When Everyone Comes, So Do the Unseen: Kenya’s UHC Pilot and the Unexpected Reach of Routine Immunization

When Everyone Comes, So Do the Unseen: Kenya’s UHC Pilot and the Unexpected Reach of Routine Immunization | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article When Everyone Comes, So Do the Unseen: Kenya’s UHC Pilot and the Unexpected Reach of Routine Immunization Alex Olateju Adjagba, Catherine Akoth, Caleb Nyakundi, Sharonmercy Okemwa, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7244451/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Immunization is a critical component of primary health care and a key driver of Universal Health Coverage (UHC). Yet, many low- and middle-income countries, including Kenya, face persistent challenges in sustaining the financing of immunization programs. As countries shift toward UHC, there is growing concern that broader health financing reforms may not strengthen and could even weaken dedicated funding for immunization. This study examines Kenya’s UHC pilot to explore whether the move toward UHC risks displacing resources currently allocated to immunization, particularly at the county level. Methods : Data were collected between June and July 2021 through in-depth interviews and focus group discussions with key informants across four UHC pilot counties in Kenya. An inductive thematic analysis was used to interpret the qualitative data, utilizing Dedoose software (Version 9.0.17) to facilitate systematic analysis. Identify patterns and themes related to immunization financing at the subnational level. Results: The implementation of UHC increased access to healthcare services, which in turn raised the demand for immunization. However, funding for operational aspects of immunization faced several obstacles. These included insufficient funding that limited outreach efforts, logistical issues, and shortages of human resources. Counties also experienced periodic stockouts of specific antigens and syringes, which were worsened by the limited financial independence of health facility managers. These service disruptions were partly mitigated by additional support from development partners, supplementing government and Gavi funding sources. Conclusion: The UHC pilot had various impacts on funding for immunization services. When services are free, families are more likely to seek care and often bring unvaccinated children with them. This suggests that removing financial barriers could be a powerful strategy for reaching zero-dose children. However, realizing this potential through UHC requires stronger county-level planning and coordination across the government to ensure sustainable financing for immunization services. Further research is needed to assess how to mitigate the impact of UHC reforms on immunization, especially for underserved populations. Immunization financing universal health coverage Kenya planning budgeting public financial management health financing UHC financing county planning county budget sustainability of healthcare funding aid Gavi vaccines Introduction Each year, roughly 150 million people worldwide face catastrophic health expenses, and nearly 100 million are driven into poverty due to out-of-pocket healthcare costs [3, 4]. Recognizing the significant economic and social impacts of unaffordable healthcare, the United Nations has highlighted the importance of financial protection as a key element of sustainable development [6, 7]. Ensuring equitable access to quality healthcare services, delivered when and where they are needed, was established as a global priority in the post-2015 development agenda, culminating in Target 3.8 of the Sustainable Development Goals (SDGs) [1, 5]. Universal Health Coverage (UHC) reflects this goal by aiming to provide essential health services without causing financial hardship for individuals [2]. In Kenya, the pursuit of UHC has been a longstanding policy goal, reflected in a series of health sector reforms since independence [8, 9]. A significant milestone was reached in 2017 when the government committed to achieving UHC by 2022 as part of the President’s Big Four Agenda. This initiative aimed to expand access to essential health services by subsidizing care in public facilities [10]. Despite notable progress, Kenya still faces significant challenges in UHC. These include limited national resources, a high disease burden, and widespread poverty. For many low-income households, healthcare remains unaffordable without causing significant financial hardship [4, 11]. Kenya’s UHC framework is built on three main pillars: a) publicly funded primary healthcare, including preventive, promotive, outpatient, and basic diagnostic services, with patients able to select providers based on a regulated tariff; b) a Social Health Insurance Fund (SHIF) managed through the National Health Insurance Fund (NHIF); and c) a national fund for chronic and catastrophic illnesses, covering conditions such as cancer, diabetes, stroke, accident rehabilitation, and pandemics [12]. This fund is supported by a combination of insurance levies and government contributions, marking a significant step toward comprehensive health coverage. Immunization is a vital part of primary healthcare and a key element of UHC [13]. It not only prevents millions of deaths each year but also strengthens the connection between families and health systems, creating opportunities for integrated service delivery [14]. As one of the most cost-effective health interventions, immunization provides significant economic returns; each dollar invested can save up to US$44 in societal costs [15, 16]. Between 2011 and 2030, immunization is expected to prevent approximately US$1.5 trillion in illness-related expenses and generate over US$5.6 trillion in economic benefits across 94 low- and middle-income countries (LMICs) [17]. By lowering disease burden, immunization also improves financial risk protection, shielding households from catastrophic health costs [18]. However, despite the introduction of new vaccines and programmatic advances, immunization coverage in Kenya and many LMICs remains inadequate [19]. A major obstacle is the lack of sustainable funding. As governments face competing priorities and donor support declines, funding gaps have widened [20]. In Africa alone, immunization needs were estimated at US$17 billion between 2016 and 2020, with governments expected to cover only about one-third of the costs, resulting in a shortfall of roughly US$5 billion [21]. Many countries, including Kenya, still rely heavily on external funding sources, such as Gavi [22]. Kenya’s immunization financing challenges are particularly urgent amid the push for expanding UHC. The anticipated reduction of support from Gavi by 2029 poses a significant risk: without firm domestic financing plans, progress in immunization coverage could regress, ultimately negatively impacting overall health outcomes [23]. As UHC advances, establishing sustainable financing systems to support and expand immunization services becomes essential. Background on Kenya’s health sector Kenya is a lower-middle-income country in East Africa with a population of 47.564 million, according to the 2019 population and housing census. The average population in each county varies widely. The five largest counties are Nairobi, Kiambu, Nakuru, Kakamega, and Bungoma. Kenya reformed its government system in 2013 following the adoption of the new constitution in 2010. The most notable feature of the Kenyan Constitution of 2010 was the introduction of a devolved system of government, which is unique to Kenya and provides for one (1) national government and forty-seven (47) county governments. The governments at the national and county levels are “distinct and interdependent” and are expected to manage their relationship through “consultation and cooperation.” The uniqueness of the governments under the devolved system is outlined by the Fourth Schedule of the Constitution, which assigns different functions to each level of government. The national government has traditionally led all aspects of the immunization program. It oversees the development of health policies, training, and procurement of vaccines and other essential supplies for all counties. It procures traditional vaccines for routine immunization independently, with external support from Gavi, the Vaccine Alliance, for vaccines and other supplies required for the immunization program. The devolution reform has primarily focused on transferring decision-making related to health sector resources to lower-level management units, with proper oversight by governance structures, including facility management committees (FMCs) and district/hospital management boards (D/HMBs), which comprise a mix of elected community representatives and appointed public officials. The 2010 constitution and subsequent legislation outline the structures of county governments with two independent branches: (i) the County Executive, which includes an elected governor and their deputy, is primarily responsible for implementing all government services assigned to counties by the constitution. (ii) The County Assembly (CA) consists of elected members of the County Members of the Assembly (CMAs). Each MCA represents an electoral ward, although the CA also has a few nominated members representing special interest groups such as women, youths, and people with disabilities. Nominated MCA seats in the CA are allocated among political parties proportionally based on each party's number of members in the CA [ 28 ]. The national government is responsible for acquiring vaccines, distributing them to regional depots, developing policies and guidelines, and overseeing the training of healthcare workers. County governments, in turn, are tasked with collecting vaccines from regional depots, ensuring their transportation to service delivery points while maintaining the cold chain, providing the necessary human resources for immunization services, and procuring immunization supplies such as syringes and safety boxes. The national and county governments provide immunization funding, with additional contributions from development partners. Before the devolution process, community, facility, and district stakeholders had limited involvement in sector planning and budgeting, which caused a disconnect between needs and solutions. Although post-devolution governance, in theory, has addressed top-down planning, studies reveal a lack of capacity at the decentralized level to plan and budget, difficulties with priority setting in the health sector, and excessive politicization of health sector priority-setting processes at the county level. In December 2018, the government launched a UHC pilot in four counties: Machakos, which experiences frequent hospital visits due to accidents and injuries; Nyeri, which has the highest number of non-communicable disease cases, especially diabetes; Isiolo, a suitable place to evaluate how the package functions within the nomadic population; and Kisumu, which has high rates of infectious diseases like HIV/AIDS and tuberculosis. The UHC pilot’s goal was to evaluate the feasibility of delivering a specific set of healthcare services across the selected counties, with the government covering the cost of care. Since the pilot concluded in 2019, many lessons were learned that will guide the national implementation of UHC across all 47 counties. Study Objectives This paper explores the management of immunization services within the evolving landscape of Universal Health Coverage (UHC) in Kenya. Focusing on four counties that participated in a UHC pilot, the study investigates sub-national approaches to immunization service delivery and financing. The findings aim to inform national policy by highlighting practical lessons and strategies for integrating immunization into UHC frameworks, ultimately supporting Kenya’s goal of achieving equitable and sustainable health coverage for all. Methods Study setting & context This study was conducted in Kisumu, Machakos, Isiolo, and Nyeri counties, which were selected as pilot sites for Kenya’s Universal Health Coverage (UHC) model launched in December 2018. Study design and participant selection. This qualitative study conducted in-depth interviews (IDIs) with key informants across the four UHC pilot counties: Kisumu, Machakos, Isiolo, and Nyeri. Participants included senior officials from county health management teams, staff from selected county health facilities, and representatives from patient groups and community health workers. During the UHC pilot phase, participants at the county and facility levels were purposively selected based on their direct involvement in planning, managing, and implementing health programs, including immunization. Additionally, a convenience sampling approach was used to recruit relevant community health workers and patient representatives from each facility to participate in the study. Data collection Semi-structured interview guides were developed