By HALIMA TAKWAS

The Children Who Got the First Dose: Inside Kano, Gombe’s Fragile Immunisation Chain

UNDER the April heat in Fagge Local Government Area of Kano State, 56-year-old Uma Usman moves from compound to compound in search of children who have missed their routine vaccination appointments.

She is not a government employee. Her name is not on the payroll of the Galadima Primary Health Centre. Yet, she has become an important link in the local immunisation system.

Her task is simple but demanding: identify children who received one or more vaccines but failed to return for subsequent doses.

“I know the community very well, so I follow them house by house,” Usman explained. “If the parents don’t come, we check the register and trace the households.”

Her experience captures a problem that stretches across Kano and Gombe states.

The difficulty is often not finding vaccines.

It is getting children back to health facilities to complete the vaccination schedule.

When Access, Not Acceptance, Becomes the Barrier

For many families interviewed during an investigation into routine immunisation in the two states, missing vaccination appointments does not necessarily mean rejection of vaccines.

A child may be sick.

A mother may lack transport money.

A family may live several kilometres from the nearest health facility.

Parents may also be occupied with work and household responsibilities.

The result is the same: a child who begins vaccination may fail to receive the doses needed for full protection.

This creates a less visible problem within Nigeria’s immunisation system.

A vaccine may be physically available in a health facility, yet remain effectively inaccessible to a child living far away.

A National Problem Seen Through Two States

The Kano and Gombe experience reflects Nigeria’s wider immunisation challenge.

UNICEF identifies Nigeria as having one of the world’s largest populations of zero-dose children—those who have never received a routine vaccine.

Available data cited in the investigation indicate that only about 67 per cent of surviving infants receive the third dose of the diphtheria, tetanus and pertussis vaccine, while coverage for the second measles dose is considerably lower.

Although immunisation coverage has improved, large numbers of children still either receive no routine vaccines or drop out before completing the recommended schedule.

In Kano and Gombe, frontline workers repeatedly described the same pattern: vaccines are often available, but the system struggles to keep children connected to services.

The People Holding the System Together

At community level, volunteers, health workers and mobilisers have become the bridge between health facilities and families.

In Fagge, Usman uses immunisation registers to trace children who miss appointments.

In Takai Local Government Area of Kano, health workers travel through scattered settlements to find children who do not return to clinics.

At Gamawa Health Post, an officer in charge said vaccines were consistently available.

“There is never a time when people come and we do not have vaccines,” he said.

But availability at the facility does not guarantee coverage in the community.

Outreach teams face transport problems, difficult terrain and limited operational time. A team may have a long list of children to trace but insufficient resources to reach every household.

“We don’t refuse to go,” one health worker said. “But sometimes the list is longer than what we can physically cover in one outreach.”

That gap can translate into missed doses.

Gombe’s Geography Adds Another Layer

The challenge is similarly visible in Billiri Local Government Area of Gombe State.

Health workers and community mobilisers spend substantial time identifying children who fail to return for scheduled vaccination.

At Sansani Primary Health Centre, between 30 and 45 caregivers typically attend routine immunisation sessions.

But the work does not end when the clinic closes.

The facility’s immunisation team reviews registers and identifies children who have missed appointments across seven communities.

The exercise depends heavily on outreach funding.

The facility receives about ₦35,000 monthly for outreach activities, according to its immunisation head, Elias Ezekiel. The allocation is released quarterly through the State Primary Health Care Development Agency.

When funds are delayed, workers sometimes finance transportation and fuel themselves.

“If we stop outreach, the children will miss their vaccines,” Ezekiel said.

That personal sacrifice exposes one of the central weaknesses of the system: public health programmes can remain operational only because frontline workers absorb costs that should ordinarily be covered institutionally.

The Price of Getting a Child to a Clinic

The financial barrier facing families has also prompted interventions such as the Zero Dose Support Programme.

Ignatius Essien, general manager of eHealth Systems Africa, said the programme provides transport support to caregivers bringing children for immunisation.

The support began at ₦500 and later increased to between ₦1,000 and ₦2,500, depending on the vaccine type and rising transportation costs.

The rationale is straightforward.

Some families want to vaccinate their children but cannot afford the cost of reaching the health facility.

A small transport stipend can therefore determine whether a child receives the next dose or becomes a dropout statistic.

Kano Faces the Burden of Scale

Kano and Gombe do not face exactly the same problem.

Kano’s challenge is partly its enormous population.

With more than 17 million residents and hundreds of thousands of births annually, the state’s primary healthcare system must serve a vast and continuously expanding population.

The 2021 Multiple Indicator Cluster Survey estimated that about 30.2 per cent of children in Kano were zero-dose, while only about 48 per cent completed the full routine immunisation schedule by their first birthday.

UNICEF has also estimated that Kano carries a substantial share of the zero-dose burden in the North-West.

For health facilities serving such a population, even small operational weaknesses can produce large numbers of missed children.

Gombe’s Challenge Is Distance

Gombe faces a different structural problem.

