The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali

The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali | 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 The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali Abdourahmane Coulibaly, Valéry Ridde This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8454940/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Despite the unprecedented speed of COVID-19 vaccine development, vaccination coverage in Mali was low. Research has primarily focused on individual vaccine hesitancy, overlooking systemic issues related to the implementation of vaccination in health facilities. This article analyses the implementation of Mali’s national vaccination strategy in 2021 and 2022 to understand the challenges associated with COVID-19 vaccination coverage and the lessons learned. The study employed a qualitative approach. Data collection involved field observations (n = 15 days) and semi-structured interviews (n = 57) conducted at two Primary Health Centres ( Centres de Sante Communautaire , or CSComs) in Bamako, Mali. The analysis utilised a conceptual quality implementation framework to identify factors that influenced the successes or limitations of the campaign. Vaccination campaigns intensified gradually between 2021 and 2023. The implementation used a top-down approach controlled mainly by the staff of the Health District. The limited involvement of CSComs in key vaccination activities (planning, capacity building, supervision) prompted them to develop adaptation strategies to meet their assigned objectives. The analyses showed that the implementation of the national vaccination strategy did not have the same intensity depending on the quality phases of implementation. The CSComs conducted very few evaluation activities. We cannot fully understand vaccine coverage without a thorough analysis of implementation mechanisms. This study highlights the importance of building local capacity, customising strategies to fit community realities, and enhancing documentation of field practices for future public health interventions. COVID-19 Vaccination Implementation Mali Planning INTRODUCTION It took 39 years following the discovery of the tuberculosis pathogen to have a single vaccine. However, within a year of the SARS-CoV-2 (COVID-19) discovery at the end of 2019, 18 vaccines were available, and an additional 109 vaccine candidates were being tested. 1 The high mortality and morbidity rates, especially in Western countries, prompted global health authorities to support the urgent search for a vaccine. Vaccine production was carried out swiftly through established procedures, supported by global collaboration, massive funding, and the use of pre-existing technologies such as mRNA-based vaccines. This response was unprecedented in the history of public health and allowed for the rapid launch of national vaccination campaigns. However, the accelerated vaccine availability raised questions about international priorities, the fairness of vaccine distribution, and the systemic vision of fighting a pandemic. 2 To ensure fair access to vaccines on a worldwide scale, the COVAX initiative was set up, which posed particular challenges, such as vaccination targets and funding challenges. 2 To support countries, the WHO published a guidance document on COVID-19 vaccination campaigns. 3 It specified the essential steps needed for operational planning of mass vaccinations: estimating targets, calculating vaccine needs, managing human resources, and monitoring the campaign implementation. In most French-speaking West African countries, despite several vaccination campaigns, coverage rates remained low. As of December 4, 2022, only 30.4% of the population in the WHO Africa region received a first dose of the COVID-19 vaccine. In Mali, only 11.3% of the population received the first round of COVID-19 vaccine doses. The country is ranked the 7th least vaccinated of the 27 countries for which the WHO has shared data. It is not included in the list of 35 African countries with data on booster coverage of this vaccine. 4 Thus, numerous studies have been carried out in the region to understand this phenomenon, analysing vaccine intent, acceptance, or hesitation. 5–8 These studies show the importance of people’s trust in health professionals and government, the role of misconceptions and rumours, past vaccination experiences, and the socio-economic variables of the people concerned. In Mali, low coverage has mostly been linked to vaccine hesitation, fuelled by persistent rumours about the risks of COVID-19 vaccines 9 or a lack of confidence in the vaccine. 10 However, systemic issues have often been overlooked in these analyses, which have usually focused on individuals and their relationship to vaccination. For several years now, international debates on health system planning and management have emphasized the need to move beyond individual-centered approaches in order to analyze organizational dynamics, implementation capacities, and context-specific adaptation strategies. These discussions have highlighted that the effectiveness of interventions depends not only on their content or acceptability, but also on how they are concretely implemented within health structures 11 , 12 Moreover, this focus of studies on an outcome variable (vaccination), with quantitative approaches, does not provide a detailed understanding of the challenges of the implementation of immunisation by the health system. This dimension is sometimes briefly understood as a contextual or explanatory variable of quantitative studies. However, research has long shown that the implementation of an intervention is complex and determined by multiple factors 12 – 14 . Moreover, analysis of the implementation of public health interventions remains rare in West Africa and Mali, particularly those using a proven conceptual framework. 15 Thus, the objective of this article is to analyse the implementation of the national vaccination strategy in 2021 and 2022 to understand the challenges related to COVID-19 vaccination coverage and lessons learned. METHODOLOGY Before explaining the method of this research, we will describe the national vaccination strategy whose implementation we will analyse. A. The national vaccination strategy against COVID-19 WHO recommendations guided national COVID-19 vaccine planning. 16 The health authorities defined several strategies to ensure optimal vaccination coverage: integration of COVID-19 vaccination into the Expanded Programme on Immunisation (EPI); mass vaccination campaigns in public places; mobilisation of social networks; communication campaigns to combat false rumours, etc. As part of international cooperation, the authorities gradually received doses of different vaccines. The vaccination campaign was carried out in four phases (Table 1 ). Phase 1 Preparation (end 2020 – March 2021) The activities carried out during this phase concerned the development of the deployment and vaccination plan, the identification of priority groups (health workers, older people, people with comorbidities), and the mobilisation of partners (COVAX, WHO, UNICEF). Phase 2 Initial launch (March 2021) The first vaccines were welcomed as valuable commodities. Indeed, the Malian authorities formed a delegation to receive the first vaccines (396,000 AstraZeneca doses) that arrived on March 5, 2021, under the COVAX Facility (a global initiative led by GAVI, WHO, CEPI and UNICEF). The government presence at the airport and its media coverage symbolised a strong political act. Vaccines were made available to the reference health centres ( Centre de Santé de Référence , or CSREF: district hospitals and health district authorities). They were then distributed among the Community Health Centres ( Centres de Sante Communautaire , or CSComs) by CSREF staff. AstraZeneca doses were received, and the COVID-19 vaccination campaign was officially launched on March 31, 2021. The health authorities targeted people who were particularly exposed (socio-health workers) or considered vulnerable (people over 60 years of age and people with comorbidities such as diabetes, high blood pressure, or respiratory diseases). Their names were first entered in the so-called "targeting" register, and then, once the person received their vaccination, their names were added to the vaccination register. Phase 3 Extension and proximity strategies (August 2021-August 2022) Phase 3 was marked by the deployment of new vaccines, including Johnson and Johnson (August 23, 2021), Sinovac (November 11, 2021), Moderna (end of 2021), Pfizer (May 9, 2022), and Sinopharm (January 26, 2022). Thanks to the COVAX initiative, the US government sent Bamako 151,200 doses of Johnson and Johnson vaccines. These vaccines were primarily administered in remote areas of the country as a single dose. Vaccination was open to people aged 18 and over. Then, the government received 835,000 doses of Sinovac from China. These vaccines were intended for people over the age of 18 who had not yet been vaccinated. The introduction of Pfizer vaccines (USA) extended vaccination to adolescents aged 12 to 17 years, as well as pregnant and breastfeeding women. The arrival of 300,000 doses of Sinopharm offered by China made it possible to extend vaccination to people aged at least 18 years throughout the country. At the end of November 2021, authorities received 201,600 doses of the Moderna vaccine (via the COVAX initiative). These doses were intended to increase vaccination coverage in addition to others (AstraZeneca, Johnson & Johnson, Sinovac, Sinopharm and Pfizer). Phase 4 Integration of the vaccine into the ENP (April 2024) April 30, 2024, marked the integration of COVID-19 vaccination into the ENP, encompassing all types of vaccines. The aim was to increase coverage in remote areas and to promote the fight against emerging variants. Our study is limited to Phases 2 and 3. Table 1 Chronology of the deployment of the different types of COVID-19 vaccines in Mali Phases Vaccine name Target populations Launch date Donor Phase 1 (Preparation) - -- - Phase 2 (Initial Launch) AstraZeneca Health workers, ≥ 60 years, people with comorbidities March 31, 2021 COVAX Phase 3 (Extension) Johnson & Johnson Any person ≥ 18 years of age not yet vaccinated August 23, 2021 United States via COVAX Sinovac Adults ≥ 18 years of age not vaccinated November 11, 2021 China via COVAX Sinopharm Adults ≥ 18 years of age throughout the country January 26, 2022 China Pfizer-BioNTech Adolescents (12–17 years), pregnant and breastfeeding women 9 May 2022 United States via Covax Moderna People not vaccinated or waiting for 2nd dose End 2021 – through 2022 United States via COVAX Phase 4 (ENP integration) All vaccines Routine immunisation in routine health services April 30, 2024 In total, there were 10 COVID-19 vaccination campaigns in Mali between 2021 and 2023. A campaign refers to a one-off vaccination action, often limited in time (10 days), with specific coverage objectives and resources mobilised. These campaigns are the operational component of a phase. The breakdown of the campaigns by year is as follows: two national campaigns in 2021 (Campaign 1 with AstraZeneca and Campaign 2 with Johnson and Johnson), one single campaign in 2022 (Pfizer, Sinopharm, Sinovac, Johnson & Johnson, AstraZeneca) and seven campaigns in 2023 (Pfizer, Moderna, Johnson and Johnson, Sinopharm, Sinovac, AstraZeneca). B. The conceptual framework There is a significant number of theories and analytical frameworks for studying the implementation of public health interventions, which is complex but essential. 17 In this case, we needed a solid but relatively flexible approach to adapt to our terrain and to research that was essentially qualitative and anthropological. Moreover, it was not a question of studying the determinants of implementation, such as the Consolidated Framework for Implementation Research (CFIR), for example, 18 but instead of understanding its challenges and, in particular, the quality of its organisation. Thus, our choice was based on the use of Meyers’ framework 19 because it is essentially concerned with the quality of the implementation. From 25 different frameworks for analysing implementation, Meyers et al. proposed to examine the processes of organising an intervention in the light of 14 critical stages organised in four specific phases: (1) initial considerations regarding the reception context of vaccination, (2) creation of a structure for implementation, (3) continuous structure once implementation has started, and (4) improvement of future implementation. It is, therefore, using this analytical framework that we collected and analysed empirical data in several survey sites using a qualitative approach. Table 2 Quality implementation framework Phase 1: Initial considerations for the hotel environment Evaluation strategies 1. Conduct a needs and resources assessment 2. Carry out an adequacy assessment 3. Carry out a readiness assessment Decision on adaptation 4. Opportunities for adaptation Strategies for strengthening stakeholders 5. Obtain explicit buy-in from key stakeholders and promote a supportive community organisational climate 6. Strengthen general/organisational capacity 7. Recruit and maintain staff 8. Efficiently train staff in innovation beforehand Phase 2: Create an implementation structure Structural characteristics for implementation 9. Create implementation teams 10. Develop an implementation plan Phase 3: Continuous structure after the start of implementation Strategies to support continuous implementation 11. Assistance/coaching/supervision 12. Process evaluation 13. Formative feedback mechanism Phase 4: Improving future applications Improving future applications 14. Learn from experiences This study is based on data collection carried out at two sites in the capital (Bamako), understood as two contrasting study cases located in the same health district. 20 They were chosen because they represent a certain contextual diversity, but also because their access was facilitated by a pre-survey in the context of the COVID-19 pandemic. 