specifically for this study to guide data collection (see supplementary file 1). Two members of the research team, along with trained field interviewers, conducted the interviews in quiet, private, and convenient locations selected by the participants. All interviews were conducted in English, audio-recorded with the participants' consent, and lasted approximately one hour each. Data collection took place between June and July 2021. Data analysis All audio recordings were transcribed verbatim before analysis. Transcripts were reviewed multiple times to ensure completeness, accuracy, and consistency. The study aimed to identify themes related to the impact of the UHC pilot program on immunization services across four selected counties. An inductive thematic analysis was employed, beginning with the development of a priori codes derived from the interview guides and initial transcript reviews. Transcripts were then systematically coded using Dedoose qualitative analysis software (Version 9.0.17) [ 35 ], which facilitated the identification of emerging parent and child codes. Relevant themes and concepts were iteratively refined to enhance their analytical relevance and interpretive clarity. Results Respondent characteristics The study involved 107 participants, including 19 senior officials from the County Departments of Health (CDOH), 32 healthcare workers from various roles within county health facilities, 28 community health volunteers, and 28 patient representatives. Data collection consisted of 51 in-depth interviews and seven focus group discussions conducted across the four UHC pilot counties. The sample mainly consisted of females (52%), with participants averaging 38.4 years of age. Sustained financing of immunization activities during the UHC Pilot Respondents reported that counties used their existing expertise in planning and resource allocation to support key immunization activities during the UHC pilot. These activities included vaccine distribution, data verification, supervision, and maintaining cold chain equipment. In some counties, local governments also funded specific immunization needs, such as BCG solo shots and outreach programs, with support from partners including AMREF, the Red Cross, County Health Assistants (CHA), and Community Health Volunteers (CHVs), who played a vital role in identifying and tracking defaulters. “At the county level, we create an annual work plan that covers all immunization activities for that specific fiscal year. We can allocate funds for immunization services if you carry out any training, supervision, on-the-job training, or mentorship. We also allocate money for data quality assessments and verification, as well as for supervision and periodic maintenance of immunization equipment” (KI-26-21). "It is the county that primarily supports outreach efforts. We receive funding from the World Bank and the THS CCP project, allowing us to allocate money for outreach activities. Our partners also contribute to these efforts. Additionally, we have partners like AMREF, who have supported several of the outreaches" (KI-26-21). “We compile the list of defaulters and give it to CHAs to find CHVs in those areas.” (ID-10-21) “...also, the Red Cross, particularly when floods or disasters occur, can set up medical camps. With these camps in place, we can oversee them and administer immunizations”. (KI-10-21) Funding needs for immunization grew during the UHC pilot, while outreach activities declined. During the UHC pilot, financing needs for immunization rose, yet outreach activities surprisingly declined. This gap can be linked to the lack of dedicated UHC funds specifically for immunization programs. While vaccine procurement and related supplies remained centrally managed and essentially unchanged, counties had to reallocate resources to meet the increasing demand for pharmaceuticals and non-pharmaceutical supplies. Supported in part by donors such as the World Bank, this shift highlights a significant gap in integrating immunization into broader UHC financing strategies, underscoring the need for more targeted and secure funding sources to sustain and expand immunization services. “Was immunization funding better during that time than before or after the UHC pilot? No, nothing changed" (KI-36-21). “Immunization, as I understand, is a vertical program, like HIV and TB, whereas as a county, we receive direct funding from the MOH. We get the vaccines and ARVs directly from the MOH and do not necessarily procure them ourselves”. (KI-27-21) “On our end, we discuss the expenditure for immunization because we incur zero cost since we get vaccines for free. However, we usually incur no cost. Immunization is free” (ID-47-21) “During the UHC pilot, the demand for immunization services grew. To meet this increased demand, some departments reallocated funds to support immunization efforts, especially to prevent stock-outs and ensure service delivery”. (KI-03-21) "There was a demand for immunization, and now babies are being brought in for immunization. Besides using the UHC funds, you know, there were also other departmental allocations from the exchequer." (KI-03-21) "We, as a department, made sure to allocate enough funds for immunization at that time to meet the demand. Because you bring your baby to the hospital and there is no vaccine, how will you feel?" (KI-03-21) "This World Bank grant continued. I believe it mainly focuses on immunization and family planning. Therefore, I think they complement each other. Perhaps at the facility level, the systems were able to operate more efficiently. Services could be offered in a better manner simply because the scope was larger at that point." (KI-27-21) “We had a shared procurement for pharmaceuticals and non-pharmaceuticals from the county level, and then it would be delivered to us.” (ID-21-21). The shift to UHC caused funding gaps, which led to the deprioritization of key outreach efforts and exposed a disconnect between policy goals and operational realities. This change created significant logistical challenges, including shortages of vehicles, fuel, and staff resources essential for successful outreach. Moreover, ongoing human resource shortages further disrupt routine immunization activities, with staff frequently expected to handle increased workloads without additional compensation. These issues highlight the systemic weaknesses that arise when service delivery components are not effectively integrated into UHC financing and planning systems. “With the introduction of UHC, our trend began to decline because we did not have any stable partner.” (ID-10-21) “We are required to allocate some funds for BCG syringes for outreach efforts, but most items are supplied from the national level.” (ID-32-21) “Now we are only doing outreach on an as-needed basis; we used to have regular outreach.” (KI-26-21) "You realize that sometimes we don't even have the fuel to move, so when we can't locomote like that now, we can't reach those children that have not returned." (KI-10-21) Fiscal coordination challenges: the relationship between national and county levels in funding immunization programs The shift to UHC caused funding gaps, which led to the deprioritization of key outreach activities and exposed a gap between policy goals and actual operations. This change created significant logistical issues, including shortages of vehicles, fuel, and staff resources, all of which are vital for effective outreach. Moreover, ongoing human resource shortages further disrupted routine immunization efforts, with staff often expected to handle increased workloads without additional compensation. These issues reveal systemic weaknesses that arise when service delivery components are not well integrated into UHC financing and planning frameworks. "When you brought in UHC, the way they rolled it out, there was an upsurge in numbers. The individual revenue from the facility disappears, and therefore, you are relying on money from above" (ID-30-21). “We had to wait for the usual disbursement from the national government, with money being disbursed only enough to pay salaries" (KI-38-21). "Now, with the UHC, funds come from the county. Therefore, we will need to wait for the county government to allocate a budget. Even if we send our request, we still have to wait for the County Government to send us the money, which can sometimes be very slow and late." (ID-05-21) “Therefore, this money had to be included in our budget and approved before we could use it. Yeah. Moreover, approval is through the County Assembly. Yeah. So, it took some time to get the approval for this money." (KI-03-21). “This delay impacts the daily operations of health facilities, from paying bills to maintaining essential services like internet connectivity for administrative functions. There were delays in accountability and additional requests for a refund.” (KI-38-21). “They believe the national government still manages immunization; to them, it is not a priority for the county" (KI-36-21). UHC rollout drives higher demand for immunization services Respondents reported an increase in immunization rates across most counties, mainly due to higher hospital attendance during the UHC pilot. However, this spike in demand exposed critical systemic weaknesses, particularly in human resource capacity and financial readiness at the facility level. Many healthcare facilities were inadequately equipped to handle the surge, resulting in overstretched staff and limited budgets. Consequently, the quality of care declined, illustrating the unintended effects of expanding access without sufficient investment in service delivery infrastructure. "It may have increased because more people visited hospitals. Therefore, using the supermarket approach, if you came for treatment, you also brought your child along for immunization”. (KI-05-21) " We also see mothers giving birth at the hospital, and you know that when births happen in the hospital, you must plan for immunization because the number of births increases, and these children born are the ones accessing immunization services.” (KI-26-21) "But I don't believe there was a significant impact, but even if there was, our immunizations have always been free. Therefore, I can't say there was any impact because immunizations are always free.” (ID-21-21) "There is that sense of confidence when you go somewhere, knowing you won't be charged, but there's always that fear within the community that you're going to the hospital. I don't want to be told to buy a book or do something just because they know there's no money coming from you" (KI-01-21). "We have a significant shortage of tools, especially mother and child booklets. Like now, as I am talking to you, we do not have enough." (KI-26-21) "The people responsible for this include those who handle immunizations, family planning, documentation, and reporting. Overall, you find that even our staff experience burnout, and of course, when staff burnout occurs, the output will not be good.” (KI-26-21) "During implementation, we experienced many clients coming in, so I can say there was an increased workload. People could now stay on the line longer because there was only one nurse or clinician performing the procedure, and a long line of clients waited for that single clinician to serve them.” (ID-08-21) Antigen shortages following UHC expansion While the overall supply of vaccines and syringes remained stable during the UHC pilot, mainly due to centralized procurement by the national government and partners such as Gavi and UNICEF, respondents reported occasional shortages of specific antigens, including BCG and measles vaccines. These shortages were linked to two main factors: higher demand caused by increased service utilization under UHC and broader systemic issues such as nationwide stock-outs. Although these disruptions were not widespread, they underscore the vulnerability of supply chains to both demand pressures and external logistical challenges, underscoring the need for more responsive and resilient forecasting and distribution systems. “There isn't much to say about immunization because we get our supplies from KEMSA. We usually go through the KEMPI office at the sub-county store, and if we need anything, we ask them for it. They supply a few items, like syringes, which come directly from KEMSA. The orders are placed quarterly, every three months.” (ID-06-21.) “On a national level, Gavi and UNICEF are managing it; I know that the government purchases some vaccines. The shared information comes from Gavi, which is responsible for the funding. They are the ones handling it. There’s no point at which they would say that this money is allocated to the county for us to purchase the vaccines. They purchase the vaccines there and then supply them to us” (ID-31-21). "During UHC, when it picked up, the supplies were steady. Yeah. We had consistent supplies, except for that vaccine. Nevertheless, the other supplies were available. We did not have any issues