Country Evaluation

This report evaluates strategies implemented between March 2024 and August 2025 to reach zero-dose (ZD) children in Uganda’s Wakiso, Kasese, and Mubende districts. While the general ZD burden in study communities dropped from 12.7% to 6.5%, progress was primarily driven by routine immunisation rather than targeted campaigns. Key findings include:
• Persistent Barriers: Vaccine stockouts, long wait times, poor data quality, and geographic isolation hinder identification and vaccination.
• Social Drivers: Restrictive gender norms, poverty, and religious beliefs continue to disconnect families from available services.
• Effectiveness: Only 9.3% of baseline ZD children were reached during the intervention period. However, interpersonal communication, home visits, and spousal support showed significant promise in building trust.
• Costing: Identifying a ZD child averages US$3.07, while vaccinating one costs approximately US$14, with costs rising in hard-to-reach areas.
Meaningful progress requires shifting from uniform, centrally designed approaches to strategies grounded in community realities. Future success depends on stronger governance, improved data systems, and active community engagement at every stage of service delivery.

Click the link below to read the full report and explore the findings and recommendations in detail.

Identifying and Reaching Zero-Dose Children in Uganda: Implementation, Effectiveness, and Costs of Targeted Interventions

This report from the Uganda Zero-Dose Learning Hub presents findings from a costing study conducted during the 2024 Big Catch-Up campaign. It estimates the incremental costs of identifying and reaching zero-dose and under-immunised children through house-to-house registration and targeted outreaches in three high-burden districts. Results highlight unit costs per child identified and vaccinated, cost drivers, and district variations, offering evidence to guide future planning, budgeting, and sustainability of immunisation strategies in resource-constrained settings.

Click the link below to read the full report and explore the findings and recommendations in detail.

The Cost of Identifying and Reaching Zero-Dose Children in Uganda: A Case Study of House-to-House Registration and Targeted Immunization Outreaches

The Uganda Learning Hub conducted an in-depth analysis of the country’s immunisation data ecosystem to assess the utility of existing platforms in identifying and monitoring zero-dose (ZD) and under-immunised (UI) children. While the DHIS2 remains the primary tool for data capture, its inability to collect individual-level data limits its effectiveness in characterising ZD children. Emerging platforms such as Smart-Paper Technology (SPT) and the electronic Community Health Information System (eCHIS) offer promising features, such as unique identifiers and household-level data collection, but face challenges with integration, coverage, and sustainability. Findings highlight significant discrepancies in ZD and UI estimates across systems, driven by variations in data quality, sources, and denominators. To improve the accuracy of ZD identification and immunisation tracking, the study recommends deploying a functional digital system at the community level, enhancing data triangulation, and integrating immunisation tracking with civil registration systems. These steps are critical to ensuring no child is left behind in Uganda’s immunisation efforts.

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Utility of Data Capture Platforms for Identifying Zero-Dose Children in Uganda

Despite Uganda’s progress in achieving an average immunisation coverage of 90%, significant gaps remain in reaching zero-dose (ZD) and under-immunised (UI) children. A 2024 study by the Uganda Learning Hub focused on three high-risk communities in Mubende district to estimate the prevalence of ZD and UI children, understand barriers to immunisation, and provide actionable solutions. The study revealed that 12.7% of children in these communities were ZD, with many born outside health facilities or cared for by non-biological guardians. Key barriers included negative attitudes among health workers, caregiver knowledge gaps, cultural resistance, fear of side effects, and logistical challenges, such as distance to health facilities. The findings emphasise the importance of targeted outreach, improving health worker attitudes, caregiver education, and strengthening health infrastructure and data systems to close the immunisation gap and ensure no child is left behind.

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Burden of Zero-Dose Children in Pastoralist, Hard-to-Reach and Underserved Communities: A Case Study of Mubende District, Uganda

With support from the ELMA Vaccines and Immunisation Foundation, UNICEF has been working to strengthen Uganda’s Expanded Program on Immunisation to better identify and reach zero-dose (ZD) and under-immunised (UI) children. In 2023, interventions were prioritised in the districts of Wakiso, Kamuli, Kampala, and Mukono.

This report, developed by the Uganda Learning Hub, evaluates progress toward UNICEF’s objective to strengthen microplanning as a follow-up system for identifying and immunising ZD and UI children in urban and high-density areas. Specifically, it assesses UNICEF’s support for Village Health Teams to register children, track their immunisation status, and conduct defaulter tracing in Kamuli and Wakiso districts.

The findings are intended to inform the scale-up of ZD interventions to additional districts, guide implementation under the Equity Accelerator Fund, and support the development of Uganda’s national ZD guidelines.

