HIV/AIDS and malaria services, countries like Botswana, Ethiopia, and Tanzania reported full integration, while others like Comoros and Madagascar lacked adequate reporting. Ethiopia and Tanzania also demonstrated better integration of malaria preventive measures. To improve service delivery, countries with lower integration should adopt best practices from high performers, enhance data reporting, and invest in health worker training and community engagement.

Limitations: the main limitation of this study is its reliance on secondary data from the electronic WHO-UNICEF Joint Reporting Form (eJRF), which may contain gaps and inconsistencies. The absence of primary data restricts the ability to validate findings and explore the factors influencing the integration of health services with routine immunization. By excluding data from before 2018, the study limits long-term trend analysis of integrated service delivery. Additionally, the lack of perspectives from EPI managers, health workers, and policymakers constrains insights into the dynamics shaping integration efforts. Conducting a comparative policy analysis across ESA countries could help to identify best practices and barriers. Furthermore, a longitudinal study on the effects of initiatives such as the Gavi transition and the Immunization Agenda 2030 would provide valuable insights for the integration of services scheduled alongside routine vaccination.

Conclusion     

Our study shows that many essential health services are being effectively integrated with routine immunization in several countries across the ESA subregion. These services include vitamin A supplementation, growth monitoring, referrals, deworming, micronutrient supplementation, family planning, and health education related to breastfeeding, hygiene, and disease prevention. Countries such as Botswana, Ethiopia, Lesotho, South Africa, Tanzania, and Zambia have demonstrated strong implementation, aligning with WHO´s Immunization Agenda 2030. However, gaps still exist in countries like South Sudan, Mauritius, and Seychelles, where integration is limited or non-existent. Additionally, Mozambique and Zimbabwe face challenges with inconsistent reporting, making assessment difficult. There is a notably higher uptake of these services among children aged 0-11 months compared to those aged 12-23 months, indicating a need for more balanced targeting across age groups. Despite the progress, the integration of services such as deworming and micronutrient supplementation remains inconsistent, particularly for infants under one year old. Some countries have even discontinued previously established programs, pointing to a need for renewed policy focus and resource allocation. Family planning services have been well-integrated in several regions, but disparities continue in places like South Sudan, Comoros, and Uganda. Health education and disease prevention services including breastfeeding promotion, water, sanitation, and hygiene (WASH), as well as interventions for HIV/AIDS and malaria, have also been integrated to varying extents. Ethiopia and Tanzania stand out for their comprehensive approach, while other countries lag due to systemic issues or reporting challenges. In conclusion, while the ESA subregion has made significant progress in integrating health services with routine immunization, further efforts are necessary to ensure equitable and consistent delivery across all countries. Strengthening coordination between immunization and child survival programs, improving data systems, investing in health worker capacity, and enhancing community engagement are essential strategies to address existing gaps and maximize the impact of integrated service delivery.

Competing interests     

The auhtors declare no competing interests.

Authors' contributions     

Daudi Manyanga and Maryanna Ochieng conceptualized and designed the study, constructed the background information, data collection, study analysis, interpretation, discussion, review and organization of the entire manuscript for publication. Sarah Wanyoike reviewed the manuscript and contributed to the discussion and conclusion. All the authors read and approved the final version of this manuscript.

Acknowledgments     

We acknowledge the efforts of all EPI Managers from Ministries of Health, WHO (all three levels), and other partners in the ESA countries for their unwavering commitment to delivering safe vaccines to all children.

Tables     

Table 1: average reported integration of vitamin a supplementation, growth monitoring, and referral services during routine vaccination contacts in the public sector (2018-2024), by country in the ESA sub-region

Table 2: average reported integration of deworming treatment, Micronutrient supplementation and family planning for the caregiver services during routine vaccination contacts in the public sector (2018-2024), by country in the ESA sub-region

Table 3: average reported integration of health education on breast feeding and water, sanitation and hygiene services during routine vaccination contacts in the public sector (2018-2024), by country in the ESA sub-region

Table 4: average reported integration of HIV/AIDs, malaria preventive treatment, and distribution of bed nets services during routine vaccination contacts in the public sector (2018-2024), by country in the ESA sub-region

References