with the syringes, safety boxes, cotton wool, or any other items because they were all present and accounted for.” (ID-27-21) “Therefore, it reached a point where hospitals lack drugs, non-pharmaceutical supplies, or resources to support immunization or even maternity care, because immunization begins during maternity. When this baby is born, before the mother and baby go home, you must ensure that the baby receives BCG and the first dose of polio. (KI-10-21) "There was a time when we experienced a shortage of specific vaccines such as measles and pentavalent, but it was nationwide, not just in this county”. (ID-31-21) To address emerging supply constraints, health facilities adjusted their ordering practices to accommodate the increased client load during the UHC pilot. Respondents observed that the introduction of UHC led to more proactive and data-driven adjustments in the procurement of vaccines and non-pharmaceutical supplies. This change improved forecasting accuracy and planning efficiency, indicating that UHC implementation, despite its challenges, sparked positive developments in supply chain responsiveness at the facility level. “We had to make adjustments, so we went to the store and said we had been picking this, and we adjusted due to the high number of clients.” (ID-34-21) "Once we realized we were getting high numbers, we also changed how we ordered vaccines. We started ordering more doses, going from 100 to 200 doses instead.” (ID-34-21) Strengthening immunization funding with strategic county planning The central government, through the National Vaccine and Immunization Program (NVIP), led the design and coordination of the UHC pilot, working closely with key partners and non-governmental organizations. While the national level retained responsibility for core financial and technical functions, such as vaccine and commodity procurement, county governments played a complementary role by managing operational logistics. These included hiring frontline staff and overseeing minor facility maintenance. This division of responsibilities reflects a hybrid governance model, where centralized procurement is paired with decentralized implementation, highlighting both the strengths and coordination challenges inherent in Kenya’s devolved health system. "What happened before was that you first registered all county residents, and then we issued them a universal card for registration. This allows them to access free services within the Isiolo County health facility. The NHIF and another company called Living Good, which was a partner with the county, were responsible for doing this.” (ID-35-21) “And Pharm Access, we are utilizing the M-TIBA platform for registration" (KI-01–21) "Therefore, anything related to the vaccines, including the national vaccine and immunization program called EPI, is their responsibility to plan. During campaigns or when introducing new vaccines, they are responsible for planning and organizing the rollout. They are the ones who coordinate the training and ensure everything is in place." (KI-36-21) "The national people managed everything, literally everything in terms of finances; the county would not." (KI-01-21) "The county provides support when we need to buy an extra fridge or for small repairs through the maintenance department. Additionally, for human resources, the county hires nurses for the facilities to carry out the immunization program." (KI-36-21) “The county did not fulfill part of its agreement in the first phase... they have allocated funds in the budget to pay for insurance for the indigent population.” (KI-05-21). Despite the intended objectives of the pilot, county healthcare professionals and key stakeholders described the planning phase as poorly timed and rushed. Major communication failures arose, exposing systemic coordination issues across government levels. These issues led to operational delays and widespread uncertainty during the implementation process. “ Well, in the national planning, there was very little inclusion of the county.” (KI-05-21) "No, no, no. This task was completed at the national and county levels without our input. In most training sessions, hospitals have medical superintendents, administrators, public health officers, and nurses in charge. They should have been involved from the very beginning idea." (ID-07-21). "As I had said, most of us, as implementers, were not involved in UHC inception, but they tried what they could." (ID-07-21) "When I involve you in doing something or want you to participate, we will communicate to prepare. For example, maybe only a few people were informed, say, one week before the rollout. Then, we needed to register people for UHC. Now it seems like we are pushing people to register that way, but we didn't have proper objectives or a clear flow of events." (KI-10-21) Key findings on immunization financing during Kenya’s UHC pilot Kenya’s immunization program has traditionally depended on donor-funded, vertically organized financing systems managed centrally by the national government. This structure remained unchanged during the UHC pilot, with counties continuing to receive vaccines and supplies from the MoH at no cost and without engaging in local procurement. As a result, the UHC pilot did not significantly alter the immunization financing responsibilities at the county level. Despite this, the UHC pilot had a significant impact on service demand and delivery. Respondents reported a threefold increase in vaccination rates across the pilot counties, indicating a substantial improvement in health-seeking behavior. This rise in demand necessitated additional financial resources, which were secured through a combination of national government allocations, county contributions, and support from development partners, including UNICEF and the World Bank. The vaccine supply chain remained stable, managed centrally by the MoH and its partners such as Gavi and UNICEF. One of the most notable improvements attributed to the UHC pilot was an increase in supply chain efficiency. Respondents noted better availability of essential immunization supplies, such as syringes and safety boxes. Counties also took a more active role in planning, resource allocation, and outreach efforts. However, the pilot revealed ongoing challenges in financing the operational aspects of immunization, as inadequate funding led to reduced outreach activities, logistical delays, and shortages of human resources. Additionally, counties faced intermittent stockouts of specific antigens and syringes. These problems were worsened by limited financial autonomy at the facility level and delays in disbursement due to new intergovernmental financial management procedures, especially the routing of UHC funds through county treasuries. A critical insight from respondents was the urgent need for more inclusive and timely planning. They emphasized that the rushed, top-down approach to UHC implementation hindered effective coordination. Greater involvement of county healthcare professionals and local stakeholders, rather than just administrators, was identified as essential for addressing these systemic challenges and ensuring the smoother implementation of future health reforms. Discussion The implementation of UHC in Kenya marked a significant shift in the country’s healthcare system, aiming to improve access to affordable, high-quality health services. This change also impacted immunization services, particularly in terms of funding structures and service delivery. This study analyzed the impact of the UHC pilot, conducted in four counties, on immunization services, with a focus on financing methods. Before launching the UHC pilot, counties engaged in preparatory planning involving both national and local stakeholders. According to respondents, the national government played a central role in procuring vaccines and essential supplies, while counties managed logistical support, including staff recruitment and minor facility upgrades. Development partners, including the NHIF, KEMSA, and various international organizations, assisted counties in registering beneficiaries and distributing resources. Despite this multi-stakeholder involvement, respondents noted that the planning process was predominantly top-down, with limited input from county health professionals and other key local stakeholders. This exclusion was apparent in immunization planning. It conflicted with the principles outlined in the UHC Policy Framework 2020–2030, which stresses shared leadership and defined roles for both national and county governments in health sector governance and stakeholder engagement [ 36 ]. Similarly, frontline health workers, including facility staff and community health volunteers, were often left out during the planning phase. These findings mirror earlier studies that reported the exclusion of immunization program officers from budgeting and planning processes [ 37 ]. This lack of inclusive consultation led to communication and coordination failures between national and county governments, which in turn disrupted the smooth rollout of immunization services under UHC. Respondents also emphasized that the quick rollout of UHC, without sufficient preparation for the counties, worsened logistical and operational problems. Counties found it hard to reallocate their financial and human resources to handle the rising demand for services. This supports earlier research showing that poor coordination between national and county governments can weaken health system efficiency, raise transactional costs, and hinder service delivery [ 37 , 38 ]. Importantly, the UHC pilot did not result in significant changes to the core financing of immunization services. In Kenya, immunization has traditionally been funded through donor contributions and vertical financing mechanisms, mainly managed by the national government [ 20 ]. This setup remained unchanged during the UHC period, with counties continuing to receive vaccines and related supplies from the MoH at no cost. As a result, counties were not required to use significant local funds for immunization, and the UHC initiative did not fundamentally change the financial structure of vaccination at the county level. Although respondents emphasized that the core immunization funding mechanisms remained unchanged during the UHC pilot, the program had notable indirect effects on how immunization services operated. The rollout of UHC caused a significant rise in demand for immunization, fueled by better access to healthcare and a shift in health-seeking behavior. In response, some counties reallocated departmental funds to support immunization efforts, especially to manage the increased demand during the pilot phase. However, outreach activities vital for reaching remote and underserved populations were often limited by funding shortages. These challenges highlight the need for stronger financial planning and targeted resource allocation to maintain immunization services as healthcare access expands. The UHC pilot introduced new public finance management structures that reshaped the distribution of funds. A key change involved routing UHC funds through county treasuries before disbursing them into health facilities. This shift disrupted the financial independence of facilities, which had previously depended on user fees for operational flexibility and stability. As a result, facilities became reliant on county-level allocations, which were often delayed or insufficient to cover operational costs. These changes negatively impacted the efficiency of health services, including immunization support. Similar findings have been documented in earlier studies, which noted that slow and unpredictable fund disbursement from the national government significantly hampered the implementation of county health budgets and affected interventions such as immunization [ 37 ]. These financial management challenges seem to be ongoing issues inherited from the transitional authority during the devolution of health functions [ 39 ]. Logistical constraints, such as shortages of vehicles, fuel, and other essential resources required for immunization outreach, were frequently reported. These gaps were often linked to a lack of county-level commitment to UHC programs. For example, in Isiolo County, shifting from input-based to output-based financing led to a lack of sustained support for outreach services, which exacerbated resource shortages and disrupted service continuity [ 40 ]. Human resource challenges also worsened, as healthcare workers were often pulled from their regular duties to support immunization activities without receiving extra pay. This led to staff burnout and a decline in service efficiency. These findings align with other studies that have reported increased workloads and chronic understaffing in facilities implementing UHC programs [ 41 , 42 ]. These challenges emphasize the urgent need for better resource allocation and workforce planning to sustain immunization services. Despite