1 After studying the effects of the pandemic at the hospital level, 21 the vaccination analysis was carried out at the level of the primary health centres where the implementation was organised. The CSCom is a health institution providing front-line services. It is managed by a Community Health Association ( Association de Santé Communautaire , ASACO). The choice of the two peripheral health centres was guided by the possibility of comparing data from an older CSCom with a high volume of care offerings (CSCom1) with another, more recent CSCom with a significantly lower volume of care offerings (CSCom2). CSCom 1 is a referral CSCom with a staff of around 22 people (15 permanent staff members + seven DES trainees) as of 2021. It was established a long time ago (2009). It offers services including immunisation, maternal and child care, medical consultations, and preventive care activities. It is a university-affiliated community health centre that provides specialised consultations and offers student internships. In 2021, the facility carried out 26,013 treatment consultations including both new and follow-up visits. The CSCom 2 is a more modest centre with a smaller number of staff. In 2021, there were 17 staff members. In 2021, it carried out 4,553 consultations (new and old), five times fewer than CSCom 1. The services offered are based on activities that are usually found in CSCom, including curative consultations (malaria, respiratory infections, chronic diseases), maternal and child health (births, PMTCT), and community health education activities (awareness-raising, hygiene, nutrition). C. Sampling and data collection This study uses qualitative research based on data collected through individual interviews and field observations. 22 First, we conducted 53 semi-structured interviews (first pass) and 15 observation days, plus four semi-structured interviews (second pass), in both CSComs in June 2021 and September 2022. Sampling was as comprehensive as possible within each of the two sites by seeking to meet most of the people involved in the implementation of vaccination while maximising the diversification of profiles to strengthen data triangulation. We recruited participants based on a pre-established list of agent profiles and random meetings in a snowball approach. Thus, the participants interviewed were the technical director of the centre (DTC), a doctor (med), nurses (inf), midwives (SF), doctors, community health workers (CHAs), community relays, vaccinators, health information system managers (SIS), leaders of community health associations (ASACO), and community leaders. We interviewed the participants in the CSCom premises at times decided by them based on their availability. Table 3 Distribution of respondents by category of participants DTC Med Social Service Inf SF SIS Vaccinator Relays Mem. ASACO Leader com. CSCom 1 Passage 1 1 1 1 1 1 13 2 2 4 26 Passage 2 1 3 4 CSCom 2 Passage 1 1 1 2 1 11 6 4 1 27 Passage 2 0 Total 3 1 1 2 2 2 27 8 6 5 57 The gender distribution highlights a clear dominance of female participants for both CSCom 2 (17 women vs. 10 men) and CSCom1 (16 women vs. 10 men). The investigation took place in two stages. During the first visit in June 2021, investigators found that the first vaccination campaign had already ended. Thus, the assistants could not make observations. This first passage was exclusively devoted to semi-structured interviews. In September 2022, a second data collection took place. This second passage was mainly dedicated to observations of situations because the vaccination campaigns had resumed, and we took the opportunity to make observations before a new suspension. These observations (n = 20 days) focused on the progress of vaccination activities (interactions between teams and vaccine candidates, organisation of teams in the field). The value of collecting data in two phases allowed us to study possible variations in the implementation of vaccination campaigns over time. Two experienced research assistants collected data from the study. We designed interview guides based on the dimensions of the conceptual framework, but the data collection was open and therefore allowed us to go beyond these dimensions. Each of the assistants worked in a single CSCom. All data collection activities were supervised by the senior researcher based in Bamako (AC) during field visits and daily phone reports. AC also carried out the field exploration by conducting semi-structured interviews with the managers of the two centres. The other researcher (VR) coordinated all the research in which this study was carried out 1 and visited the two CSComs in 2021 to prepare this study with AC. The two authors collaborated in the drafting of the protocol, its implementation, analysis, and publication. D. Analysis of data We recorded and transcribed all interviews in french langage. They were then subject to open and inductive manual coding before being organised according to the dimensions of the conceptual framework and in the context of an analytical discussion between the two authors. RESULTS The results of this study align with the dimensions of the previously proposed implementation quality framework. We opted for a comprehensive analysis of the data collected at the two health centres, except where empirical differences were noted. Appendix 1 summarises the results. Initial considerations for the host environment Evaluation strategy Institutionally, CSCom staff found the management of COVID-19 vaccinations to be not very inclusive. The decisions concerning the needs of the CSComs were taken by the district hospital (CSREF), without a prior concerted assessment. The CSCom staff had no choice but to receive the quantities of vaccines made available to them: It was the chefs themselves who made estimates according to the teams, and they gave us materials based on their estimate. We have not assessed our needs. These calculations were made by themselves. They did not send us a note asking us to assess our needs (Staff CSCom1). Planning documents known as "micro-plans" were drawn up by the CSREF without prior consultation with the CSCom teams. These micro-plans were then sent to the CSCom staff: They are talking about a microplan that comes from above. There are always micro-plans sent to us about COVID, so there are always changes (Vaccinator, CSCom1). ... They just parachute decisions about us without us being directly involved. We also have a say. (Staff CSCom2). If they ran out of vaccines and other inputs necessary for vaccination, they simply sent a purchase order to the CSRF with the required quantity of vaccines. Adequacy and preparedness for vaccination have not been specifically assessed. Moreover, CSCom actors often criticized the improvised nature of the announcement of the dates of vaccination campaigns. These dates were usually announced only two to three days before campaigns began. This lack of preparedness was particularly evident as these actors were accustomed to planning vaccination strategies under the ENP. The officers we interviewed often described their readiness to receive training on COVID-19 vaccination and vaccines. Adaptation decisions As with other vaccine strategies (e.g. EPI), the CSREF teams made decisions, including possible adaptations of implementation: We report to the CSREF; the CSREF dictates to us. All decisions come from there" (Staff CSCom1). Sometimes, at the insistent request of some young people who were not yet eligible, the Medical Officer-Head of the Health District was asked by the CSCom staff to give his approval for them to be vaccinated: Targeting was like that. Those eligible for vaccination are older people, the chronically ill and health workers. Otherwise, even though many people, there were young people who came to get vaccinated of their own free will. We had to ask for information. The chief doctor of the CSREF said to vaccinate them. (Staff CSCom 2). However, CSCom sometimes gave itself leeway and adapted certain activities once vaccines were delivered. These adaptations were particularly concerned with managing vaccination teams (the number of teams in fixed centres and advanced strategies), whose composition had been determined in advance by the CSRF according to the size of each health area's population. The financial constraints of CSCom also sometimes guided possible adaptations: Even if I say so, the answer is always that there is not enough money. The answer is always “we are obliged to do with our means on board”. As they said, we too at centre level will do so with our on-board means (Staff CSCom 2). At CSCom 1, reinforcements were mobilised to increase vaccination coverage capacity in the most significant areas. Once on the ground, the teams had the opportunity to organise themselves according to the contexts they encountered. This is why they moved elsewhere, once the number of people to be vaccinated decreased. In the second phase of vaccination, the number of teams was reduced. The remuneration of vaccinating agents was not always ensured on time by the CSREF, due to a lack of available funds. As a result, CSCom managers were uncomfortable having people work without pay. They temporarily reduced the teams until the funds were available again. The vaccinators did not have a formal employment contract with CSCom. A simple financial document bearing the names of the beneficiaries of the vaccination premium and called "statement of payment" was used as evidence. Strategies for capacity-building Explicit membership of key stakeholders The widespread circulation of rumours concerning the safety of the vaccine led to a distrust of the vaccine and increased vaccine hesitation. These persistent social media rumours presented vaccines as deadly threats. When vaccination teams went to neighbourhoods to target eligible people and vaccinate willing participants, they encountered many hostile reactions. Increased awareness and education were quickly recognised by staff as an effective way to combat rumours. Some survey participants also emphasised the importance of vaccinating staff to lead by example: People refused to get vaccinated. They were chasing vaccinators out of their families. We know that he did not have enough vaccine for everyone; therefore, it was decided to target an age group for the vaccine. So we started by targeting these populations. People refused to be targeted, and vaccination is not mentioned. It was the population’s reluctance to vaccinate that was the immediate consequence of the lack of in-depth awareness.” (Staff CSCom 1). Stakeholder buy-in at the community level was fostered by the involvement of key stakeholders (community health associations, neighbourhood leaders, religious leaders). As a result, healthcare staff relied heavily on ASACO: We are community members; it was the community that created the CSCOM. It is the people who agree to look for the receipt. They set up the office, and they recruit staff. If a vaccination is required, it is said to ASACO, which informs those responsible for the neighbourhood, who in turn inform the population through mosques, gathering places, etc. We also raise awareness at our level. (Staff CSCom 1). To overcome resistance, the CSCom teams put strategies in place to raise awareness among reluctant people: But during the campaigns, if we have cases of refusal, we deploy a team to raise awareness. If they persist, they are left as this is not mandatory.” (CSCom 2 -Vaccinator). In CSCom 2, in addition to these influential personalities, a griotte (traditional storyteller) was asked to spread the message within families. Furthermore, in health centres, the themes discussed daily by ENP staff during educational talks with patients have been enriched by COVID-19 vaccination. However, the observations showed that after an interruption period at the end of May 2021, the resumption of fixed centre vaccination in June 2021 was not sufficiently communicated to patients by staff, contrary to what patients claimed. Strengthening overall organisational capacity. The DTC (responsible for CSCom), the ENP officer and his team were particularly mobilised to prepare the departure of the vaccination teams on the ground. Reinforcements have sometimes been mobilised to support vaccination teams. To strengthen the supply capacities of the vaccination teams, the CSCom covered the travel costs related to the supply. The CSREF did not budge these costs, and they were, therefore, a community contribution. For the implementation of the campaign, many management materials were made available to the CSCom by the CSREF (vaccine scorecards, supervision sheet, MAPI sheet, etc.). The registers were simpler to fill in than those usually found. Masks, gloves, and vaccination cards were occasionally damaged during campaigns. CSCom 1 often had to use its funds to address the shortage. Recruiting and maintaining staff. Recruitment of staff was closed because the workforce was mainly made up of interns and volunteers already working in the CSComs. This has not been without suspending, even temporarily, the curative activities within the CSComs, as these trainees and volunteers are generally essential to the functioning of the CSComs: We suspended our activities and gathered the teams in the large meeting room of the centre to quickly discuss the vaccination of COVID, and we began the vaccination. (Vaccinator CSCom 1). In the absence of official remuneration, the bonuses granted in the context of vaccination activities were a source of motivation for those volunteers. However, delays in the payment of these premiums had the opposite effect. At CSCom 1, a strike was decreed after two months of late payment. In addition, for CSCom 1, the announced premium for vaccinators was reduced due to budget constraints because there was an error in the CSREF team’s estimation of the number of vaccinators. In CSCom 2, an ASACO member highlighted the challenges of carrying out unmotivated vaccination tasks by health workers and the efforts made by ASACO to avoid demotivation. He explained that they had limited financial support, and community funds were limited and couldn’t be used for that purpose. Observations on the ground have shown that the presence of vaccination agents at their posts decreased significantly over time, notably at CSCom 2 (June 25, 2021): On this Friday, I arrive in CSCom 2 at 8:10 am. Today, the volunteer nurse who really takes care of the vaccination did not come. The DTC is still in training. The vaccination officer arrived at 9 a.m. but did not even wear a gown. He walks around the yard to smoke. At 10.30 am, he left the centre because he had to take care of a personal matter. That is where I ask him a question : Q: Does Ny not have a vaccination today? R: We're a little discouraged. We have not yet received the money from the previous COVID vaccination we administered. Without it, we even refused to send the vaccination data (pointing). After this response, he takes his motorcycle and leaves the centre quickly. Training staff effectively. The CSREF team provided training for the CSCom staff with the support of national trainers. The training focused on the types of vaccines, behaviours in the field, and the targeting of eligible people. However, one of the vaccinators noted the hasty nature of the training he received at CSREF and then the launch of the campaign: No, we weren’t ready... One or two days after this meeting, the DTC calls me to inform me that the CSREF has just called him to tell him to train the teams, and vaccination will start next week. We were both surprised and astonished that day because for vaccination campaigns of this magnitude, we have to give ourselves time to train the teams, prepare them, express our needs. They did things hurriedly, tac, tac, tac, and paf, let’s go. They forced us to get vaccinated the week they had told us. That day, I told the DTC that I had not seen a hasty vaccination campaign. Making a vaccination campaign overnight, especially since this vaccination is something new, people are unprepared (CSCom 1). Furthermore, practice demonstrated that not all staff needs were sufficiently addressed during the training sessions. For instance, the completion of registries by vaccinators frequently resulted in requests for corrections from supervisors. 