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Identifying the Zero-Dose Child: Insights from the UNICEF-Supported House-to-House Registration of Children by Village Health Teams in Uganda

The Uganda National Expanded Program on Immunisation (UNEPI) has made great strides in improving immunisation coverage over the last 20 years. Despite these efforts, challenges in reaching every child with vaccines remain. These challenges are illustrated by the observed increase in the number of zero-dose children (ZDC). To characterise and understand the challenges of reaching the ZDC, under-immunised children, and missed communities, the Uganda Learning Hub for Immunisation Equity conducted a rapid assessment in three districts with a high burden of ZDC in Uganda (Wakiso, Mubende, and Kasese) between August 2023 and March 2024

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Report on a Rapid Assessment of the Zero-Dose Situation in Uganda

Despite improvements in vaccination coverage in Uganda, immunisation gaps remain and require innovative strategies to bridge them and address vaccine inequities. Uganda’s diverse in-country settings contribute to variability in the drivers of zero-dose children (ZDC), under-immunised children (UIC), and missed communities. These drivers are complex, interrelated, and context-specific.
The Uganda Learning Hub for Immunisation Equity –composed of the Infectious Diseases Research Collaboration, PATH in Uganda, and Makerere University School of Public Health–developed an overarching learning agenda that describes learning questions, methods, and approaches using ongoing work on ZDC and UIC identification performed by the Uganda Ministry of Health and immunisation partners. This learning agenda serves as a platform for understanding perspectives on equity in immunisation in Uganda.

Click the link below to read the full report and explore the findings and recommendations in detail.

Uganda Learning Hub for immunisation equity – Zero-Dose Learning Agenda

PCE is a comprehensive, country-level, prospective evaluation that utilize a variety of methods in order to provide a detailed, real-time picture of the implementation, effectiveness and impact of Global Fund-supported programmes in selected countries. The goal of PCE is to generate evidence on program implementation through impact in order to accelerate progress towards strategic objectives of the Global Fund Strategy and to facilitate continuous improvement of program implementation and quality.

Objectives:

PCE will establish country evaluation platform that supports dynamic, continuous monitoring and evaluation, learning, and problem solving with the objectives of:

• Examining and analysing implementation of the Global Fund Strategic Objectives
• Providing real-time information to allow countries and the Secretariat to adapt and adjust programme implementation
• Identifying challenges that impede programme performance and opportunities to inform and improve programme quality for impact, effectiveness, and value-for-money
• Measuring programme contributions to impact
• Strengthening country M&E systems for robust measurement and
• Identifying and disseminating best practices to improve the Global Fund model.

Global Fund Evaluation Reports:

1. Global Fund Prospective Country Evaluation- Resource Tracking Study For Malaria.    Download Report.
2. Prospective Country Evaluation Uganda 2021 Extension Report.    Download Report.
3. Prospective Country Evaluation Uganda 2020-2021 Annual Country Report.    Download Report.
4. Prospective Country Evaluation Uganda 2020 Annual Country Report.    Download Report.
5. Prospective Country Evaluation Uganda 2019 Annual Country Report.    Download Report.
6. Global Fund Prospective Country Evaluation-Resource tracking Study for Malaria 2019.    Download Report.
7. The Global Fund Prospective Country Evaluation Uganda Report: Evidence from Uganda’s 2017 application process.    Download Report.
8. Prospective Country Evaluation Uganda 2018 Annual Country Report.    Download Report.
9. Global Fund Prospective Country Evaluation, Final inception Phase Report for PCE in Uganda, Guatemala and Democratic Republic of the Congo.   Download Report.

With support from Gavi, IDRC has conducted evaluations of Uganda’s immunisation programme since 2013. Below is an overview of the evaluations.

1. The GAVI Full Country Evaluation (FCE):

This evaluation was conducted in two phases. Phase one (2013-2016) was implemented in Bangladesh, Mozambique, Uganda, and Zambia, in collaboration with the Institute for Health Metrics and Evaluation (IHME) at the University of Washington (UW) and PATH in the United States. The goal of this phase was to understand and quantify the barriers to, as well as the drivers of, immunisation program improvement, with emphasis on the contribution of Gavi. The methods employed in this phase included;

• Process evaluation methods (i.e. key informant interviews, stakeholder network analysis, process tracking, observation of meetings)
• Resource tracking
• Health facility and household surveys
• A vaccine effectiveness study, including innovative methods such as the use of biomarkers
• Small-area analysis, for example, at the district level of key indicators such as immunisation coverage and child mortality

At country level, the findings and recommendations generated from this phase were used to inform decisions, prepare proposals for new Gavi support such as Health System Strengthening (HSS) support, and improve readiness for and implementation of Gavi support such as New Vaccine Introductions. At the global level, the cross-country findings and recommendations were used as inputs for review of the recently approved Health System and Immunisation Strengthening support (HSIS) framework, for updating Gavi guidelines, and for the design of new programs and initiatives, such as the strategic focus areas of sustainability, strengthening in-country Leadership, Management and Coordination (LMC), and design of the HPV 2.0 program.