these operational and financial constraints, the demand for immunization services grew during the UHC pilot. This increase was not directly attributed to UHC's targeting of immunization, but rather a broader rise in healthcare utilization. Respondents described a “supermarket approach,” where patients visiting facilities for other services also accessed immunization for their children. However, it remains unclear whether this rise was mainly caused by improved health-seeking behavior or the removal of user fees, a factor known to increase service use [ 41 , 43 , 44 ]. One of the more positive outcomes of the UHC pilot was the improvement in supply chain management. Respondents reported better availability of essential supplies, such as syringes and safety boxes, facilitated by consistent procurement through KEMSA. This improvement was observed across all four pilot counties, although occasional delays were noted [ 42 ]. However, intermittent shortages of specific antigens, such as BCG and measles vaccines, were reported due to increased demand; facilities adapted by improving forecasting and scaling their orders accordingly. The overall stability of the vaccine supply was primarily due to centralized procurement and strong partnerships with organizations such as Gavi and UNICEF. These partners played a crucial role in supporting government efforts to meet immunization needs [ 45 ]. However, this dependence on donor support raises concerns about long-term sustainability. As shown in previous studies, neither national nor county governments are yet sufficiently prepared for a transition away from donor funding [ 46 ]. This highlights the urgent need for a comprehensive, well-documented immunization financing strategy that guarantees continuity beyond external support. Strengths and limitations This study is the first in-depth qualitative investigation in Kenya to explore the implications of UHC on immunization financing across four pilot counties. By incorporating insights from a diverse range of stakeholders, including county health officials and frontline healthcare workers, this research provides a nuanced understanding of both the systemic challenges and operational successes encountered during the UHC pilot. The inclusion of multiple perspectives enriches the analysis and offers a grounded view of how immunization financing was managed in practice. However, the study is limited by its time frame, as it focuses solely on the pilot period. It does not capture post-pilot developments in immunization coverage, financial allocations, or broader health outcomes, which remain critical areas for future research. Conclusion Although immunization funding mechanisms remained essentially unchanged during Kenya’s UHC pilot, with minimal direct financial contributions across the four counties, the increased demand for immunization and other health services put additional pressure on county budgets. This rise in service use highlighted the need for extra funding and revealed ongoing challenges in maintaining immunization outreach, overcoming logistical barriers, and managing human resource limitations. These findings provide important insights for expanding UHC in Kenya and offer valuable lessons for other countries pursuing similar health system reforms. Notably, the reported tripling in the number of vaccinated children during the UHC pilot suggests that UHC platforms may play a pivotal role in identifying and reaching “zero-dose” children, those who have not received any routine vaccinations. These results indicate that when services are free, families are more likely to come forward, and in doing so, they often bring along children who have never received vaccinations. This natural uptake suggests that removing financial barriers could be one of the most powerful levers for reaching the unreached. To make this a reality, effective UHC implementation must be grounded in better planning at the county level and stronger coordination across all levels of government to ensure sustainable financing for immunization services. Tackling these systemic challenges is essential for ensuring continuity, equity, and trust in service delivery. Further research is needed to explore how donor funding can be more strategically aligned with UHC goals, especially in reaching children who are at risk of being zero-dose and remain persistently underserved. Abbreviations UHC Universal Health Coverage LMICs Low- and middle-income countries PHC Primary health care US United States IDI In-Depth Interview FGD Focus Group Discussion CDOH County Department of Health BCG Bacillus Calmette–Guérin (vaccine) AMREF African Medical and Research Foundation CHA Community health assistant CHVs Community health volunteers MoH Ministry of Health UNICEF United Nations International Children's Emergency Fund KEMSA Kenya Medical Supplies Authority KI Key informant ID Identification NHIF National Hospital Insurance Fund Declarations Ethics approval and consent to participate All procedures conducted in this study adhered to the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Moi University Institutional Ethics and Research Committee (approval number: 0003605). Before participation, all respondents were provided with an information sheet detailing the study’s objectives, procedures, potential risks and benefits, the intended use of the data, and the contact information of the research team. Participants were allowed to ask questions and seek clarification. Informed consent was obtained from all participants through the signing of a written consent form. Consent for publication Not required Competing Interests The authors declare that they have no competing interests. Clinical trial number Not applicable Authors’ information Alex Olateju Adjagba; https://orcid.org/0000-0002-1041-8836 Caleb Nyakundi; https://orcid.org/0000-0001-9142-1924 Catherine Akoth; https://orcid.org/0000–0002–9958–3490 James Oguta; https://orcid.org/0000–0002–2401–9895 Sharonmercy Okemwa: https://orcid.org/0000-0001-5939-3839 Funding This study was funded by a grant from the U.S. Centers for Disease Control and Prevention (CDC) to the United Nations Children’s Fund (UNICEF) in support of the Kenya Country Office. Author Contribution AOA conceptualized the study. JOO was responsible for data collection. AOA, JOO, and PO provided administrative and logistical support throughout the study. JOO, AOA, and CA transcribed the audio of the interview. AOA, JOO, CN, S.O., and CA conducted data analysis. AOA, CN, JOO, and CA prepared the initial manuscript draft. All authors critically reviewed the manuscript and approved the final version for publication. Acknowledgement The authors gratefully acknowledge Mark Omollo's support during data collection and transcription. Data Availability Data will be made available upon reasonable request by contacting the corresponding author [ [email protected] ](mailto: [email protected] ) References O’Donnell OA, Wagstaff A. Catastrophic payments for health care. Analyzing health equity using household survey data: a guide to techniques and their implementation. Washington DC: The World Bank; 2008. Evans DB, Etienne C. Health Systems Financing and the Path to Universal Coverage. Bull World Health Organ. 2010;88:402–3. Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet. 2012;380:864–5. Duran A, Kutzin J, Menabde N. Universal coverage challenges require health system approaches; the case of India. Health Policy. 2014;114:269–77. World Health Organization. Universal Health Coverage. 2024. https://www.who.int/health-topics/universal-health-coverage#tab=tab_1 . 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Ministry of Health; 2023. Tsofa B, Molyneux S, Gilson L, Goodman C. How does decentralization affect health sector planning and financial management? A case study of early effects of devolution in Kilifi County, Kenya. Int J Equity Health. 2017;16:151. Njuguna DK, Wangia E, Wainaina S, Ndavi TW. Budgeting County Level Kenya: What has Worked, Challenges Recommendations. Public Health Res. 2020;10:58–63. Waithaka D, Tsofa B, Kabia E, Barasa E. Describing and evaluating healthcare priority setting practices at the county level in Kenya. Int J Health Plann Manage. 2018. https://doi.org/10.1002/hpm.2527 . Kenya Vision 2030. County Governments At The Centre of Achieving Universal Health Care. 2018. https://vision2030.go.ke/county-governments-at-the-center-of-achieving-universal-health-care/ Nzwili F. Kenyan President Launches Benchmark Universal Health Coverage Pilot To Become Nationwide In 18 Months. Health Policy Watch. 2018. https://healthpolicy-watch.news/kenyan-president-launches-benchmark-universal-health-coverage-pilot-to-become-nationwide-in-18-months/ . Accessed 11 Oct 2024. Los Angeles CA. SocioCultural Research Consultants, LLC. Dedoose cloud application for managing, analyzing, and presenting qualitative and mixed-method research data. 2021. Ministry of Health. Kenya Universal Health Coverage Policy 2020–2030. Government of Kenya; 2020. Adjagba AO, Akoth C, Oguta JO, Wambiya EO, Nonvignon J, Jackson D. Financing Immunization in Kenya: Examining bottlenecks in health sector planning and budgeting at the decentralized level. Res Square. 2024. Nyawira L, Njuguna RG, Tsofa B, Musiega A, Munywoki J, Hanson K, et al. Examining the influence of health sector coordination on the efficiency of county health systems in Kenya. BMC Health Serv Res. 2023;23:355. Wairimu Mwaniki LO. Oct. Challenges to Attaining Universal Health Coverage in Kenya. KMA Public Health Committee. https://kma.co.ke/component/content/article/79-blog/125-challenges-facing-the-attainment-of-universal-health-coverage-in-kenya . Accessed 10 2024. Ngave PNNM, THE IMPACT OF UHC, PILOT IN ISIOLO COUNTY. Maarifa Center. 2023. https://maarifa.cog.go.ke/county-initiatives/impact-uhc-pilot-isiolo-county . Accessed 10 Oct 2024. Njuguna J. The effect of a pilot universal health coverage program on hospital workload: A comparative study of two counties in Kenya. Dialogs Health. 2023;2:100100. Vilcu SGI. A review of Afya Care- The Universal Health Coverage Pilot Program- In Isiolo County. Kenya Brief 5. Washington, DC: - Think Well; 2020. Kenya Kenya. Economics, Statistics Division Kenya. Ministry of Economic Planning, Development. Statistics Division Kenya. Ministry of Finance. Economic survey; 2005. Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan. 2011;26:1–11. Olateju A, Oguta JO, Wambiya EO, Akoth C. Strengthening health financing at the subnational level in Kenya: a stakeholder and needs mapping through a mixed methods approach. Pan Afr Med J. 2024;48. Adjagba A, Oguta J, Wambiya E, Nyakundi C, Okemwa S, Akoth C. Are we ready to transition from the Global Alliance for Vaccines and Immunization support? Perceptions from 15 Kenyan counties. Pan Afr Med J. 2024;49. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial1interviewguide.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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roughly 150 million people worldwide face catastrophic health expenses, and nearly 100 million are driven into poverty due to out-of-pocket healthcare costs [3, 4]. Recognizing the significant economic and social impacts of unaffordable healthcare, the United Nations has highlighted the importance of financial protection as a key element of sustainable development [6, 7]. Ensuring equitable access to quality healthcare services, delivered when and where they are needed, was established as a global priority in the post-2015 development agenda, culminating in Target 3.8 of the Sustainable Development Goals (SDGs) [1, 5]. Universal Health Coverage (UHC) reflects this goal by aiming to provide essential health services without causing financial hardship for individuals [2].\u003c/p\u003e\n\u003cp\u003eIn Kenya, the pursuit of UHC has been a longstanding policy goal, reflected in a series of health sector reforms since independence [8, 9]. A significant milestone was reached in 2017 when the government committed to achieving UHC by 2022 as part of the President’s Big Four Agenda. This initiative aimed to expand access to essential health services by subsidizing care in public facilities [10].\u003c/p\u003e\n\u003cp\u003eDespite notable progress, Kenya still faces significant challenges in UHC. These include limited national resources, a high disease burden, and widespread poverty. For many low-income households, healthcare remains unaffordable without causing significant financial hardship [4, 11].\u003c/p\u003e\n\u003cp\u003eKenya’s UHC framework is built on three main pillars: a) publicly funded primary healthcare, including preventive, promotive, outpatient, and basic diagnostic services, with patients able to select providers based on a regulated tariff; b) a Social Health Insurance Fund (SHIF) managed through the National Health Insurance Fund (NHIF); and c) a national fund for chronic and catastrophic illnesses, covering conditions such as cancer, diabetes, stroke, accident rehabilitation, and pandemics [12]. This fund is supported by a combination of insurance levies and government contributions, marking a significant step toward comprehensive health coverage.