2. Create a structure for implementation. Structural characteristics for implementation Create implementation teams Vaccination teams are usually composed of a vaccinator, a recorder, and a mobiliser. Depending on the location of the intervention, some teams vaccinated inside the CSCom (fixed strategy), while others operated outside (advanced strategy). Each advanced strategy team had a specific number of sectors to cover. Advanced strategy teams could choose to create a single vaccination point or go door-to-door to mobilise more people. The CSREF determined the number of teams to be set up in the CSComs according to the size of the population. At the beginning of the vaccination at CSCom 1, 14 teams (including two fixed) of five people were set up there. The size of the teams (two or three people) varied depending on the funding of each international partner. A register of vaccinators was compiled and used for each vaccination campaign. This choice to seek experienced vaccinators avoided resuming training. Each vaccination team received doses composed of different types of vaccines. Recruitment of community relays in vaccination teams was strategic: The relays know the population. They know their neighbourhood. The presence of the relays, therefore, facilitated the introduction of the teams into the communities, which was the idea. (CSCom, Vaccinator 1). In the absence of financial resources, a period of demobilisation followed the first vaccination campaign. Vaccination teams were significantly reduced by the CSRF, according to national guidelines: When the DTC told me to reduce the number of teams, I asked him the question, saying, “Is COVID money available?” She replied by saying, "Walaye, I don’t know, at least they told me to downsize the teams.” I told him that if we check that nothing is ready, there is a money problem. So instead of 14 teams, we worked that day with three teams." (Vaccinator CSCom 1). Thus, the reduction in staff numbers did not enable the implementation of vaccination as an advanced strategy. The CSComs chose to vaccinate as a fixed strategy. Develop an implementation plan. Implementation planning was a task exclusively carried out by CSREF through the development of micro-plans. It was an instrument for centralising decision-making by the CSREF. The rush of implementation forced the CSComs to improvise their local planning. In addition, the urgency of launching vaccination was compounded by the need to use vaccine doses that were at risk of expiring. Efforts to foster community involvement in CSCom contrasted with CSREF's vertical approach; CSREF carried out plans using the resources allocated at the national level. On the other hand, at the CSCom level, there was no formal planning and community resources had to be mobilised. The CSREF provided instructions for targeting and awareness activities prior to vaccination. These instructions resulted in changes to certain work routines. Thus, in CSCom 1, while the incumbent doctors checked the quality of the filling of the registers, the in-house doctors had to arrive early to do the curative consultations. Given the difficulties in estimating vaccine doses during the various field trips, vaccination teams had to had to base their planning on how many people showed up the day before: Since everything depends on the availability of the population to get the vaccine, for example, if we do not have many people to vaccinate today, tomorrow we will reduce the number of vaccines that we give to the teams. On the other hand, if the teams manage to use all the vaccines they have brought to the field, tomorrow we will increase the number of doses we have given. (Staff CSCom 1). 3. Continuous structure after the start of implementation Strategies to support implementation Assistance/coaching/technical supervision The tasks defined for the supervision were multiple and concerned, in particular, the control of the quality of the data and the presence of the vaccinators in the field: We look at the registers, the scorecards, we look at the number of vaccinations they have done, and we check whether it is this number that is actually on the scorecard. We'll see if we have the same number in the register. We look at how they manage the hardware, and how they use it. Vaccinators work with needles and should not infect populations. We check these things when we are under supervision. We also look at how they do the mobilisation, how they position themselves when they do the injections, we check all that. (CSCOM Vaccinator 1). However, some supervisors stepped out of their role to support relays in immunisation activities on an ad hoc basis. The relays considered their involvement in these activities as a technical guarantee to convince the population more effectively. Yet, unlike routine vaccinations, the COVID-19 vaccination has been characterised by a low presence of supervisors in the field. Finally, staff have often had to manage the consequences of the improvised implementation of COVID-19 vaccination by continuing to train vaccinators after field reports and difficulties reported by vaccination teams. Process evaluation The implementation of the national COVID-19 vaccination strategy did not lead to a process assessment at the CSCom level, nor at other scales of the health system. Although the idea of evaluating the processes seemed relevant to the participants in this study, its implementation was a challenge due to the difficulties in mobilising financial resources to carry out vaccination campaigns. Actors have therefore focused more on concrete implementation than on its real-time analysis. Formative feedback mechanism Supervision by the CSCom staff consisted of checking the compliance of the procedures applied by the vaccination teams with the standards learned during the initial training. Supervision feedback allowed vaccinators to correct deficiencies based on recommendations from supervisors. In some cases, supervision and associated feedback took place on-site at CSCom when vaccinators returned from the field. This is off-site supervision and does not include observing vaccinators conducting the vaccination activity. Yes, when the vaccinators come back, we check the data and sometimes I send the young supervisors to the field to be able to correct certain shortcomings. (Staff CSCom 1). 4. Improving future applications Learn from experiences Changes in strategies occurred during the campaigns when vaccination staff realised that something else needed to be done. Therefore, the composition of the teams was redefined to account for the fact that community relays come from the neighbourhoods, which ensured greater mobilisation capacity: That’s what I was telling you, it’s a job that is both easy and difficult. If I were not known in this area, we would not have the few people we manage to see. After the first doses, I was placed on a plateau where I was not very familiar with the populations. I only had a few people to vaccinate. The agents who were put in my sector spent the whole day turning away even one person they did not get because they are not from the sector, and they are not known here. According to these agents, they tried everything: strategies, fixed, mobile door-to-door, but they had nothing. She was a lady with no vaccination experience who had placed teams in the sectors in any way. After that day of failure, they corrected it by sending the agents to operate in their sector. They told us to practice a fixed strategy, but we go door to door (Staff CSCom 1). Finally, during the field surveys, participants drew lessons and suggested improvements for future vaccination campaigns concerning certain aspects of the conceptual framework (Table 4 ). These proposals emphasised the need for changes in human resources, equipment, materials, and business planning. Table 4 Lessons learned according to specific dimensions of the implementation framework Sub-dimensions of the conceptual framework What worked well Which worked less well What would have to change if it were to be done again Recruit and maintain staff Availability of human resources Delay in payment of premiums Obtain explicit buy-in from key stakeholders and promote a supportive community organisational climate The application of various awareness-raising strategies Delay in awareness raising - Sensitize sufficiently before the start of vaccination - Increase the duration of vaccination campaigns as well as the duration of awareness raising - Provide clarifications to vaccinators on the payment of premiums prior to the start of vaccination activities Collaboration with community actors Conflicting explanations on COVID-19 during staff training Voluntary vaccination of staff to lead by example Strengthen general/organizational capacity Input mobilization One-off breaks in certain inputs Estimation of needs by local actors Vaccine redemption in the first phase Register management (find the names of volunteers for the 2nd doses of vaccinations) DISCUSSION This study examined how local actors in Bamako, Mali, implemented COVID-19 vaccination strategies set by national and international health authorities. Thus, the analysis showed that there was a disconnect between the official theoretical framing and the practical application carried out by CSCom staff and community actors. Our study reiterates the existence of an implementation gap that has been widely studied worldwide for several decades. 23 The vaccination challenges faced in Mali are similar to issues previously documented in Senegal during the COVID-19 pandemic. 24 More broadly across the African continent, the implementation of COVID-19 vaccination campaigns was hindered by structural and organizational challenges. Analyses highlighted weaknesses in intersectoral coordination, the logistical management of supplies, staff training, as well as risk communication and community engagement 25 While the content of theoretically effective public health interventions is generally well known, their level of coverage remains low. 26 This was the case for COVID-19 vaccination in Mali. However, these questions have often focused more on definition of the content of interventions and much less on the conditions for their implementation. This is also usually the case for vaccinations strategies. For example, the 50-year impact models of the Expanded Programme on Immunisation often overlook the analysis of implementation challenges for the countries involved. 27 However, the recent difficulties of vaccination, particularly in countries with high levels of conflict such as Mali, 28 showed the importance of resilient health systems and adapting strategies to local contexts. 29–31 This study in Mali shows that all 14 dimensions studied are multiple contextual factors that affect implementation. 12,32 The context is obviously at the heart of analyses of the implementation of public policies. 33 Thus, the study of these contextual factors showed that the different phases of vaccination did not manifest themselves in the same way during the implementation process. Sometimes other factors influenced them. Phase 1 (initial host environment considerations) was partially implemented, as some dimensions, such as assessment strategies, were not operationalised. Instead, the focus was on dimensions such as the decision on adaptation, strategy for capacity building or general/organisational capacity building. We know that in West Africa, needs analyses are rare in the field of health, and the evaluation systems of ministries of health are more often oriented towards monitoring indicators for funders of vertical programmes than population needs analysis. 34 Monitoring systems are also of relatively poor quality in conflict contexts, such as in Mali. 35 In this context of a dependence of vertical programmes such as vaccination on international funding, 30 we often see a greater focus on securing financial resources than on meeting local needs. 36 The same applies to human resources capacity-building activities, which, without funding for development projects, are virtually non-existent. Phase 2 (creating a structure for implementation) focused more on the creation of implementation teams (Dimension 9) than on the development of implementation plans (Dimension 10). It was decided to rely on teams already in place, which is positive in terms of adaptation and sustainability of the interventions. 37 However, the process was too vertical, as is often the case in the region, 24,38,39 leaving aside the involvement of street-level workers in the process. Moreover, the creation of the implementation teams confirms the importance of staff motivation and, in particular, the influence of per diems in carrying out activities. 40 Our results reinforce other studies, which have shown that late payment of premiums can be a source of demotivation, 39,41,42 contrary to the objective pursued. The implementation of Phase 3 (continuous structure after the start of implementation) was partial and was based on tasks related to technical supervision and feedback tasks. Process evaluation was thought out or operationalised. Again, the shortcomings of the evaluation processes of the Ministries of Health are well known in the region. 43 In addition, the few evaluations carried out focused on the effectiveness and analysis of implementation, which are often overlooked. 44 And when performed, the quality and depth of analysis are limited. 45 Phase 4 (improving future applications) resulted in a few redevelopments of activities. Nevertheless, it did not seem to us that the process of improvement has been systematic or that we are in a learning health system as it should be today. 