Phase two (2017-2018):

The evaluation approach in phase two shifted from a largely descriptive emphasis in phase one (when shedding light on Gavi and country processes was needed) to a more targeted approach, in which the evaluation questions were developed following consultation with country and global level stakeholders. Phase two was implemented in Mozambique, Uganda, and Zambia, in collaboration with PATH in the United States. The goal of this phase was to evaluate the new policies, programs, and processes implemented by the Gavi 2016–2020 strategy. The Uganda-specific evaluation questions of this phase were:

1. What are the drivers of vaccine coverage and equity?
2. What is the effect of an interruption in Gavi HSS funding on routine service delivery, highlighting the Government of Uganda and other partner funding?
3. What are the demand-side reasons for the low coverage of HPV vaccine second dose in Uganda?
4. What are the positive and negative consequences of the new/updated Gavi processes (e.g., program capacity assessments (PCAs) and grant performance frameworks)?
5. What is the composition of the immunization partnership in the country at national and district levels?

Data were collected through document review, attendance and observation at meetings related to immunization planning and implementation, analysis of secondary data and key informant interviews with stakeholders.

2. Evaluation of the drivers of urban immunisation in Uganda, A case study of Kampala city.

Given the notable capacity in prospective evaluation built over six years of implementation of the FCE, IDRC conducted this evaluation as a prime grant recipient. The aim of this evaluation was to evaluate the extent to which the EPI programming in Uganda is designed to address immunisation in an urban context, using Kampala city as a case study. This evaluation was conducted in two phases;

Phase one (June 2019-May 2020):

The focus for this phase was the demand-side drivers of urban immunisation in Kampala city. The evaluation sub-questions of this sub-phase were:

1. To what extent is the EPI model for delivery of immunisation services in Kampala effective?
2. What are the demand side drivers of immunisation coverage in Kampala city?
3. Whether and how is the EPI program demand side approach adapting to the challenges of immunization in an urban context.

This phase employed a parallel convergence mixed methods design. Data were collected through document reviews and partner mapping, Key Informant Interviews (KIIs), Focus Group Discussion (FGDs), observation at meetings related to immunization planning and implementation, In-Depth Interviews (IDIs) and fact checking interviews. A household survey to quantify the drivers of the coverage in Kampala city was conducted among 590 caregivers of children aged 12 – 23 months.

Phase two (June 2020-May 2021):

The focus of this phase was the supply-side drivers of urban immunisation in Kampala city. The evaluation sub-questions of this sub-phase were:

1. What are the supply side drivers of immunization coverage in Kampala city?
2. To what extent is the supply side approach of the EPI program, KCCA and partners adapting to the challenges of immunisation in an urban context?
3. In what ways has COVID-19 and its control measures affected the delivery of immunisation services in Kampala city?

This phase employed a sequential transformative study design. Data were collected through document review, KIIs, IDIs, observation at meetings related to immunization planning and implementation and fact checking interviews. A health facility assessment to identify and measure supply side constraints to vaccination at health facility level was conducted at 90 health facilities in Kampala city. The health facility assessment encompassed three (3) components i.e., 1) Assessment of the vaccine delivery system, 2) Observation of immunisation sessions and 3) Exit interviews with mothers/caregivers of children aged under 5 years who received immunisation services at the health facilities.

The findings and recommendations generated from this evaluation led to the development of the urban immunisation communication plan to guide social mobilization for immunisation in urban settings, and informed the development of the urban immunisation guidelines for Uganda.

GAVI Evaluation Reports:

1. Evaluation of the drivers of Urban Immunisation in Uganda: A case study of Kampala city: August 2021.    Download Report.
2. Gavi Full Country Evaluations May 2020 Annual Dissemination Report.    Download Report.
3. Gavi Full Country Evaluations 2017-2018 Annual Dissemination Report.    Download Report.
4. Gavi Full Country Evaluations 2016 Annual Dissemination Report.    Download Report.
5. Gavi Full Country Evaluations 2015 Annual Dissemination Report.    Download Report.
6. Resource Tracking For Immunization In Uganda 2014/15 & 2015/16.    Download Report.

GAVI Debriefs:

1. Evaluation of the drivers of urban Immunisation in Uganda: a case study of Kampala city August – 2021 .    Download Report.
2. Findings from the 2017 Gavi Full Country Evaluations.    Download Report.
3. Overview of Gavi Full Country Evaluations Findings.    Download Report.
4. Findings from the 2015 Gavi Full Country Evaluations.    Download Report.
5. Findings from the 2014 Gavi Full Country Evaluations.    Download Report.