\u003c/p\u003e\n\u003cp\u003eImmunization is a vital part of primary healthcare and a key element of UHC [13]. It not only prevents millions of deaths each year but also strengthens the connection between families and health systems, creating opportunities for integrated service delivery [14]. As one of the most cost-effective health interventions, immunization provides significant economic returns; each dollar invested can save up to US$44 in societal costs [15, 16]. Between 2011 and 2030, immunization is expected to prevent approximately US$1.5 trillion in illness-related expenses and generate over US$5.6 trillion in economic benefits across 94 low- and middle-income countries (LMICs) [17]. By lowering disease burden, immunization also improves financial risk protection, shielding households from catastrophic health costs [18].\u003c/p\u003e\n\u003cp\u003eHowever, despite the introduction of new vaccines and programmatic advances, immunization coverage in Kenya and many LMICs remains inadequate [19]. A major obstacle is the lack of sustainable funding. As governments face competing priorities and donor support declines, funding gaps have widened [20]. In Africa alone, immunization needs were estimated at US$17 billion between 2016 and 2020, with governments expected to cover only about one-third of the costs, resulting in a shortfall of roughly US$5 billion [21]. Many countries, including Kenya, still rely heavily on external funding sources, such as Gavi [22].\u003c/p\u003e\n\u003cp\u003eKenya’s immunization financing challenges are particularly urgent amid the push for expanding UHC. The anticipated reduction of support from Gavi by 2029 poses a significant risk: without firm domestic financing plans, progress in immunization coverage could regress, ultimately negatively impacting overall health outcomes [23]. As UHC advances, establishing sustainable financing systems to support and expand immunization services becomes essential.\u003c/p\u003e\n\u003ch3\u003eBackground on Kenya’s health sector\u003c/h3\u003e\n\u003cp\u003eKenya is a lower-middle-income country in East Africa with a population of 47.564\u0026nbsp;million, according to the 2019 population and housing census. The average population in each county varies widely. The five largest counties are Nairobi, Kiambu, Nakuru, Kakamega, and Bungoma.\u003c/p\u003e\u003cp\u003eKenya reformed its government system in 2013 following the adoption of the new constitution in 2010. The most notable feature of the Kenyan Constitution of 2010 was the introduction of a devolved system of government, which is unique to Kenya and provides for one (1) national government and forty-seven (47) county governments. The governments at the national and county levels are “distinct and interdependent” and are expected to manage their relationship through “consultation and cooperation.” The uniqueness of the governments under the devolved system is outlined by the Fourth Schedule of the Constitution, which assigns different functions to each level of government. The national government has traditionally led all aspects of the immunization program. It oversees the development of health policies, training, and procurement of vaccines and other essential supplies for all counties. It procures traditional vaccines for routine immunization independently, with external support from Gavi, the Vaccine Alliance, for vaccines and other supplies required for the immunization program.\u003c/p\u003e\u003cp\u003eThe devolution reform has primarily focused on transferring decision-making related to health sector resources to lower-level management units, with proper oversight by governance structures, including facility management committees (FMCs) and district/hospital management boards (D/HMBs), which comprise a mix of elected community representatives and appointed public officials.\u003c/p\u003e\u003cp\u003eThe 2010 constitution and subsequent legislation outline the structures of county governments with two independent branches: (i) the County Executive, which includes an elected governor and their deputy, is primarily responsible for implementing all government services assigned to counties by the constitution. (ii) The County Assembly (CA) consists of elected members of the County Members of the Assembly (CMAs). Each MCA represents an electoral ward, although the CA also has a few nominated members representing special interest groups such as women, youths, and people with disabilities. Nominated MCA seats in the CA are allocated among political parties proportionally based on each party's number of members in the CA [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e The national government is responsible for acquiring vaccines, distributing them to regional depots, developing policies and guidelines, and overseeing the training of healthcare workers. County governments, in turn, are tasked with collecting vaccines from regional depots, ensuring their transportation to service delivery points while maintaining the cold chain, providing the necessary human resources for immunization services, and procuring immunization supplies such as syringes and safety boxes. The national and county governments provide immunization funding, with additional contributions from development partners.\u003c/p\u003e\u003cp\u003eBefore the devolution process, community, facility, and district stakeholders had limited involvement in sector planning and budgeting, which caused a disconnect between needs and solutions. Although post-devolution governance, in theory, has addressed top-down planning, studies reveal a lack of capacity at the decentralized level to plan and budget, difficulties with priority setting in the health sector, and excessive politicization of health sector priority-setting processes at the county level.\u003c/p\u003e\u003cp\u003eIn December 2018, the government launched a UHC pilot in four counties: Machakos, which experiences frequent hospital visits due to accidents and injuries; Nyeri, which has the highest number of non-communicable disease cases, especially diabetes; Isiolo, a suitable place to evaluate how the package functions within the nomadic population; and Kisumu, which has high rates of infectious diseases like HIV/AIDS and tuberculosis.\u003c/p\u003e\u003cp\u003eThe UHC pilot’s goal was to evaluate the feasibility of delivering a specific set of healthcare services across the selected counties, with the government covering the cost of care. Since the pilot concluded in 2019, many lessons were learned that will guide the national implementation of UHC across all 47 counties.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Objectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis paper explores the management of immunization services within the evolving landscape of Universal Health Coverage (UHC) in Kenya. Focusing on four counties that participated in a UHC pilot, the study investigates sub-national approaches to immunization service delivery and financing. The findings aim to inform national policy by highlighting practical lessons and strategies for integrating immunization into UHC frameworks, ultimately supporting Kenya’s goal of achieving equitable and sustainable health coverage for all.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy setting \u0026amp; context\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was conducted in Kisumu, Machakos, Isiolo, and Nyeri counties, which were selected as pilot sites for Kenya’s Universal Health Coverage (UHC) model launched in December 2018.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy design and participant selection.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis qualitative study conducted in-depth interviews (IDIs) with key informants across the four UHC pilot counties: Kisumu, Machakos, Isiolo, and Nyeri. Participants included senior officials from county health management teams, staff from selected county health facilities, and representatives from patient groups and community health workers. During the UHC pilot phase, participants at the county and facility levels were purposively selected based on their direct involvement in planning, managing, and implementing health programs, including immunization. Additionally, a convenience sampling approach was used to recruit relevant community health workers and patient representatives from each facility to participate in the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSemi-structured interview guides were developed specifically for this study to guide data collection (see supplementary file 1). Two members of the research team, along with trained field interviewers, conducted the interviews in quiet, private, and convenient locations selected by the participants. All interviews were conducted in English, audio-recorded with the participants' consent, and lasted approximately one hour each. Data collection took place between June and July 2021.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll audio recordings were transcribed verbatim before analysis. Transcripts were reviewed multiple times to ensure completeness, accuracy, and consistency. The study aimed to identify themes related to the impact of the UHC pilot program on immunization services across four selected counties. An inductive thematic analysis was employed, beginning with the development of a priori codes derived from the interview guides and initial transcript reviews. Transcripts were then systematically coded using Dedoose qualitative analysis software (Version 9.0.17) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], which facilitated the identification of emerging parent and child codes. Relevant themes and concepts were iteratively refined to enhance their analytical relevance and interpretive clarity.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eRespondent characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study involved 107 participants, including 19 senior officials from the County Departments of Health (CDOH), 32 healthcare workers from various roles within county health facilities, 28 community health volunteers, and 28 patient representatives. Data collection consisted of 51 in-depth interviews and seven focus group discussions conducted across the four UHC pilot counties. The sample mainly consisted of females (52%), with participants averaging 38.4 years of age.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSustained financing of immunization activities during the UHC Pilot\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRespondents reported that counties used their existing expertise in planning and resource allocation to support key immunization activities during the UHC pilot. These activities included vaccine distribution, data verification, supervision, and maintaining cold chain equipment. In some counties, local governments also funded specific immunization needs, such as BCG solo shots and outreach programs, with support from partners including AMREF, the Red Cross, County Health Assistants (CHA), and Community Health Volunteers (CHVs), who played a vital role in identifying and tracking defaulters.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At the county level, we create an annual work plan that covers all immunization activities for that specific fiscal year. We can allocate funds for immunization services if you carry out any training, supervision, on-the-job training, or mentorship. We also allocate money for data quality assessments and verification, as well as for supervision and periodic maintenance of immunization equipment\u0026rdquo; (KI-26-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It is the county that primarily supports outreach efforts. We receive funding from the World Bank and the THS CCP project, allowing us to allocate money for outreach activities. Our partners also contribute to these efforts. Additionally, we have partners like AMREF, who have supported several of the outreaches\" (KI-26-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We compile the list of defaulters and give it to CHAs to find CHVs in those areas.\u0026rdquo; (ID-10-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;...also, the Red Cross, particularly when floods or disasters occur, can set up medical camps. With these camps in place, we can oversee them and administer immunizations\u0026rdquo;. (KI-10-21)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFunding needs for immunization grew during the UHC pilot, while outreach activities declined.