46 While two intra-action reviews (IARs) were carried out in Mali during the pandemic, in line with WHO recommendations, 47 no one was aware at the local level. Their reports were not available on the WHO’s IAR website. Moreover, no reflexive analysis appears to have been undertaken at the regional level, suggesting that these IAR meetings remain confined to the national level. 48 As in many places during the pandemic, implementing actors often cited the urgency of the intervention to justify prioritizing vaccination efforts over earlier actions, even though those prior actions are essential for the intervention’s effectiveness. 24 , 49 Actions to gain stakeholder buy-in (Dimension 5) involved mobilising community leaders and fewer people. However, the two actions had to be complementary since the mobilisation of community leaders was intended to promote greater mobilisation of populations. As in Senegal, there is still a missed opportunity for a more inclusive and community-based approach to the fight against epidemics. 50 Although community health is central in West Africa and Mali, 51 the issue of public participation remains a challenge for public health, 52,53 particularly in vaccination efforts in conflict zones. 30,31 Similarly, health personnel are an essential component of the stakeholders involved in this intervention. Still, we have seen that they have been managed more administratively than through the search for real involvement of street-level workers. The vertical approach, central to the region’s health systems and the approaches of international donors, marked the implementation of the intervention and did little to encourage the involvement of CSOs in critical decision-making. Work stoppages due to late payment of wages have been detrimental to implementation and contribute to low vaccination coverage. Adjustments were undertaken by the CSComs, which quickly found themselves in the need to mobilise their adaptation strategies, which shows a certain resilience of health facilities. 1,21 The weak evaluation strategies have reinforced the mobilisation of these adaptation strategies. Yet, the preparation of health systems is an essential step in creating the conditions for effective implementation, 30 including the establishment of collective responsibility, the mobilisation of available resources (public and private), and a strong and engaged workforce. 54 In the case of the CSComs concerned by this study, collective responsibility was manifested through stakeholder engagement. However, the fact that these structures had little control over resource mobilisation impeded the engagement of local vaccinators. The CSComs, where we collected the data for this survey, demonstrated their ability to reorganise themselves by providing specific responses to emerging challenges. As elsewhere in Mali, these health centres have been able to develop minimal resilience, 55 although vaccination coverage remains low. CONCLUSION This study examined stakeholder involvement in the implementation of health interventions through a case study on vaccination coverage. The results showed that this involvement has not been explicit throughout the process in Mali. While multi-level community engagement is known to contribute to the success of vaccination coverage in conflict zones, 30 in the case of Mali, it remained mainly "administrative" in terms of partnerships with community actors. Community representatives were largely excluded from coordination processes between the health district and community health centres. The gradual increase in COVID-19 vaccination uptake was primarily due to a better perception of its value, which was influenced by the growing threat of the epidemic and the lack of side effects among vaccinated individuals, rather than the quality of the vaccination campaign scheme itself. Declarations Acknowledgements We thank the participants who took part in the semi-structured interviews and the managers of the two community health centers (CSCOMs) for authorizing data collection among their staff. We also thank Seydou Diabaté and Yacouba Diarra for their contribution to data collection. All individuals mentioned by name have given their consent to be acknowledged in this manuscript. Author contributions: The study protocol design, the development of data collection tools, and the planning and implementation of the fieldwork were carried out by A.C, with contributions from V.R. Data analysis was conducted jointly by A.C and V.R. The manuscript was written by A.C, with revisions, suggestions, and intellectual contributions from V.R. Data availability The data used in this study are qualitative in nature (interviews and observations). Due to the sensitive nature of the information and in order to ensure the anonymity and confidentiality of participants, the data are not publicly available. Anonymized excerpts may be provided upon reasonable request to the corresponding author, subject to ethical approval. Competing interests: The authors declare no competing interests Ethics: In addition to the voluntary principle that conditioned participation in the survey, pseudonymisation of the collected data was applied to recordings and transcripts. The designations of agent profiles (Table 1) were diluted into more generic categories. The protocol has been approved by the National Commission on Ethics and Health Sciences (Decision No. 1 120/MSDS/CNESS). The Directorate-General has provided an administrative authorisation for Health and Public Hygiene of the Ministry of Health. Written informed consent for the publication of anonymized data was obtained from all participants The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (2013 revision). Clinical trial registration : Not applicable Funding and Ethics Statement: No funding was received for this research References Ridde V, Traverson L, Zinszer K. Hospital Resilience to the COVID-19 Pandemic in Five Countries: A Multiple Case Study. Health Syst Reform. 2023;9(2):2242112. 10.1080/23288604.2023.2242112 . Bell D, Brown GW, Oyibo WA, et al. COVAX - Time to reconsider the strategy and its target. Health Policy OPEN. 2023;4:100096. 10.1016/j.hpopen.2023.100096 . OMS. Cadre pour la prise de décision: mise en oeuvre de campagnes de vaccination de masse dans le contexte de la COVID-19, Orientations provisoires. Published online 2020. 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Santé Publique. 2001;13(1):35–48. Ag Ahmed MA, Ly BA, Diarra NH, et al. Challenges to the implementation and adoption of physical distancing measures against COVID-19 by internally displaced people in Mali: a qualitative study. Confl Health. 2021;15(1):88. 10.1186/s13031-021-00425-x . Gautier L, Touré L, Ridde V. L’adoption de la réforme du système de santé au Mali: rhétorique et contradictions autour d’un prétendu retour de la santé communautaire. In: Une Couverture Sanitaire Universelle En 2030 ? Éditions science et bien commun; 2021:147–176. https://scienceetbiencommun.pressbooks.pub/cus/ Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet Lond Engl. 2015;385(9980):1910–2. 10.1016/S0140-6736(15)60755-3 . Lerosier T, Touré L, Diabaté S, Diarra Y, Ridde V. Minimal resilience and insurgent conflict: qualitative analysis of the resilience process in six primary health centres in central Mali. BMJ Glob Health. 2023;7(Suppl 9):e010683. 10.1136/bmjgh-2022-010683 . Ridde V, Gautier L, Dagenais C, et al. Learning from public health and hospital resilience to the SARS-CoV-2 pandemic: protocol for a multiple case study (Brazil, Canada, China, France, Japan, and Mali). Health Res Policy Syst. 2021;19(1):76. 10.1186/s12961-021-00707-z . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8454940","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582567287,"identity":"96b75bc2-127f-4772-b34b-cc742d533344","order_by":0,"name":"Abdourahmane Coulibaly","email":"data:image/png;base64,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","orcid":"","institution":"Université des Sciences, des Techniques et des Technologies de Bamako","correspondingAuthor":true,"prefix":"","firstName":"Abdourahmane","middleName":"","lastName":"Coulibaly","suffix":""},{"id":582567288,"identity":"287936c0-0c37-4daa-9145-7a98d8278507","order_by":1,"name":"Valéry Ridde","email":"","orcid":"","institution":"CEPED/IRD/INSERM/Université Paris Cité (France).","correspondingAuthor":false,"prefix":"","firstName":"Valéry","middleName":"","lastName":"Ridde","suffix":""}],"badges":[],"createdAt":"2025-12-26 11:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8454940/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8454940/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101752101,"identity":"00def819-9cd0-44b1-8ff0-428ca255e3a3","added_by":"auto","created_at":"2026-02-03 10:25:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1107202,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8454940/v1/a294b78a-504e-4ec6-a4e5-38afd0fcd2b1.pdf"},{"id":101484210,"identity":"c0ff9247-ea16-4b2b-b5cf-b2974a115f1b","added_by":"auto","created_at":"2026-01-30 08:52:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19110,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8454940/v1/bca4decb723f3ad7eca479a3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIt took 39 years following the discovery of the tuberculosis pathogen to have a single vaccine. However, within a year of the SARS-CoV-2 (COVID-19) discovery at the end of 2019, 18 vaccines were available, and an additional 109 vaccine candidates were being tested. \u003csup\u003e1\u003c/sup\u003e The high mortality and morbidity rates, especially in Western countries, prompted global health authorities to support the urgent search for a vaccine. Vaccine production was carried out swiftly through established procedures, supported by global collaboration, massive funding, and the use of pre-existing technologies such as mRNA-based vaccines. This response was unprecedented in the history of public health and allowed for the rapid launch of national vaccination campaigns. However, the accelerated vaccine availability raised questions about international priorities, the fairness of vaccine distribution, and the systemic vision of fighting a pandemic. \u003csup\u003e2\u003c/sup\u003e To ensure fair access to vaccines on a worldwide scale, the COVAX initiative was set up, which posed particular challenges, such as vaccination targets and funding challenges. \u003csup\u003e2\u003c/sup\u003e To support countries, the WHO published a guidance document on COVID-19 vaccination campaigns. \u003csup\u003e3\u003c/sup\u003e It specified the essential steps needed for operational planning of mass vaccinations: estimating targets, calculating vaccine needs, managing human resources, and monitoring the campaign implementation.\u003c/p\u003e \u003cp\u003eIn most French-speaking West African countries, despite several vaccination campaigns, coverage rates remained low. As of December 4, 2022, only 30.4% of the population in the WHO Africa region received a first dose of the COVID-19 vaccine. In Mali, only 11.3% of the population received the first round of COVID-19 vaccine doses. The country is ranked the 7th least vaccinated of the 27 countries for which the WHO has shared data. It is not included in the list of 35 African countries with data on booster coverage of this vaccine. \u003csup\u003e4\u003c/sup\u003e Thus, numerous studies have been carried out in the region to understand this phenomenon, analysing vaccine intent, acceptance, or hesitation. \u003csup\u003e5\u0026ndash;8\u003c/sup\u003e These studies show the importance of people\u0026rsquo;s trust in health professionals and government, the role of misconceptions and rumours, past vaccination experiences, and the socio-economic variables of the people concerned. In Mali, low coverage has mostly been linked to vaccine hesitation, fuelled by persistent rumours about the risks of COVID-19 vaccines \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e or a lack of confidence in the vaccine. \u003csup\u003e10\u003c/sup\u003e However, systemic issues have often been overlooked in these analyses, which have usually focused on individuals and their relationship to vaccination.\u003c/p\u003e \u003cp\u003eFor several years now, international debates on health system planning and management have emphasized the need to move beyond individual-centered approaches in order to analyze organizational dynamics, implementation capacities, and context-specific adaptation strategies. These discussions have highlighted that the effectiveness of interventions depends not only on their content or acceptability, but also on how they are concretely implemented within health structures\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, this focus of studies on an outcome variable (vaccination), with quantitative approaches, does not provide a detailed understanding of the challenges of the implementation of immunisation by the health system. This dimension is sometimes briefly understood as a contextual or explanatory variable of quantitative studies. However, research has long shown that the implementation of an intervention is complex and determined by multiple factors\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Moreover, analysis of the implementation of public health interventions remains rare in West Africa and Mali, particularly those using a proven conceptual framework. \u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThus, the objective of this article is to analyse the implementation of the national vaccination strategy in 2021 and 2022 to understand the challenges related to COVID-19 vaccination coverage and lessons learned.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003eBefore explaining the method of this research, we will describe the national vaccination strategy whose implementation we will analyse.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eA. The national vaccination strategy against COVID-19\u003c/h2\u003e \u003cp\u003eWHO recommendations guided national COVID-19 vaccine planning. \u003csup\u003e16\u003c/sup\u003e The health authorities defined several strategies to ensure optimal vaccination coverage: integration of COVID-19 vaccination into the Expanded Programme on Immunisation (EPI); mass vaccination campaigns in public places; mobilisation of social networks; communication campaigns to combat false rumours, etc. As part of international cooperation, the authorities gradually received doses of different vaccines. The vaccination campaign was carried out in four phases (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePhase 1\u003c/strong\u003e \u003cp\u003ePreparation (end 2020 \u0026ndash; March 2021)\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe activities carried out during this phase concerned the development of the deployment and vaccination plan, the identification of priority groups (health workers, older people, people with comorbidities), and the mobilisation of partners (COVAX, WHO, UNICEF).