Barriers to Malaria Vaccine Delivery in the Bono East Region, Ghana: A Qualitative Study among Healthcare Workers

Abstract

Background The RTS,S/AS01E malaria vaccine was introduced in the Bono East Region of Ghana in 2019 as part of the national scale-up of the Malaria Vaccine Implementation Programme. Despite demonstrable reductions in malaria morbidity at the population level, persistent operational challenges including high fourth-dose dropout, cold chain constraints, and financing gaps — continue to limit the vaccine's realized impact. Understanding the lived experience of frontline healthcare workers responsible for delivering the vaccine is essential for designing context-specific programmatic solutions.
Methods
A descriptive qualitative study was conducted using in-depth key informant interviews (KIIs) with twelve healthcare workers purposively sampled across six districts and municipalities of the Bono East Region. Participants included Disease Control Officers, Field Technicians, EPI Coordinators, Technical Officers, and Community Health Nurses with between 4 and 16 years of professional experience. Interviews were audio-recorded, transcribed verbatim, and analyzed using Braun and Clarke's six-phase thematic analysis framework, supported by NVivo software. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.
Results
Four major theme categories were identified: (1) RTS,S/AS01E effectiveness perceptions and dose adherence; (2) vaccine delivery, logistics, and cold chain management; (3) community acceptance, caregiver trust, and AEFI communication; and (4) funding, sustainability, and local ownership. Participants universally reported perceived reductions in paediatric malaria burden since vaccine introduction but identified systemic barriers that constrain programme performance. Fourth-dose dropout was attributed to caregiver mobility, inadequate defaulter tracing resources, and the extended interval between dose three and dose four. Logistical barriers included bulky packaging incompatible with CHPS cold storage capacity, motorbike-dependent outreach, poor road conditions, and recurrent fuel shortages. Pre-rollout training was described as adequate but refresher training was absent, creating competency gaps among new staff. Community acceptance was generally positive, attributable to visible health improvements, but persistent misinformation including rumours associating the vaccine with infertility and AEFI-driven hesitancy undermined dose completion. Funding emerged as the most critical sustainability concern, with districts dependent on Internally Generated Funds (IGF) following Gavi and PATH withdrawal, and no dedicated malaria vaccine budget line established at district level.
Conclusions
The malaria vaccine programme in the Bono East Region demonstrates operational feasibility and visible health impact, yet its long-term sustainability and effectiveness are threatened by remediable structural and financial barriers. Context-specific interventions including dedicated district budget lines for malaria vaccination, cold chain infrastructure investment at the CHPS level, mandatory refresher training, culturally sensitive AEFI communication strategies, and fourth-dose schedule alignment are needed to close the gap between the vaccine's established efficacy and its realized population-level impact.

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