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 | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 16 August 2025 V1 Latest version Share on The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali Authors : Abdourahmane Coulibaly 0009-0003-6119-5200 [email protected] and Valéry Ridde 0000-0001-9299-8266 Authors Info & Affiliations https://doi.org/10.22541/au.175534206.64531724/v1 153 views 73 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share 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 design. 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 comprehensive analysis of implementation mechanisms. This study emphasises the importance of developing local capacity, tailoring strategies to align with community realities, and improving documentation of field practices for future public health interventions. The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali Abdourahmane Coulibaly 1 , Valéry Ridde 2 1-Bamako University of Science, Technology and Technology (USTTB), Faculty of Medicine and Odontostomatology (Mali) 2- Université Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm, Ceped, F-75006 Paris, France Acknowledgements We would like to express our sincere gratitude to Mr. Heather Hickey for his careful translation of this article into English. We also warmly thank all the individuals and community members who generously participated in our fieldwork and shared their experiences, without whom this research would not have been possible Funding This work was supported by Canadian Institute of Health Research grant number DC0190GP, the French National Research Agency (ANR Flash Covid 2019) grant number ANR-20-COVI-0001-01, and Japan Science and Technology Agency (JST J-RAPID) grant number JPMJJR2011. Conflict of interest The authors declare that they have no competing interests. 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 design. 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 comprehensive analysis of implementation mechanisms. This study emphasises the importance of developing local capacity, tailoring strategies to align with community realities, and improving documentation of field practices for future public health interventions. Highlights: • The gradual increase in COVID-19 vaccination uptake was primarily due to growing threat of the epidemic and the lack of side effects among vaccinated individuals • Local staff adapted protocols to resource and trust constraints. • Campaigns revealed gaps in logistics and community engagement. • Community involvement remained mostly administrative during campaign planning. Keywords: COVID-19, Vaccination, Implementation, Mali, Planning, Evaluation 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. 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 11–13 . Moreover, analysis of the implementation of public health interventions remains rare in West Africa and Mali, particularly those using a proven conceptual framework. 14 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. The national vaccination strategy against COVID-19 WHO recommendations guided national COVID-19 vaccine planning. 15 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. 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 EPI (April 2024) April 30, 2024, marked the integration of COVID-19 vaccination into the EPI, 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 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 (EPI 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). 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. 16 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, 17 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 18 because it is essentially concerned with the quality of the implementation. From 25 different frameworks for analysing implementation, Meyers et al. 18 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 Evaluation strategies Conduct a needs and resources assessment Carry out an adequacy assessment Carry out a readiness assessment Decision on adaptation Opportunities for adaptation Strategies for strengthening stakeholders Obtain explicit buy-in from key stakeholders and promote a supportive community organisational climate Strengthen general/organisational capacity Recruit and maintain staff Efficiently train staff in innovation beforehand Phase 2: Create an implementation structure Structural characteristics for implementation Create implementation teams Develop an implementation plan Phase 3: Continuous structure after the start of implementation Strategies to support continuous implementation Assistance/coaching/supervision Process evaluation Formative feedback mechanism Phase 4: Improving future applications Improving future applications 14. Learn from experiences Investigation sites 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. 19 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, 20 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. 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). Sampling and data collection This study uses qualitative research based on data collected through individual interviews and field observations. 21 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 (MD), social service (SOC), nurses (NUR), midwives (MW), community health workers (CHW), vaccinators (VAC), 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 CSCom 1 Pass 1 1 1 1 1 1 13 2 2 4 26 Pass 2 1 3 4 CSCom 2 Pass 1 1 1 2 1 11 6 4 1 27 Pass 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 CSCom 1 (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. Analysis of data We recorded and transcribed all interviews in French. 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. Ethical considerations 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. 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 EPI. 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). Stakeholders 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 encounter refusals, 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 disseminate the message within families. Furthermore, in health centres, the topics discussed daily by EPI staff during educational talks with patients have been expanded to include 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 EPI 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 for vaccine supplies. 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. 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, we will increase the number of doses we have given tomorrow. (Staff CSCom 1). 