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePhase 2\u003c/strong\u003e \u003cp\u003eInitial launch (March 2021)\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe first vaccines were welcomed as valuable commodities. Indeed, the Malian authorities formed a delegation to receive the first vaccines (396,000 AstraZeneca doses) that arrived on March 5, 2021, under the COVAX Facility (a global initiative led by GAVI, WHO, CEPI and UNICEF). The government presence at the airport and its media coverage symbolised a strong political act. Vaccines were made available to the reference health centres (\u003cem\u003eCentre de Sant\u0026eacute; de R\u0026eacute;f\u0026eacute;rence\u003c/em\u003e, or CSREF: district hospitals and health district authorities). They were then distributed among the Community Health Centres (\u003cem\u003eCentres de Sante Communautaire\u003c/em\u003e, or CSComs) by CSREF staff. AstraZeneca doses were received, and the COVID-19 vaccination campaign was officially launched on March 31, 2021. The health authorities targeted people who were particularly exposed (socio-health workers) or considered vulnerable (people over 60 years of age and people with comorbidities such as diabetes, high blood pressure, or respiratory diseases). Their names were first entered in the so-called \"targeting\" register, and then, once the person received their vaccination, their names were added to the vaccination register.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePhase 3\u003c/strong\u003e \u003cp\u003eExtension and proximity strategies (August 2021-August 2022)\u003c/p\u003e \u003c/p\u003e \u003cp\u003ePhase 3 was marked by the deployment of new vaccines, including Johnson and Johnson (August 23, 2021), Sinovac (November 11, 2021), Moderna (end of 2021), Pfizer (May 9, 2022), and Sinopharm (January 26, 2022).\u003c/p\u003e \u003cp\u003eThanks to the COVAX initiative, the US government sent Bamako 151,200 doses of Johnson and Johnson vaccines. These vaccines were primarily administered in remote areas of the country as a single dose. Vaccination was open to people aged 18 and over. Then, the government received 835,000 doses of Sinovac from China. These vaccines were intended for people over the age of 18 who had not yet been vaccinated. The introduction of Pfizer vaccines (USA) extended vaccination to adolescents aged 12 to 17 years, as well as pregnant and breastfeeding women. The arrival of 300,000 doses of Sinopharm offered by China made it possible to extend vaccination to people aged at least 18 years throughout the country. At the end of November 2021, authorities received 201,600 doses of the Moderna vaccine (via the COVAX initiative). These doses were intended to increase vaccination coverage in addition to others (AstraZeneca, Johnson \u0026amp; Johnson, Sinovac, Sinopharm and Pfizer).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePhase 4\u003c/strong\u003e \u003cp\u003eIntegration of the vaccine into the ENP (April 2024)\u003c/p\u003e \u003c/p\u003e \u003cp\u003eApril 30, 2024, marked the integration of COVID-19 vaccination into the ENP, encompassing all types of vaccines. The aim was to increase coverage in remote areas and to promote the fight against emerging variants.\u003c/p\u003e \u003cp\u003eOur study is limited to Phases 2 and 3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eChronology of the deployment of the different types of COVID-19 vaccines in Mali\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaccine name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTarget populations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLaunch date\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDonor\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase 1\u003c/p\u003e \u003cp\u003e(Preparation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase 2 (Initial Launch)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAstraZeneca\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth workers, \u0026ge;\u0026thinsp;60 years, people with comorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMarch 31, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCOVAX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003ePhase 3 (Extension)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJohnson \u0026amp; Johnson\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAny person\u0026thinsp;\u0026ge;\u0026thinsp;18 years of age not yet vaccinated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAugust 23, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnited States via COVAX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSinovac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdults\u0026thinsp;\u0026ge;\u0026thinsp;18 years of age not vaccinated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNovember 11, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina via COVAX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSinopharm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdults\u0026thinsp;\u0026ge;\u0026thinsp;18 years of age throughout the country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJanuary 26, 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePfizer-BioNTech\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdolescents (12\u0026ndash;17 years), pregnant and breastfeeding women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 May 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnited States via Covax\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerna\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePeople not vaccinated or waiting for 2nd dose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnd 2021 \u0026ndash; through 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnited States via COVAX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase 4 (ENP integration)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll vaccines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRoutine immunisation in routine health services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eApril 30, 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn total, there were 10 COVID-19 vaccination campaigns in Mali between 2021 and 2023. A campaign refers to a one-off vaccination action, often limited in time (10 days), with specific coverage objectives and resources mobilised. These campaigns are the operational component of a phase.\u003c/p\u003e \u003cp\u003eThe breakdown of the campaigns by year is as follows: two national campaigns in 2021 (Campaign 1 with AstraZeneca and Campaign 2 with Johnson and Johnson), one single campaign in 2022 (Pfizer, Sinopharm, Sinovac, Johnson \u0026amp; Johnson, AstraZeneca) and seven campaigns in 2023 (Pfizer, Moderna, Johnson and Johnson, Sinopharm, Sinovac, AstraZeneca).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eB. The conceptual framework\u003c/h3\u003e\n\u003cp\u003eThere is a significant number of theories and analytical frameworks for studying the implementation of public health interventions, which is complex but essential. \u003csup\u003e17\u003c/sup\u003e In this case, we needed a solid but relatively flexible approach to adapt to our terrain and to research that was essentially qualitative and anthropological. Moreover, it was not a question of studying the determinants of implementation, such as the Consolidated Framework for Implementation Research (CFIR), for example, \u003csup\u003e18\u003c/sup\u003e but instead of understanding its challenges and, in particular, the quality of its organisation. Thus, our choice was based on the use of Meyers\u0026rsquo; framework \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e because it is essentially concerned with the quality of the implementation. From 25 different frameworks for analysing implementation, Meyers et al. proposed to examine the processes of organising an intervention in the light of 14 critical stages organised in four specific phases: (1) initial considerations regarding the reception context of vaccination, (2) creation of a structure for implementation, (3) continuous structure once implementation has started, and (4) improvement of future implementation. It is, therefore, using this analytical framework that we collected and analysed empirical data in several survey sites using a qualitative approach.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality implementation framework\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePhase 1: Initial considerations for the hotel environment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Conduct a needs and resources assessment\u003c/p\u003e \u003cp\u003e2. Carry out an adequacy assessment\u003c/p\u003e \u003cp\u003e3. Carry out a readiness assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecision on adaptation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4. Opportunities for adaptation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategies for strengthening stakeholders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5. Obtain explicit buy-in from key stakeholders and promote a supportive community organisational climate\u003c/p\u003e \u003cp\u003e6. Strengthen general/organisational capacity\u003c/p\u003e \u003cp\u003e7. Recruit and maintain staff\u003c/p\u003e \u003cp\u003e8. Efficiently train staff in innovation beforehand\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhase 2: Create an implementation structure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStructural characteristics for implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9. Create implementation teams\u003c/p\u003e \u003cp\u003e10. Develop an implementation plan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhase 3: Continuous structure after the start of implementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategies to support continuous implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11. Assistance/coaching/supervision\u003c/p\u003e \u003cp\u003e12. Process evaluation\u003c/p\u003e \u003cp\u003e13. Formative feedback mechanism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhase 4: Improving future applications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImproving future applications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14. Learn from experiences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis study is based on data collection carried out at two sites in the capital (Bamako), understood as two contrasting study cases located in the same health district. \u003csup\u003e20\u003c/sup\u003e They were chosen because they represent a certain contextual diversity, but also because their access was facilitated by a pre-survey in the context of the COVID-19 pandemic. \u003csup\u003e1\u003c/sup\u003e After studying the effects of the pandemic at the hospital level, \u003csup\u003e21\u003c/sup\u003e the vaccination analysis was carried out at the level of the primary health centres where the implementation was organised. The CSCom is a health institution providing front-line services. It is managed by a Community Health Association (\u003cem\u003eAssociation de Sant\u0026eacute; Communautaire\u003c/em\u003e, ASACO). The choice of the two peripheral health centres was guided by the possibility of comparing data from an older CSCom with a high volume of care offerings (CSCom1) with another, more recent CSCom with a significantly lower volume of care offerings (CSCom2).\u003c/p\u003e \u003cp\u003eCSCom 1 is a referral CSCom with a staff of around 22 people (15 permanent staff members\u0026thinsp;+\u0026thinsp;seven DES trainees) as of 2021. It was established a long time ago (2009). It offers services including immunisation, maternal and child care, medical consultations, and preventive care activities. It is a university-affiliated community health centre that provides specialised consultations and offers student internships. In 2021, the facility carried out 26,013 treatment consultations including both new and follow-up visits. The CSCom 2 is a more modest centre with a smaller number of staff. In 2021, there were 17 staff members. In 2021, it carried out 4,553 consultations (new and old), five times fewer than CSCom 1. The services offered are based on activities that are usually found in CSCom, including curative consultations (malaria, respiratory infections, chronic diseases), maternal and child health (births, PMTCT), and community health education activities (awareness-raising, hygiene, nutrition).\u003c/p\u003e\n\u003ch3\u003eC. Sampling and data collection\u003c/h3\u003e\n\u003cp\u003eThis study uses qualitative research based on data collected through individual interviews and field observations. \u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFirst, we conducted 53 semi-structured interviews (first pass) and 15 observation days, plus four semi-structured interviews (second pass), in both CSComs in June 2021 and September 2022. Sampling was as comprehensive as possible within each of the two sites by seeking to meet most of the people involved in the implementation of vaccination while maximising the diversification of profiles to strengthen data triangulation. We recruited participants based on a pre-established list of agent profiles and random meetings in a snowball approach. Thus, the participants interviewed were the technical director of the centre (DTC), a doctor (med), nurses (inf), midwives (SF), doctors, community health workers (CHAs), community relays, vaccinators, health information system managers (SIS), leaders of community health associations (ASACO), and community leaders. We interviewed the participants in the CSCom premises at times decided by them based on their availability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eDistribution of respondents by category of participants\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDTC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSocial Service\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSIS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVaccinator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRelays\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eMem. ASACO\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLeader com.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCSCom 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePassage 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePassage 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCSCom 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePassage 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePassage 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e27\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e57\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe gender distribution highlights a clear dominance of female participants for both CSCom 2 (17 women vs. 10 men) and CSCom1 (16 women vs. 10 men).