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDuring the UHC pilot, financing needs for immunization rose, yet outreach activities surprisingly declined. This gap can be linked to the lack of dedicated UHC funds specifically for immunization programs. While vaccine procurement and related supplies remained centrally managed and essentially unchanged, counties had to reallocate resources to meet the increasing demand for pharmaceuticals and non-pharmaceutical supplies. Supported in part by donors such as the World Bank, this shift highlights a significant gap in integrating immunization into broader UHC financing strategies, underscoring the need for more targeted and secure funding sources to sustain and expand immunization services.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Was immunization funding better during that time than before or after the UHC pilot? No, nothing changed\" (KI-36-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Immunization, as I understand, is a vertical program, like HIV and TB, whereas as a county, we receive direct funding from the MOH. We get the vaccines and ARVs directly from the MOH and do not necessarily procure them ourselves\u0026rdquo;. (KI-27-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;On our end, we discuss the expenditure for immunization because we incur zero cost since we get vaccines for free. However, we usually incur no cost. Immunization is free\u0026rdquo; (ID-47-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;During the UHC pilot, the demand for immunization services grew. To meet this increased demand, some departments reallocated funds to support immunization efforts, especially to prevent stock-outs and ensure service delivery\u0026rdquo;. (KI-03-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"There was a demand for immunization, and now babies are being brought in for immunization. Besides using the UHC funds, you know, there were also other departmental allocations from the exchequer.\" (KI-03-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We, as a department, made sure to allocate enough funds for immunization at that time to meet the demand. Because you bring your baby to the hospital and there is no vaccine, how will you feel?\" (KI-03-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"This World Bank grant continued. I believe it mainly focuses on immunization and family planning. Therefore, I think they complement each other. Perhaps at the facility level, the systems were able to operate more efficiently. Services could be offered in a better manner simply because the scope was larger at that point.\" (KI-27-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We had a shared procurement for pharmaceuticals and non-pharmaceuticals from the county level, and then it would be delivered to us.\u0026rdquo; (ID-21-21).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe shift to UHC caused funding gaps, which led to the deprioritization of key outreach efforts and exposed a disconnect between policy goals and operational realities. This change created significant logistical challenges, including shortages of vehicles, fuel, and staff resources essential for successful outreach. Moreover, ongoing human resource shortages further disrupt routine immunization activities, with staff frequently expected to handle increased workloads without additional compensation. These issues highlight the systemic weaknesses that arise when service delivery components are not effectively integrated into UHC financing and planning systems.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;With the introduction of UHC, our trend began to decline because we did not have any stable partner.\u0026rdquo; (ID-10-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We are required to allocate some funds for BCG syringes for outreach efforts, but most items are supplied from the national level.\u0026rdquo; (ID-32-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Now we are only doing outreach on an as-needed basis; we used to have regular outreach.\u0026rdquo; (KI-26-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"You realize that sometimes we don't even have the fuel to move, so when we can't locomote like that now, we can't reach those children that have not returned.\" (KI-10-21)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFiscal coordination challenges: the relationship between national and county levels in funding immunization programs\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe shift to UHC caused funding gaps, which led to the deprioritization of key outreach activities and exposed a gap between policy goals and actual operations. This change created significant logistical issues, including shortages of vehicles, fuel, and staff resources, all of which are vital for effective outreach. Moreover, ongoing human resource shortages further disrupted routine immunization efforts, with staff often expected to handle increased workloads without additional compensation. These issues reveal systemic weaknesses that arise when service delivery components are not well integrated into UHC financing and planning frameworks.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"When you brought in UHC, the way they rolled it out, there was an upsurge in numbers. The individual revenue from the facility disappears, and therefore, you are relying on money from above\" (ID-30-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We had to wait for the usual disbursement from the national government, with money being disbursed only enough to pay salaries\" (KI-38-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Now, with the UHC, funds come from the county. Therefore, we will need to wait for the county government to allocate a budget. Even if we send our request, we still have to wait for the County Government to send us the money, which can sometimes be very slow and late.\"\u003c/em\u003e (ID-05-21)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Therefore, this money had to be included in our budget and approved before we could use it. Yeah. Moreover, approval is through the County Assembly. Yeah. So, it took some time to get the approval for this money.\" (KI-03-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;This delay impacts the daily operations of health facilities, from paying bills to maintaining essential services like internet connectivity for administrative functions. There were delays in accountability and additional requests for a refund.\u0026rdquo; (KI-38-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They believe the national government still manages immunization; to them, it is not a priority for the county\" (KI-36-21).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eUHC rollout drives higher demand for immunization services\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRespondents reported an increase in immunization rates across most counties, mainly due to higher hospital attendance during the UHC pilot. However, this spike in demand exposed critical systemic weaknesses, particularly in human resource capacity and financial readiness at the facility level. Many healthcare facilities were inadequately equipped to handle the surge, resulting in overstretched staff and limited budgets. Consequently, the quality of care declined, illustrating the unintended effects of expanding access without sufficient investment in service delivery infrastructure.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"It may have increased because more people visited hospitals. Therefore, using the supermarket approach, if you came for treatment, you also brought your child along for immunization\u0026rdquo;. (KI-05-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\" We also see mothers giving birth at the hospital, and you know that when births happen in the hospital, you must plan for immunization because the number of births increases, and these children born are the ones accessing immunization services.\u0026rdquo; (KI-26-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"But I don't believe there was a significant impact, but even if there was, our immunizations have always been free. Therefore, I can't say there was any impact because immunizations are always free.\u0026rdquo; (ID-21-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"There is that sense of confidence when you go somewhere, knowing you won't be charged, but there's always that fear within the community that you're going to the hospital. I don't want to be told to buy a book or do something just because they know there's no money coming from you\" (KI-01-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"We have a significant shortage of tools, especially mother and child booklets. Like now, as I am talking to you, we do not have enough.\" (KI-26-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The people responsible for this include those who handle immunizations, family planning, documentation, and reporting. Overall, you find that even our staff experience burnout, and of course, when staff burnout occurs, the output will not be good.\u0026rdquo; (KI-26-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"During implementation, we experienced many clients coming in, so I can say there was an increased workload. People could now stay on the line longer because there was only one nurse or clinician performing the procedure, and a long line of clients waited for that single clinician to serve them.\u0026rdquo; (ID-08-21)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAntigen shortages following UHC expansion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile the overall supply of vaccines and syringes remained stable during the UHC pilot, mainly due to centralized procurement by the national government and partners such as Gavi and UNICEF, respondents reported occasional shortages of specific antigens, including BCG and measles vaccines. These shortages were linked to two main factors: higher demand caused by increased service utilization under UHC and broader systemic issues such as nationwide stock-outs. Although these disruptions were not widespread, they underscore the vulnerability of supply chains to both demand pressures and external logistical challenges, underscoring the need for more responsive and resilient forecasting and distribution systems.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There isn't much to say about immunization because we get our supplies from KEMSA. We usually go through the KEMPI office at the sub-county store, and if we need anything, we ask them for it. They supply a few items, like syringes, which come directly from KEMSA. The orders are placed quarterly, every three months.\u0026rdquo; (ID-06-21.)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;On a national level, Gavi and UNICEF are managing it; I know that the government purchases some vaccines. The shared information comes from Gavi, which is responsible for the funding. They are the ones handling it. There\u0026rsquo;s no point at which they would say that this money is allocated to the county for us to purchase the vaccines. They purchase the vaccines there and then supply them to us\u0026rdquo; (ID-31-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"During UHC, when it picked up, the supplies were steady. Yeah. We had consistent supplies, except for that vaccine. Nevertheless, the other supplies were available. We did not have any issues with the syringes, safety boxes, cotton wool, or any other items because they were all present and accounted for.\u0026rdquo; (ID-27-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Therefore, it reached a point where hospitals lack drugs, non-pharmaceutical supplies, or resources to support immunization or even maternity care, because immunization begins during maternity. When this baby is born, before the mother and baby go home, you must ensure that the baby receives BCG and the first dose of polio. (KI-10-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"There was a time when we experienced a shortage of specific vaccines such as measles and pentavalent, but it was nationwide, not just in this county\u0026rdquo;. (ID-31-21)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo address emerging supply constraints, health facilities adjusted their ordering practices to accommodate the increased client load during the UHC pilot. Respondents observed that the introduction of UHC led to more proactive and data-driven adjustments in the procurement of vaccines and non-pharmaceutical supplies. This change improved forecasting accuracy and planning efficiency, indicating that UHC implementation, despite its challenges, sparked positive developments in supply chain responsiveness at the facility level.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We had to make adjustments, so we went to the store and said we had been picking this, and we adjusted due to the high number of clients.\u0026rdquo; (ID-34-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Once we realized we were getting high numbers, we also changed how we ordered vaccines. We started ordering more doses, going from 100 to 200 doses instead.