Its population is considerably smaller than Kano’s, but communities are often dispersed and distances between settlements and health facilities can be considerable.

Estimates cited in the investigation place the state’s zero-dose prevalence in the range of 18 to 22 per cent, while full immunisation coverage remains low in some datasets.

In remote communities, the distance between a child and a vaccine can be measured not simply in kilometres but in transport costs, lost working hours and the availability of outreach services.

Where the System Begins to Fray

The investigation found that the weakest point in the immunisation chain is often continuity.

At Galadima Primary Health Centre in Kano, an assistant head of the facility pointed to a solar-powered vaccine refrigerator stocked with vaccines.

“We have complete vaccines in the fridge,” she said.

The facility conducts immunisation sessions several times a week and uses other days for outreach.

“The real issue is not availability. It is continuity.”

That distinction is crucial.

A functioning immunisation system must do more than procure, store and administer vaccines.

It must identify children, bring them into the system, track their appointments and ensure they return for subsequent doses.

The Funding Gap

The operational burden becomes clearer when funding is examined.

In Fagge and Takai, health workers said PHCs receive about ₦7,000 monthly for outreach transport, with several months’ allocations sometimes paid together in arrears.

Gombe PHCs receive larger monthly allocations, but workers also reported delays.

Health posts face an additional disadvantage because they do not receive dedicated transport allocations despite serving remote communities.

This creates a contradiction.

The communities that most require outreach can be the communities least equipped to support it.

Budgets Are Rising, But Frontline Gaps Remain

Both Kano and Gombe have recorded major increases in their overall state budgets.

Kano’s spending plan rose from about ₦221.24 billion in 2022 to approximately ₦1.47 trillion in 2026.

Gombe’s budget increased from roughly ₦154.96 billion to about ₦617.95 billion over the same period.

Yet higher headline budgets do not automatically translate into timely operational funding at primary healthcare facilities.

Both states also carry significant debt-service obligations.

Kano budgeted about ₦69.84 billion for debt repayment in 2026, while Gombe allocated approximately ₦37.23 billion.

For frontline workers, the question is therefore not simply how much a state budgets.

It is whether the money required for a particular health intervention reaches the people doing the work at the time they need it.

The Contrast in Spending Priorities

The investigation also highlights competing public expenditure priorities.

Kano approved the purchase of 41 SUVs for members of its House of Assembly in 2024 at a reported cost of about ₦2.6 billion.

Gombe similarly approved vehicle procurements for lawmakers and commissioners and allocated more than ₦2 billion for judicial vehicles in its 2025 budget.

Government authorities may justify such expenditure on administrative and operational grounds.

But the contrast remains striking for health workers who sometimes walk, use motorcycles or pay their own transport costs to reach children in remote communities.

The issue is therefore not simply whether governments spend money.

It is how spending priorities affect the ability of essential services to reach citizens.

A Quiet Crisis of Zero-Dose Children

The human consequences are significant.

UNICEF estimated in April 2025 that about 53,000 children in Gombe had never received a routine vaccine.

In Kano and neighbouring North-West states, the number is substantially larger.

UNICEF officials have warned that these children face increased vulnerability to outbreaks of preventable diseases.

The problem also extends beyond children who have never received a vaccine.

A child who receives the first dose but fails to complete the schedule remains inadequately protected.

Public health expert Abdulhameed Adediran said immunisation programmes must therefore focus on continuity rather than treating the first vaccination as the end of the process.

Government Acknowledges the Gaps

Authorities in Gombe acknowledged that delays in releasing outreach funds can occur.

The State Immunisation Officer, Abdulkarim Aliyu, attributed some delays to administrative procedures, financial reconciliation and the timing of development-partner support.

He nevertheless praised frontline workers for continuing outreach activities despite resource constraints.

The agency said it has strengthened defaulter tracking and community mobilisation through Ward Development Committees, CHIPS agents and the Mama-to-Mama initiative.

It also said it was pursuing workforce training, supportive supervision and strategic staff deployment.

In Kano, the Director-General of the State Primary Health Care Management Board, Salisu Ibrahim, said outreach payments operate through a performance-tracking system.

He said records of completed outreach sessions must be verified before payments are processed.

The state has also increased outreach stipends, conducted data validation exercises and expanded community awareness efforts, according to the official.

The Fragile Chain

The evidence from Kano and Gombe points to a health system that is functioning, but under strain.

Vaccines can be available.

Refrigerators can be working.

Clinics can conduct scheduled sessions.

Yet children can still remain unprotected when transport, staffing, outreach funding and follow-up systems fail.

That is why people such as Uma Usman matter.

Every household she visits represents a potential break in the immunisation chain.

Every child she finds represents an opportunity to close that gap.

The broader lesson from Kano and Gombe is that immunisation is not merely a matter of vaccine supply. It is a logistics, financing, workforce, community-engagement and governance challenge.

Until those links become stronger, Nigeria’s efforts to reduce its enormous population of zero-dose and under-immunised children will continue to depend too heavily on the persistence of individuals working at the very edge of the system.