\u003c/p\u003e \u003cp\u003eThe investigation took place in two stages. During the first visit in June 2021, investigators found that the first vaccination campaign had already ended. Thus, the assistants could not make observations. This first passage was exclusively devoted to semi-structured interviews. In September 2022, a second data collection took place. This second passage was mainly dedicated to observations of situations because the vaccination campaigns had resumed, and we took the opportunity to make observations before a new suspension. These observations (n\u0026thinsp;=\u0026thinsp;20 days) focused on the progress of vaccination activities (interactions between teams and vaccine candidates, organisation of teams in the field). The value of collecting data in two phases allowed us to study possible variations in the implementation of vaccination campaigns over time.\u003c/p\u003e \u003cp\u003eTwo experienced research assistants collected data from the study. We designed interview guides based on the dimensions of the conceptual framework, but the data collection was open and therefore allowed us to go beyond these dimensions. Each of the assistants worked in a single CSCom. All data collection activities were supervised by the senior researcher based in Bamako (AC) during field visits and daily phone reports. AC also carried out the field exploration by conducting semi-structured interviews with the managers of the two centres. The other researcher (VR) coordinated all the research in which this study was carried out \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e and visited the two CSComs in 2021 to prepare this study with AC. The two authors collaborated in the drafting of the protocol, its implementation, analysis, and publication.\u003c/p\u003e\n\u003ch3\u003eD. Analysis of data\u003c/h3\u003e\n\u003cp\u003eWe recorded and transcribed all interviews in french langage. They were then subject to open and inductive manual coding before being organised according to the dimensions of the conceptual framework and in the context of an analytical discussion between the two authors.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe results of this study align with the dimensions of the previously proposed implementation quality framework. We opted for a comprehensive analysis of the data collected at the two health centres, except where empirical differences were noted. Appendix 1 summarises the results.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInitial considerations for the host environment\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation strategy\u003c/h2\u003e \u003cp\u003eInstitutionally, CSCom staff found the management of COVID-19 vaccinations to be not very inclusive. The decisions concerning the needs of the CSComs were taken by the district hospital (CSREF), without a prior concerted assessment. The CSCom staff had no choice but to receive the quantities of vaccines made available to them:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt was the chefs themselves who made estimates according to the teams, and they gave us materials based on their estimate. We have not assessed our needs. These calculations were made by themselves. They did not send us a note asking us to assess our needs\u003c/em\u003e (Staff CSCom1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePlanning documents known as \"micro-plans\" were drawn up by the CSREF without prior consultation with the CSCom teams. These micro-plans were then sent to the CSCom staff:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThey are talking about a microplan that comes from above. There are always micro-plans sent to us about COVID, so there are always changes\u003c/em\u003e (Vaccinator, CSCom1).\u003c/p\u003e\u003cp\u003e...\u003cem\u003eThey just parachute decisions about us without us being directly involved. We also have a say.\u003c/em\u003e (Staff CSCom2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIf they ran out of vaccines and other inputs necessary for vaccination, they simply sent a purchase order to the CSRF with the required quantity of vaccines.\u003c/p\u003e \u003cp\u003eAdequacy and preparedness for vaccination have not been specifically assessed. Moreover, CSCom actors often criticized the improvised nature of the announcement of the dates of vaccination campaigns. These dates were usually announced only two to three days before campaigns began. This lack of preparedness was particularly evident as these actors were accustomed to planning vaccination strategies under the ENP. The officers we interviewed often described their readiness to receive training on COVID-19 vaccination and vaccines.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAdaptation decisions\u003c/h3\u003e\n\u003cp\u003eAs with other vaccine strategies (e.g. EPI), the CSREF teams made decisions, including possible adaptations of implementation:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe report to the CSREF; the CSREF dictates to us. All decisions come from there\"\u003c/em\u003e (Staff CSCom1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSometimes, at the insistent request of some young people who were not yet eligible, the Medical Officer-Head of the Health District was asked by the CSCom staff to give his approval for them to be vaccinated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eTargeting was like that. Those eligible for vaccination are older people, the chronically ill and health workers. Otherwise, even though many people, there were young people who came to get vaccinated of their own free will. We had to ask for information. The chief doctor of the CSREF said to vaccinate them.\u003c/em\u003e (Staff CSCom 2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, CSCom sometimes gave itself leeway and adapted certain activities once vaccines were delivered. These adaptations were particularly concerned with managing vaccination teams (the number of teams in fixed centres and advanced strategies), whose composition had been determined in advance by the CSRF according to the size of each health area's population. The financial constraints of CSCom also sometimes guided possible adaptations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eEven if I say so, the answer is always that there is not enough money. The answer is always \u0026ldquo;we are obliged to do with our means on board\u0026rdquo;. As they said, we too at centre level will do so with our on-board means\u003c/em\u003e (Staff CSCom 2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAt CSCom 1, reinforcements were mobilised to increase vaccination coverage capacity in the most significant areas. Once on the ground, the teams had the opportunity to organise themselves according to the contexts they encountered. This is why they moved elsewhere, once the number of people to be vaccinated decreased. In the second phase of vaccination, the number of teams was reduced.\u003c/p\u003e \u003cp\u003eThe remuneration of vaccinating agents was not always ensured on time by the CSREF, due to a lack of available funds. As a result, CSCom managers were uncomfortable having people work without pay. They temporarily reduced the teams until the funds were available again. The vaccinators did not have a formal employment contract with CSCom. A simple financial document bearing the names of the beneficiaries of the vaccination premium and called \"statement of payment\" was used as evidence.\u003c/p\u003e\n\u003ch3\u003eStrategies for capacity-building\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eExplicit membership of key stakeholders\u003c/h2\u003e \u003cp\u003eThe widespread circulation of rumours concerning the safety of the vaccine led to a distrust of the vaccine and increased vaccine hesitation. These persistent social media rumours presented vaccines as deadly threats. When vaccination teams went to neighbourhoods to target eligible people and vaccinate willing participants, they encountered many hostile reactions. Increased awareness and education were quickly recognised by staff as an effective way to combat rumours. Some survey participants also emphasised the importance of vaccinating staff to lead by example:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003ePeople refused to get vaccinated. They were chasing vaccinators out of their families. We know that he did not have enough vaccine for everyone; therefore, it was decided to target an age group for the vaccine. So we started by targeting these populations. People refused to be targeted, and vaccination is not mentioned. It was the population\u0026rsquo;s reluctance to vaccinate that was the immediate consequence of the lack of in-depth awareness.\u0026rdquo;\u003c/em\u003e (Staff CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStakeholder buy-in at the community level was fostered by the involvement of key stakeholders (community health associations, neighbourhood leaders, religious leaders). As a result, healthcare staff relied heavily on ASACO:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe are community members; it was the community that created the CSCOM. It is the people who agree to look for the receipt. They set up the office, and they recruit staff. If a vaccination is required, it is said to ASACO, which informs those responsible for the neighbourhood, who in turn inform the population through mosques, gathering places, etc. We also raise awareness at our level.\u003c/em\u003e (Staff CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTo overcome resistance, the CSCom teams put strategies in place to raise awareness among reluctant people:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eBut during the campaigns, if we have cases of refusal, we deploy a team to raise awareness. If they persist, they are left as this is not mandatory.\u0026rdquo;\u003c/em\u003e (CSCom 2 -Vaccinator).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn CSCom 2, in addition to these influential personalities, a \u003cem\u003egriotte\u003c/em\u003e (traditional storyteller) was asked to spread the message within families. Furthermore, in health centres, the themes discussed daily by ENP staff during educational talks with patients have been enriched by COVID-19 vaccination.\u003c/p\u003e \u003cp\u003eHowever, the observations showed that after an interruption period at the end of May 2021, the resumption of fixed centre vaccination in June 2021 was not sufficiently communicated to patients by staff, contrary to what patients claimed.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStrengthening overall organisational capacity.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe DTC (responsible for CSCom), the ENP officer and his team were particularly mobilised to prepare the departure of the vaccination teams on the ground. Reinforcements have sometimes been mobilised to support vaccination teams. To strengthen the supply capacities of the vaccination teams, the CSCom covered the travel costs related to the supply. The CSREF did not budge these costs, and they were, therefore, a community contribution.\u003c/p\u003e \u003cp\u003eFor the implementation of the campaign, many management materials were made available to the CSCom by the CSREF (vaccine scorecards, supervision sheet, MAPI sheet, etc.). The registers were simpler to fill in than those usually found. Masks, gloves, and vaccination cards were occasionally damaged during campaigns. CSCom 1 often had to use its funds to address the shortage.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRecruiting and maintaining staff.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eRecruitment of staff was closed because the workforce was mainly made up of interns and volunteers already working in the CSComs. This has not been without suspending, even temporarily, the curative activities within the CSComs, as these trainees and volunteers are generally essential to the functioning of the CSComs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe suspended our activities and gathered the teams in the large meeting room of the centre to quickly discuss the vaccination of COVID, and we began the vaccination.\u003c/em\u003e (Vaccinator CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the absence of official remuneration, the bonuses granted in the context of vaccination activities were a source of motivation for those volunteers. However, delays in the payment of these premiums had the opposite effect. At CSCom 1, a strike was decreed after two months of late payment. In addition, for CSCom 1, the announced premium for vaccinators was reduced due to budget constraints because there was an error in the CSREF team\u0026rsquo;s estimation of the number of vaccinators. In CSCom 2, an ASACO member highlighted the challenges of carrying out unmotivated vaccination tasks by health workers and the efforts made by ASACO to avoid demotivation. He explained that they had limited financial support, and community funds were limited and couldn\u0026rsquo;t be used for that purpose. Observations on the ground have shown that the presence of vaccination agents at their posts decreased significantly over time, notably at CSCom 2 (June 25, 2021):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eOn this Friday, I arrive in CSCom 2 at 8:10 am. Today, the volunteer nurse who really takes care of the vaccination did not come. The DTC is still in training. The vaccination officer arrived at 9 a.m. but did not even wear a gown. He walks around the yard to smoke. At 10.30 am, he left the centre because he had to take care of a personal matter. That is where I ask him a question\u003c/em\u003e:\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eQ: Does Ny not have a vaccination today?\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003eR: We're a little discouraged. We have not yet received the money from the previous COVID vaccination we administered. Without it, we even refused to send the vaccination data (pointing). After this response, he takes his motorcycle and leaves the centre quickly.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTraining staff effectively.