\u0026rdquo; (ID-34-21)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengthening immunization funding with strategic county planning\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe central government, through the National Vaccine and Immunization Program (NVIP), led the design and coordination of the UHC pilot, working closely with key partners and non-governmental organizations. While the national level retained responsibility for core financial and technical functions, such as vaccine and commodity procurement, county governments played a complementary role by managing operational logistics. These included hiring frontline staff and overseeing minor facility maintenance. This division of responsibilities reflects a hybrid governance model, where centralized procurement is paired with decentralized implementation, highlighting both the strengths and coordination challenges inherent in Kenya\u0026rsquo;s devolved health system.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"What happened before was that you first registered all county residents, and then we issued them a universal card for registration. This allows them to access free services within the Isiolo County health facility. The NHIF and another company called Living Good, which was a partner with the county, were responsible for doing this.\u0026rdquo; (ID-35-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And Pharm Access, we are utilizing the M-TIBA platform for registration\"\u003c/em\u003e (KI-01\u0026ndash;21)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Therefore, anything related to the vaccines, including the national vaccine and immunization program called EPI, is their responsibility to plan. During campaigns or when introducing new vaccines, they are responsible for planning and organizing the rollout. They are the ones who coordinate the training and ensure everything is in place.\" (KI-36-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The national people managed everything, literally everything in terms of finances; the county would not.\" (KI-01-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The county provides support when we need to buy an extra fridge or for small repairs through the maintenance department. Additionally, for human resources, the county hires nurses for the facilities to carry out the immunization program.\" (KI-36-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The county did not fulfill part of its agreement in the first phase... they have allocated funds in the budget to pay for insurance for the indigent population.\u0026rdquo; (KI-05-21).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDespite the intended objectives of the pilot, county healthcare professionals and key stakeholders described the planning phase as poorly timed and rushed. Major communication failures arose, exposing systemic coordination issues across government levels. These issues led to operational delays and widespread uncertainty during the implementation process.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWell, in the national planning, there was very little inclusion of the county.\u0026rdquo; (KI-05-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"No, no, no. This task was completed at the national and county levels without our input. In most training sessions, hospitals have medical superintendents, administrators, public health officers, and nurses in charge. They should have been involved from the very beginning idea.\" (ID-07-21).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"As I had said, most of us, as implementers, were not involved in UHC inception, but they tried what they could.\" (ID-07-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"When I involve you in doing something or want you to participate, we will communicate to prepare. For example, maybe only a few people were informed, say, one week before the rollout. Then, we needed to register people for UHC. Now it seems like we are pushing people to register that way, but we didn't have proper objectives or a clear flow of events.\" (KI-10-21)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eKey findings on immunization financing during Kenya\u0026rsquo;s UHC pilot\u003c/b\u003e\u003c/p\u003e\u003cp\u003eKenya\u0026rsquo;s immunization program has traditionally depended on donor-funded, vertically organized financing systems managed centrally by the national government. This structure remained unchanged during the UHC pilot, with counties continuing to receive vaccines and supplies from the MoH at no cost and without engaging in local procurement. As a result, the UHC pilot did not significantly alter the immunization financing responsibilities at the county level.\u003c/p\u003e\u003cp\u003eDespite this, the UHC pilot had a significant impact on service demand and delivery. Respondents reported a threefold increase in vaccination rates across the pilot counties, indicating a substantial improvement in health-seeking behavior. This rise in demand necessitated additional financial resources, which were secured through a combination of national government allocations, county contributions, and support from development partners, including UNICEF and the World Bank. The vaccine supply chain remained stable, managed centrally by the MoH and its partners such as Gavi and UNICEF.\u003c/p\u003e\u003cp\u003eOne of the most notable improvements attributed to the UHC pilot was an increase in supply chain efficiency. Respondents noted better availability of essential immunization supplies, such as syringes and safety boxes. Counties also took a more active role in planning, resource allocation, and outreach efforts.\u003c/p\u003e\u003cp\u003eHowever, the pilot revealed ongoing challenges in financing the operational aspects of immunization, as inadequate funding led to reduced outreach activities, logistical delays, and shortages of human resources. Additionally, counties faced intermittent stockouts of specific antigens and syringes. These problems were worsened by limited financial autonomy at the facility level and delays in disbursement due to new intergovernmental financial management procedures, especially the routing of UHC funds through county treasuries.\u003c/p\u003e\u003cp\u003eA critical insight from respondents was the urgent need for more inclusive and timely planning. They emphasized that the rushed, top-down approach to UHC implementation hindered effective coordination. Greater involvement of county healthcare professionals and local stakeholders, rather than just administrators, was identified as essential for addressing these systemic challenges and ensuring the smoother implementation of future health reforms.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe implementation of UHC in Kenya marked a significant shift in the country\u0026rsquo;s healthcare system, aiming to improve access to affordable, high-quality health services. This change also impacted immunization services, particularly in terms of funding structures and service delivery. This study analyzed the impact of the UHC pilot, conducted in four counties, on immunization services, with a focus on financing methods.\u003c/p\u003e\u003cp\u003eBefore launching the UHC pilot, counties engaged in preparatory planning involving both national and local stakeholders. According to respondents, the national government played a central role in procuring vaccines and essential supplies, while counties managed logistical support, including staff recruitment and minor facility upgrades. Development partners, including the NHIF, KEMSA, and various international organizations, assisted counties in registering beneficiaries and distributing resources.\u003c/p\u003e\u003cp\u003eDespite this multi-stakeholder involvement, respondents noted that the planning process was predominantly top-down, with limited input from county health professionals and other key local stakeholders. This exclusion was apparent in immunization planning. It conflicted with the principles outlined in the UHC Policy Framework 2020\u0026ndash;2030, which stresses shared leadership and defined roles for both national and county governments in health sector governance and stakeholder engagement [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSimilarly, frontline health workers, including facility staff and community health volunteers, were often left out during the planning phase. These findings mirror earlier studies that reported the exclusion of immunization program officers from budgeting and planning processes [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This lack of inclusive consultation led to communication and coordination failures between national and county governments, which in turn disrupted the smooth rollout of immunization services under UHC.\u003c/p\u003e\u003cp\u003eRespondents also emphasized that the quick rollout of UHC, without sufficient preparation for the counties, worsened logistical and operational problems. Counties found it hard to reallocate their financial and human resources to handle the rising demand for services. This supports earlier research showing that poor coordination between national and county governments can weaken health system efficiency, raise transactional costs, and hinder service delivery [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImportantly, the UHC pilot did not result in significant changes to the core financing of immunization services. In Kenya, immunization has traditionally been funded through donor contributions and vertical financing mechanisms, mainly managed by the national government [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This setup remained unchanged during the UHC period, with counties continuing to receive vaccines and related supplies from the MoH at no cost. As a result, counties were not required to use significant local funds for immunization, and the UHC initiative did not fundamentally change the financial structure of vaccination at the county level.\u003c/p\u003e\u003cp\u003eAlthough respondents emphasized that the core immunization funding mechanisms remained unchanged during the UHC pilot, the program had notable indirect effects on how immunization services operated. The rollout of UHC caused a significant rise in demand for immunization, fueled by better access to healthcare and a shift in health-seeking behavior. In response, some counties reallocated departmental funds to support immunization efforts, especially to manage the increased demand during the pilot phase. However, outreach activities vital for reaching remote and underserved populations were often limited by funding shortages. These challenges highlight the need for stronger financial planning and targeted resource allocation to maintain immunization services as healthcare access expands.\u003c/p\u003e\u003cp\u003eThe UHC pilot introduced new public finance management structures that reshaped the distribution of funds. A key change involved routing UHC funds through county treasuries before disbursing them into health facilities. This shift disrupted the financial independence of facilities, which had previously depended on user fees for operational flexibility and stability. As a result, facilities became reliant on county-level allocations, which were often delayed or insufficient to cover operational costs. These changes negatively impacted the efficiency of health services, including immunization support. Similar findings have been documented in earlier studies, which noted that slow and unpredictable fund disbursement from the national government significantly hampered the implementation of county health budgets and affected interventions such as immunization [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These financial management challenges seem to be ongoing issues inherited from the transitional authority during the devolution of health functions [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLogistical constraints, such as shortages of vehicles, fuel, and other essential resources required for immunization outreach, were frequently reported. These gaps were often linked to a lack of county-level commitment to UHC programs. For example, in Isiolo County, shifting from input-based to output-based financing led to a lack of sustained support for outreach services, which exacerbated resource shortages and disrupted service continuity [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Human resource challenges also worsened, as healthcare workers were often pulled from their regular duties to support immunization activities without receiving extra pay. This led to staff burnout and a decline in service efficiency. These findings align with other studies that have reported increased workloads and chronic understaffing in facilities implementing UHC programs [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. These challenges emphasize the urgent need for better resource allocation and workforce planning to sustain immunization services.