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 the control of the quality of the data and the presence of the vaccinators in the field: We look at the registers, the scorecards, and the number of vaccinations they have done, and we check whether it is this number that is 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). 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 proposed improvements for future vaccination campaigns regarding specific aspects of the conceptual framework (Table 4). These suggestions highlighted the need for changes in human resources, equipment, materials, and business planning. Table 4: Lessons learned according to specific dimensions of the implementation framework 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 \tightlist Voluntary vaccination of staff to lead by example \tightlist 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 planning 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. 22 The vaccination challenges faced in Mali are similar to issues previously documented in Senegal during the COVID-19 pandemic, which revealed significant discrepancies between planning and execution, mainly due to a lack of community involvement. 23 While the content of theoretically effective public health interventions is generally well known, their level of coverage remains low. 24 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. 25 However, the recent difficulties of vaccination, particularly in countries with high levels of conflict such as Mali, 26 showed the importance of resilient health systems and adapting strategies to local contexts. 27–29 This study in Mali shows that all 14 dimensions studied are multiple contextual factors that affect implementation. 12,30 The context is obviously at the heart of analyses of the implementation of public policies. 31 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. 33 Monitoring systems are also of relatively poor quality in conflict contexts, such as in Mali. 34 In this context of a dependence of vertical programmes such as vaccination on international funding, 28 we often see a greater focus on securing financial resources than on meeting local needs. 35 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. 36 However, the process was too vertical, as is often the case in the region, 23,32,37 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. 38 Our results reinforce other studies, which have shown that late payment of premiums can be a source of demotivation, 37,39,40 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. 41 In addition, the few evaluations carried out focused on the effectiveness and analysis of implementation, which are often overlooked. 42 And when performed, the quality and depth of analysis are limited. 43 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. 44 While two intra-action reviews (IARs) were carried out in Mali during the pandemic, in line with WHO recommendations, 45 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. 46 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. 23,47 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. 48 Although community health is central in West Africa and Mali, 49 the issue of public participation remains a challenge for public health, 50,51 particularly in vaccination efforts in conflict zones. 28,29 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. 1,20 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, 28 including the establishment of collective responsibility, the mobilisation of available resources (public and private), and a strong and engaged workforce. 52 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, 53 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, 28 in the case of Mali, it remained mainly ”administrative” in terms of partnerships with community actors. Community representatives were not involved during the health district’s collaboration with community health centres. 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BMJ Glob Health . 2023;7(Suppl 9):e010683. doi:10.1136/bmjgh-2022-010683 Appendix 1: Summary of results Sub-dimensions CSCom 1 CSCom 2 Conduct a needs and resources assessment Top down dominated by the health district Carry out an adequacy assessment No assessment Carry out a readiness assessment No assessment Possibility for adaptation Multiple adaptation measures taken by the CSCom depending on the context Obtain explicit buy-in from key stakeholders and promote a favourable organisational climate Awareness-raising activities Collaboration with influential community actors Patient awareness during consultations Door – to – door Vaccinating staff to lead by example Strengthen general/organizational capacity Mobilisation of staff Supply of assets by the Sanitary District \tightlist One-off financial contribution from CSCom One-off financial contribution from ASACO Recruit and maintain staff Recruitment of vaccinators from internal resources (staff, relays, trainees) Efficiently train staff prior to innovation Cascading training: District Staff CSCom – vaccinators Phase 2 Create implementation teams 14 teams of five people during the first phase of vaccination 20 teams of two people Develop an implementation plan Application of the micro-plan developed by the health district Measuring the adjustment of vaccination strategies according to contexts Phase 3 Assistance/coaching/supervision Cascading supervision (Health District – CSCom) Low field presence of supervisors Evaluation of the process Lack of process assessment activities Formative feedback mechanism Informal feedback Phase 4 Learn from experiences Need to raise awareness before vaccinating Ensure availability of funds to pay for vaccinators’ premiums Need to increase the duration of awareness raising Information & Authors Information Version history V1 Version 1 16 August 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords covid-19 implementation mali planning vaccination Authors Affiliations Abdourahmane Coulibaly 0009-0003-6119-5200 [email protected] Universite des Sciences des Techniques et des Technologies de Bamako Faculte de Medecine et d'Odontostomatologie View all articles by this author Valéry Ridde 0000-0001-9299-8266 Universite Sorbonne Paris Nord View all articles by this author Metrics & Citations Metrics Article Usage 153 views 73 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Abdourahmane Coulibaly, Valéry Ridde. The implementation of vaccination campaigns for COVID-19 in primary healthcare centres in Bamako, Mali. Authorea . 16 August 2025. DOI: https://doi.org/10.22541/au.175534206.64531724/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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