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe CSREF team provided training for the CSCom staff with the support of national trainers. The training focused on the types of vaccines, behaviours in the field, and the targeting of eligible people. However, one of the vaccinators noted the hasty nature of the training he received at CSREF and then the launch of the campaign:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eNo, we weren\u0026rsquo;t ready... One or two days after this meeting, the DTC calls me to inform me that the CSREF has just called him to tell him to train the teams, and vaccination will start next week. We were both surprised and astonished that day because for vaccination campaigns of this magnitude, we have to give ourselves time to train the teams, prepare them, express our needs. They did things hurriedly, tac, tac, tac, and paf, let\u0026rsquo;s go. They forced us to get vaccinated the week they had told us. That day, I told the DTC that I had not seen a hasty vaccination campaign. Making a vaccination campaign overnight, especially since this vaccination is something new, people are unprepared\u003c/em\u003e (CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, practice demonstrated that not all staff needs were sufficiently addressed during the training sessions. For instance, the completion of registries by vaccinators frequently resulted in requests for corrections from supervisors.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. Create a structure for implementation.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStructural characteristics for implementation\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eCreate implementation teams\u003c/h2\u003e \u003cp\u003eVaccination teams are usually composed of a vaccinator, a recorder, and a mobiliser. Depending on the location of the intervention, some teams vaccinated inside the CSCom (fixed strategy), while others operated outside (advanced strategy). Each advanced strategy team had a specific number of sectors to cover. Advanced strategy teams could choose to create a single vaccination point or go door-to-door to mobilise more people.\u003c/p\u003e \u003cp\u003eThe CSREF determined the number of teams to be set up in the CSComs according to the size of the population. At the beginning of the vaccination at CSCom 1, 14 teams (including two fixed) of five people were set up there. The size of the teams (two or three people) varied depending on the funding of each international partner. A register of vaccinators was compiled and used for each vaccination campaign. This choice to seek experienced vaccinators avoided resuming training.\u003c/p\u003e \u003cp\u003eEach vaccination team received doses composed of different types of vaccines. Recruitment of community relays in vaccination teams was strategic:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe relays know the population. They know their neighbourhood. The presence of the relays, therefore, facilitated the introduction of the teams into the communities, which was the idea.\u003c/em\u003e (CSCom, Vaccinator 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the absence of financial resources, a period of demobilisation followed the first vaccination campaign. Vaccination teams were significantly reduced by the CSRF, according to national guidelines:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhen the DTC told me to reduce the number of teams, I asked him the question, saying, \u0026ldquo;Is COVID money available?\u0026rdquo; She replied by saying, \"Walaye, I don\u0026rsquo;t know, at least they told me to downsize the teams.\u0026rdquo; I told him that if we check that nothing is ready, there is a money problem. So instead of 14 teams, we worked that day with three teams.\"\u003c/em\u003e (Vaccinator CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThus, the reduction in staff numbers did not enable the implementation of vaccination as an advanced strategy. The CSComs chose to vaccinate as a fixed strategy.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDevelop an implementation plan.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eImplementation planning was a task exclusively carried out by CSREF through the development of micro-plans. It was an instrument for centralising decision-making by the CSREF. The rush of implementation forced the CSComs to improvise their local planning. In addition, the urgency of launching vaccination was compounded by the need to use vaccine doses that were at risk of expiring.\u003c/p\u003e \u003cp\u003eEfforts to foster community involvement in CSCom contrasted with CSREF's vertical approach; CSREF carried out plans using the resources allocated at the national level. On the other hand, at the CSCom level, there was no formal planning and community resources had to be mobilised. The CSREF provided instructions for targeting and awareness activities prior to vaccination. These instructions resulted in changes to certain work routines. Thus, in CSCom 1, while the incumbent doctors checked the quality of the filling of the registers, the in-house doctors had to arrive early to do the curative consultations.\u003c/p\u003e \u003cp\u003eGiven the difficulties in estimating vaccine doses during the various field trips, vaccination teams had to had to base their planning on how many people showed up the day before:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSince everything depends on the availability of the population to get the vaccine, for example, if we do not have many people to vaccinate today, tomorrow we will reduce the number of vaccines that we give to the teams. On the other hand, if the teams manage to use all the vaccines they have brought to the field, tomorrow we will increase the number of doses we have given.\u003c/em\u003e (Staff CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e \u003cb\u003e3. Continuous structure after the start of implementation\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrategies to support implementation\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eAssistance/coaching/technical supervision\u003c/h2\u003e \u003cp\u003eThe tasks defined for the supervision were multiple and concerned, in particular, the control of the quality of the data and the presence of the vaccinators in the field:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe look at the registers, the scorecards, we look at the number of vaccinations they have done, and we check whether it is this number that is actually on the scorecard. We'll see if we have the same number in the register. We look at how they manage the hardware, and how they use it. Vaccinators work with needles and should not infect populations. We check these things when we are under supervision. We also look at how they do the mobilisation, how they position themselves when they do the injections, we check all that.\u003c/em\u003e (CSCOM Vaccinator 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, some supervisors stepped out of their role to support relays in immunisation activities on an \u003cem\u003ead hoc\u003c/em\u003e basis. The relays considered their involvement in these activities as a technical guarantee to convince the population more effectively. Yet, unlike routine vaccinations, the COVID-19 vaccination has been characterised by a low presence of supervisors in the field. Finally, staff have often had to manage the consequences of the improvised implementation of COVID-19 vaccination by continuing to train vaccinators after field reports and difficulties reported by vaccination teams.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eProcess evaluation\u003c/h2\u003e \u003cp\u003eThe implementation of the national COVID-19 vaccination strategy did not lead to a process assessment at the CSCom level, nor at other scales of the health system. Although the idea of evaluating the processes seemed relevant to the participants in this study, its implementation was a challenge due to the difficulties in mobilising financial resources to carry out vaccination campaigns. Actors have therefore focused more on concrete implementation than on its real-time analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eFormative feedback mechanism\u003c/h2\u003e \u003cp\u003eSupervision by the CSCom staff consisted of checking the compliance of the procedures applied by the vaccination teams with the standards learned during the initial training. Supervision feedback allowed vaccinators to correct deficiencies based on recommendations from supervisors. In some cases, supervision and associated feedback took place on-site at CSCom when vaccinators returned from the field. This is off-site supervision and does not include observing vaccinators conducting the vaccination activity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYes, when the vaccinators come back, we check the data and sometimes I send the young supervisors to the field to be able to correct certain shortcomings.\u003c/em\u003e (Staff CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e4. Improving future applications\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLearn from experiences\u003c/h2\u003e \u003cp\u003eChanges in strategies occurred during the campaigns when vaccination staff realised that something else needed to be done. Therefore, the composition of the teams was redefined to account for the fact that community relays come from the neighbourhoods, which ensured greater mobilisation capacity:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThat\u0026rsquo;s what I was telling you, it\u0026rsquo;s a job that is both easy and difficult. If I were not known in this area, we would not have the few people we manage to see. After the first doses, I was placed on a plateau where I was not very familiar with the populations. I only had a few people to vaccinate. The agents who were put in my sector spent the whole day turning away even one person they did not get because they are not from the sector, and they are not known here. According to these agents, they tried everything: strategies, fixed, mobile door-to-door, but they had nothing. She was a lady with no vaccination experience who had placed teams in the sectors in any way. After that day of failure, they corrected it by sending the agents to operate in their sector. They told us to practice a fixed strategy, but we go door to door\u003c/em\u003e (Staff CSCom 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFinally, during the field surveys, participants drew lessons and suggested improvements for future vaccination campaigns concerning certain aspects of the conceptual framework (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These proposals emphasised the need for changes in human resources, equipment, materials, and business planning.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLessons learned according to specific dimensions of the implementation framework\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSub-dimensions of the conceptual framework\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat worked well\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhich worked less well\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWhat would have to change if it were to be done again\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecruit and maintain staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailability of human resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelay in payment of premiums\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eObtain explicit buy-in from key stakeholders and promote a supportive community organisational climate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe application of various awareness-raising strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelay in awareness raising\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e- Sensitize sufficiently before the start of vaccination\u003c/p\u003e \u003cp\u003e- Increase the duration of vaccination campaigns as well as the duration of awareness raising\u003c/p\u003e \u003cp\u003e- Provide clarifications to vaccinators on the payment of premiums prior to the start of vaccination activities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollaboration with community actors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConflicting explanations on COVID-19 during staff training\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVoluntary vaccination of staff to lead by example\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eStrengthen general/organizational capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInput mobilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOne-off breaks in certain inputs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEstimation of needs by local actors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVaccine redemption in the first phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRegister management (find the names of volunteers for the 2nd doses of vaccinations)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study examined how local actors in Bamako, Mali, implemented COVID-19 vaccination strategies set by national and international health authorities. Thus, the analysis showed that there was a disconnect between the official theoretical framing and the practical application carried out by CSCom staff and community actors. Our study reiterates the existence of an implementation gap that has been widely studied worldwide for several decades. \u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe vaccination challenges faced in Mali are similar to issues previously documented in Senegal during the COVID-19 pandemic. \u003csup\u003e24\u003c/sup\u003e More broadly across the African continent, the implementation of COVID-19 vaccination campaigns was hindered by structural and organizational challenges. Analyses highlighted weaknesses in intersectoral coordination, the logistical management of supplies, staff training, as well as risk communication and community engagement\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile the content of theoretically effective public health interventions is generally well known, their level of coverage remains low. \u003csup\u003e26\u003c/sup\u003e This was the case for COVID-19 vaccination in Mali. However, these questions have often focused more on definition of the content of interventions and much less on the conditions for their implementation. This is also usually the case for vaccinations strategies. For example, the 50-year impact models of the Expanded Programme on Immunisation often overlook the analysis of implementation challenges for the countries involved. \u003csup\u003e27\u003c/sup\u003e However, the recent difficulties of vaccination, particularly in countries with high levels of conflict such as Mali, \u003csup\u003e28\u003c/sup\u003e showed the importance of resilient health systems and adapting strategies to local contexts. \u003csup\u003e29\u0026ndash;31\u003c/sup\u003e This study in Mali shows that all 14 dimensions studied are multiple contextual factors that affect implementation. \u003csup\u003e12,32\u003c/sup\u003e The context is obviously at the heart of analyses of the implementation of public policies. \u003csup\u003e33\u003c/sup\u003e Thus, the study of these contextual factors showed that the different phases of vaccination did not manifest themselves in the same way during the implementation process. Sometimes other factors influenced them.