\u003c/p\u003e\u003cp\u003eDespite these operational and financial constraints, the demand for immunization services grew during the UHC pilot. This increase was not directly attributed to UHC's targeting of immunization, but rather a broader rise in healthcare utilization. Respondents described a \u0026ldquo;supermarket approach,\u0026rdquo; where patients visiting facilities for other services also accessed immunization for their children. However, it remains unclear whether this rise was mainly caused by improved health-seeking behavior or the removal of user fees, a factor known to increase service use [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne of the more positive outcomes of the UHC pilot was the improvement in supply chain management. Respondents reported better availability of essential supplies, such as syringes and safety boxes, facilitated by consistent procurement through KEMSA. This improvement was observed across all four pilot counties, although occasional delays were noted [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. However, intermittent shortages of specific antigens, such as BCG and measles vaccines, were reported due to increased demand; facilities adapted by improving forecasting and scaling their orders accordingly.\u003c/p\u003e\u003cp\u003eThe overall stability of the vaccine supply was primarily due to centralized procurement and strong partnerships with organizations such as Gavi and UNICEF. These partners played a crucial role in supporting government efforts to meet immunization needs [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. However, this dependence on donor support raises concerns about long-term sustainability. As shown in previous studies, neither national nor county governments are yet sufficiently prepared for a transition away from donor funding [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. This highlights the urgent need for a comprehensive, well-documented immunization financing strategy that guarantees continuity beyond external support.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study is the first in-depth qualitative investigation in Kenya to explore the implications of UHC on immunization financing across four pilot counties. By incorporating insights from a diverse range of stakeholders, including county health officials and frontline healthcare workers, this research provides a nuanced understanding of both the systemic challenges and operational successes encountered during the UHC pilot. The inclusion of multiple perspectives enriches the analysis and offers a grounded view of how immunization financing was managed in practice. However, the study is limited by its time frame, as it focuses solely on the pilot period. It does not capture post-pilot developments in immunization coverage, financial allocations, or broader health outcomes, which remain critical areas for future research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough immunization funding mechanisms remained essentially unchanged during Kenya\u0026rsquo;s UHC pilot, with minimal direct financial contributions across the four counties, the increased demand for immunization and other health services put additional pressure on county budgets. This rise in service use highlighted the need for extra funding and revealed ongoing challenges in maintaining immunization outreach, overcoming logistical barriers, and managing human resource limitations. These findings provide important insights for expanding UHC in Kenya and offer valuable lessons for other countries pursuing similar health system reforms.\u003c/p\u003e\u003cp\u003eNotably, the reported tripling in the number of vaccinated children during the UHC pilot suggests that UHC platforms may play a pivotal role in identifying and reaching \u0026ldquo;zero-dose\u0026rdquo; children, those who have not received any routine vaccinations. These results indicate that when services are free, families are more likely to come forward, and in doing so, they often bring along children who have never received vaccinations. This natural uptake suggests that removing financial barriers could be one of the most powerful levers for reaching the unreached. To make this a reality, effective UHC implementation must be grounded in better planning at the county level and stronger coordination across all levels of government to ensure sustainable financing for immunization services. Tackling these systemic challenges is essential for ensuring continuity, equity, and trust in service delivery. Further research is needed to explore how donor funding can be more strategically aligned with UHC goals, especially in reaching children who are at risk of being zero-dose and remain persistently underserved.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUHC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUniversal Health Coverage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLMICs\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow- and middle-income countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePHC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary health care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIDI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIn-Depth Interview\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eFGD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFocus Group Discussion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCDOH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCounty Department of Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eBCG\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBacillus Calmette\u0026ndash;Gu\u0026eacute;rin (vaccine)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAMREF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAfrican Medical and Research Foundation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCHA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity health assistant\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCHVs\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity health volunteers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMoH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMinistry of Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUNICEF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Nations International Children's Emergency Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eKEMSA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKenya Medical Supplies Authority\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eKI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKey informant\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eID\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIdentification\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNHIF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Hospital Insurance Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAll procedures conducted in this study adhered to the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Moi University Institutional Ethics and Research Committee (approval number: 0003605). Before participation, all respondents were provided with an information sheet detailing the study\u0026rsquo;s objectives, procedures, potential risks and benefits, the intended use of the data, and the contact information of the research team. Participants were allowed to ask questions and seek clarification. Informed consent was obtained from all participants through the signing of a written consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot required\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\n\u003cp\u003eAlex Olateju Adjagba; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-1041-8836\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eCaleb Nyakundi; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0001-9142-1924\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eCatherine Akoth; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000\u0026ndash;0002\u0026ndash;9958\u0026ndash;3490\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eJames Oguta; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000\u0026ndash;0002\u0026ndash;2401\u0026ndash;9895\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eSharonmercy Okemwa: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0001-5939-3839\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was funded by a grant from the U.S. Centers for Disease Control and Prevention (CDC) to the United Nations Children\u0026rsquo;s Fund (UNICEF) in support of the Kenya Country Office.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAOA conceptualized the study. JOO was responsible for data collection. AOA, JOO, and PO provided administrative and logistical support throughout the study. JOO, AOA, and CA transcribed the audio of the interview. AOA, JOO, CN, S.O., and CA conducted data analysis. AOA, CN, JOO, and CA prepared the initial manuscript draft. All authors critically reviewed the manuscript and approved the final version for publication.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors gratefully acknowledge Mark Omollo's support during data collection and transcription.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData will be made available upon reasonable request by contacting the corresponding author [[email protected]](mailto:[email protected])\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell OA, Wagstaff A. Catastrophic payments for health care. 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Pan Afr Med J. 2024;49.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Immunization financing, universal health coverage, Kenya, planning, budgeting, public financial management, health financing, UHC financing, county planning, county budget, sustainability of healthcare funding, aid, Gavi, vaccines","lastPublishedDoi":"10.21203/rs.3.rs-7244451/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7244451/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eImmunization is a critical component of primary health care and a key driver of Universal Health Coverage (UHC). Yet, many low- and middle-income countries, including Kenya, face persistent challenges in sustaining the financing of immunization programs. As countries shift toward UHC, there is growing concern that broader health financing reforms may not strengthen and could even weaken dedicated funding for immunization. This study examines Kenya’s UHC pilot to explore whether the move toward UHC risks displacing resources currently allocated to immunization, particularly at the county level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Data were collected between June and July 2021 through in-depth interviews and focus group discussions with key informants across four UHC pilot counties in Kenya. An inductive thematic analysis was used to interpret the qualitative data, utilizing Dedoose software (Version 9.0.17) to facilitate systematic analysis. Identify patterns and themes related to immunization financing at the subnational level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe implementation of UHC increased access to healthcare services, which in turn raised the demand for immunization. However, funding for operational aspects of immunization faced several obstacles. These included insufficient funding that limited outreach efforts, logistical issues, and shortages of human resources. Counties also experienced periodic stockouts of specific antigens and syringes, which were worsened by the limited financial independence of health facility managers. These service disruptions were partly mitigated by additional support from development partners, supplementing government and Gavi funding sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The UHC pilot had various impacts on funding for immunization services. When services are free, families are more likely to seek care and often bring unvaccinated children with them. This suggests that removing financial barriers could be a powerful strategy for reaching zero-dose children. However, realizing this potential through UHC requires stronger county-level planning and coordination across the government to ensure sustainable financing for immunization services. Further research is needed to assess how to mitigate the impact of UHC reforms on immunization, especially for underserved populations.\u003c/p\u003e","manuscriptTitle":"When Everyone Comes, So Do the Unseen: Kenya’s UHC Pilot and the Unexpected Reach of Routine Immunization","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 10:51:02","doi":"10.21203/rs.3.rs-7244451/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57758041-774c-49c5-b2a9-9473f7d7fb2b","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-04T10:10:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 10:51:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7244451","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7244451","identity":"rs-7244451","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}