\u003c/p\u003e \u003cp\u003ePhase 1 (initial host environment considerations) was partially implemented, as some dimensions, such as assessment strategies, were not operationalised. Instead, the focus was on dimensions such as the decision on adaptation, strategy for capacity building or general/organisational capacity building. We know that in West Africa, needs analyses are rare in the field of health, and the evaluation systems of ministries of health are more often oriented towards monitoring indicators for funders of vertical programmes than population needs analysis. \u003csup\u003e34\u003c/sup\u003e Monitoring systems are also of relatively poor quality in conflict contexts, such as in Mali. \u003csup\u003e35\u003c/sup\u003e In this context of a dependence of vertical programmes such as vaccination on international funding,\u003csup\u003e30\u003c/sup\u003e we often see a greater focus on securing financial resources than on meeting local needs. \u003csup\u003e36\u003c/sup\u003e The same applies to human resources capacity-building activities, which, without funding for development projects, are virtually non-existent.\u003c/p\u003e \u003cp\u003ePhase 2 (creating a structure for implementation) focused more on the creation of implementation teams (Dimension 9) than on the development of implementation plans (Dimension 10). It was decided to rely on teams already in place, which is positive in terms of adaptation and sustainability of the interventions. \u003csup\u003e37\u003c/sup\u003e However, the process was too vertical, as is often the case in the region, \u003csup\u003e24,38,39\u003c/sup\u003e leaving aside the involvement of street-level workers in the process. Moreover, the creation of the implementation teams confirms the importance of staff motivation and, in particular, the influence of \u003cem\u003eper diems\u003c/em\u003e in carrying out activities. \u003csup\u003e40\u003c/sup\u003e Our results reinforce other studies, which have shown that late payment of premiums can be a source of demotivation, \u003csup\u003e39,41,42\u003c/sup\u003e contrary to the objective pursued.\u003c/p\u003e \u003cp\u003eThe implementation of Phase 3 (continuous structure after the start of implementation) was partial and was based on tasks related to technical supervision and feedback tasks. Process evaluation was thought out or operationalised. Again, the shortcomings of the evaluation processes of the Ministries of Health are well known in the region. \u003csup\u003e43\u003c/sup\u003e In addition, the few evaluations carried out focused on the effectiveness and analysis of implementation, which are often overlooked. \u003csup\u003e44\u003c/sup\u003e And when performed, the quality and depth of analysis are limited. \u003csup\u003e45\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePhase 4 (improving future applications) resulted in a few redevelopments of activities. Nevertheless, it did not seem to us that the process of improvement has been systematic or that we are in a learning health system as it should be today. \u003csup\u003e46\u003c/sup\u003e While two intra-action reviews (IARs) were carried out in Mali during the pandemic, in line with WHO recommendations, \u003csup\u003e47\u003c/sup\u003e no one was aware at the local level. Their reports were not available on the WHO\u0026rsquo;s IAR website. Moreover, no reflexive analysis appears to have been undertaken at the regional level, suggesting that these IAR meetings remain confined to the national level. \u003csup\u003e48\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs in many places during the pandemic, implementing actors often cited the urgency of the intervention to justify prioritizing vaccination efforts over earlier actions, even though those prior actions are essential for the intervention\u0026rsquo;s effectiveness.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e Actions to gain stakeholder buy-in (Dimension 5) involved mobilising community leaders and fewer people. However, the two actions had to be complementary since the mobilisation of community leaders was intended to promote greater mobilisation of populations. As in Senegal, there is still a missed opportunity for a more inclusive and community-based approach to the fight against epidemics. \u003csup\u003e50\u003c/sup\u003e Although community health is central in West Africa and Mali,\u003csup\u003e51\u003c/sup\u003e the issue of public participation remains a challenge for public health, \u003csup\u003e52,53\u003c/sup\u003e particularly in vaccination efforts in conflict zones. \u003csup\u003e30,31\u003c/sup\u003e Similarly, health personnel are an essential component of the stakeholders involved in this intervention. Still, we have seen that they have been managed more administratively than through the search for real involvement of street-level workers. The vertical approach, central to the region\u0026rsquo;s health systems and the approaches of international donors, marked the implementation of the intervention and did little to encourage the involvement of CSOs in critical decision-making. Work stoppages due to late payment of wages have been detrimental to implementation and contribute to low vaccination coverage. Adjustments were undertaken by the CSComs, which quickly found themselves in the need to mobilise their adaptation strategies, which shows a certain resilience of health facilities. \u003csup\u003e1,21\u003c/sup\u003e The weak evaluation strategies have reinforced the mobilisation of these adaptation strategies. Yet, the preparation of health systems is an essential step in creating the conditions for effective implementation, \u003csup\u003e30\u003c/sup\u003e including the establishment of collective responsibility, the mobilisation of available resources (public and private), and a strong and engaged workforce. \u003csup\u003e54\u003c/sup\u003e In the case of the CSComs concerned by this study, collective responsibility was manifested through stakeholder engagement. However, the fact that these structures had little control over resource mobilisation impeded the engagement of local vaccinators. The CSComs, where we collected the data for this survey, demonstrated their ability to reorganise themselves by providing specific responses to emerging challenges. As elsewhere in Mali, these health centres have been able to develop minimal resilience, \u003csup\u003e55\u003c/sup\u003e although vaccination coverage remains low.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study examined stakeholder involvement in the implementation of health interventions through a case study on vaccination coverage. The results showed that this involvement has not been explicit throughout the process in Mali. While multi-level community engagement is known to contribute to the success of vaccination coverage in conflict zones, \u003csup\u003e30\u003c/sup\u003e in the case of Mali, it remained mainly \"administrative\" in terms of partnerships with community actors. Community representatives were largely excluded from coordination processes between the health district and community health centres. The gradual increase in COVID-19 vaccination uptake was primarily due to a better perception of its value, which was influenced by the growing threat of the epidemic and the lack of side effects among vaccinated individuals, rather than the quality of the vaccination campaign scheme itself.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe thank the participants who took part in the semi-structured interviews and the managers of the two community health centers (CSCOMs) for authorizing data collection among their staff. We also thank Seydou Diabat\u0026eacute; and Yacouba Diarra for their contribution to data collection. All individuals mentioned by name have given their consent to be acknowledged in this manuscript.\u003c/p\u003e\n\u003cp\u003eAuthor contributions:\u003c/p\u003e\n\u003cp\u003eThe study protocol design, the development of data collection tools, and the planning and implementation of the fieldwork were carried out by A.C, with contributions from V.R. Data analysis was conducted jointly by A.C and V.R. The manuscript was written by A.C, with revisions, suggestions, and intellectual contributions from V.R.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study are qualitative in nature (interviews and observations). Due to the sensitive nature of the information and in order to ensure the anonymity and confidentiality of participants, the data are not publicly available. Anonymized excerpts may be provided upon reasonable request to the corresponding author, subject to ethical approval.\u003c/p\u003e\n\u003cp\u003eCompeting interests: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003eEthics:\u003c/p\u003e\n\u003cp\u003eIn addition to the voluntary principle that conditioned participation in the survey, pseudonymisation of the collected data was applied to recordings and transcripts. The designations of agent profiles (Table 1) were diluted into more generic categories. The protocol has been approved by the National Commission on Ethics and Health Sciences (Decision No. 1 120/MSDS/CNESS). The Directorate-General has provided an administrative authorisation for Health and Public Hygiene of the Ministry of Health.\u003c/p\u003e\n\u003cp\u003eWritten informed consent for the publication of anonymized data was obtained from all participants\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki (2013 revision).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration\u0026nbsp;:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding and Ethics Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this research\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRidde V, Traverson L, Zinszer K. Hospital Resilience to the COVID-19 Pandemic in Five Countries: A Multiple Case Study. 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Learning from public health and hospital resilience to the SARS-CoV-2 pandemic: protocol for a multiple case study (Brazil, Canada, China, France, Japan, and Mali). Health Res Policy Syst. 2021;19(1):76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12961-021-00707-z\u003c/span\u003e\u003cspan address=\"10.1186/s12961-021-00707-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19 Vaccination, Implementation, Mali, Planning","lastPublishedDoi":"10.21203/rs.3.rs-8454940/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8454940/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDespite the unprecedented speed of COVID-19 vaccine development, vaccination coverage in Mali was low. Research has primarily focused on individual vaccine hesitancy, overlooking systemic issues related to the implementation of vaccination in health facilities. This article analyses the implementation of Mali\u0026rsquo;s national vaccination strategy in 2021 and 2022 to understand the challenges associated with COVID-19 vaccination coverage and the lessons learned.\u003c/p\u003e \u003cp\u003eThe study employed a qualitative approach. Data collection involved field observations (n\u0026thinsp;=\u0026thinsp;15 days) and semi-structured interviews (n\u0026thinsp;=\u0026thinsp;57) conducted at two Primary Health Centres (\u003cem\u003eCentres de Sante Communautaire\u003c/em\u003e, or CSComs) in Bamako, Mali. The analysis utilised a conceptual quality implementation framework to identify factors that influenced the successes or limitations of the campaign.\u003c/p\u003e \u003cp\u003eVaccination campaigns intensified gradually between 2021 and 2023. The implementation used a top-down approach controlled mainly by the staff of the Health District. The limited involvement of CSComs in key vaccination activities (planning, capacity building, supervision) prompted them to develop adaptation strategies to meet their assigned objectives. The analyses showed that the implementation of the national vaccination strategy did not have the same intensity depending on the quality phases of implementation. The CSComs conducted very few evaluation activities.\u003c/p\u003e \u003cp\u003eWe cannot fully understand vaccine coverage without a thorough analysis of implementation mechanisms. This study highlights the importance of building local capacity, customising strategies to fit community realities, and enhancing documentation of field practices for future public health interventions.\u003c/p\u003e","manuscriptTitle":"The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 08:51:56","doi":"10.21203/rs.3.rs-8454940/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T07:46:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T09:48:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T13:02:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T20:40:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227127131530484289759283565147990890291","date":"2026-02-09T13:58:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T22:53:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245959759428670466397000361475091572819","date":"2026-01-30T13:18:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326295632258601905968419666445933860137","date":"2026-01-30T07:45:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236518143599139359896558051421847569497","date":"2026-01-29T11:09:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336724875318956689853481978380517684590","date":"2026-01-29T06:51:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260517519985528863475083867225822886680","date":"2026-01-29T05:08:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-28T18:22:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-19T18:48:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-06T11:38:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-06T11:05:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Health Systems","date":"2026-01-06T10:49:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7891bc52-39b5-42f8-b017-2fc4f183954e","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T10:08:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 08:51:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8454940","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8454940","identity":"rs-8454940","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}