Under the harsh April sun, the heat was oppressive in Fagge Local Government Area of Kano State. But 56-year-old Uma Usman kept walking from one compound to another, calling out familiar names, knocking gently on half-open doors and asking after children she had come to know over the years.

She is not an employee of the local Galadima Primary Health Centre. Her name does not appear on any government payroll. Yet, she has become one of the most important links in the community’s immunisation system.

Her job is to find children who missed their routine immunisation appointments.

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

For Mrs Usman, behind every missed appointment, there is a story.

Sometimes a child is ill. Sometimes a mother cannot raise money for transport. Sometimes parents are occupied with work or family responsibilities.

“When you reach a house, you find it is not that they don’t want to come,” she said. “Something just stood in the way.”

Mrs Usman’s daily routine illustrates a broader reality observed in a PREMIUM TIMES investigation in Kano and Gombe states.

Contrary to the widespread assumption that vaccine shortages are the biggest obstacle to routine immunisation, frontline workers in the two states described a different problem. Vaccines are usually available. The challenge is ensuring children complete the immunisation schedule.

However, for many families who spoke with PREMIUM TIMES, the barrier is not acceptance but access. Long distances to health facilities, transport costs, delayed outreach activities and the daily struggle to earn a living often interrupt follow-up visits. As a result, many children receive their first vaccine but never complete the doses needed for full protection.

The consequences extend far beyond individual families.

This investigation examined routine immunisation efforts and challenges in Kano and Gombe between 2023 and 2026, drawing on field visits, interviews, official records and data from health authorities and development partners.

The period captures the continuing struggle to reach children who have never received a vaccine, as well as those who start their vaccination schedule but fail to complete it.

According to UNICEF, Nigeria has one of the world’s largest populations of zero-dose children, those who never received a routine vaccine. Its latest data shows that only about 67 per cent of surviving infants receive the third dose of the diphtheria, tetanus and pertussis (DTP3) vaccine, while coverage for the second dose of the measles vaccine is about 35 per cent. 

Although routine immunisation coverage has improved in recent years, many children still receive no vaccines at all or fail to complete the schedule. 

Behind those national figures are thousands of individual stories like the ones Mrs Usman encounters every week.

But the investigation found another, less visible reality.

Across communities in Kano and Gombe, routine immunisation continues largely because health workers, volunteers and community mobilisers bridge gaps created by delayed funding, difficult terrain and overstretched primary healthcare systems.

Many spend their own money to reach remote settlements. Volunteers without formal employment trace children from house to house. Outreach activities continue even when operational funds arrive months late.

Different communities, same struggle

The pattern seen in Fagge extends far beyond one community.

In Takai LGA of Kano State, reaching children who miss vaccination appointments often means travelling long distances across scattered settlements. Health workers say routine clinic sessions alone are not enough; repeated outreach visits are essential to find children who fail to return.

“There is never a time when people come and we do not have vaccines,” said Muhammad Ali, the officer-in-charge at Gamawa Health Post in neighbouring Gombe State.

Field records reviewed by PREMIUM TIMES and interviews with frontline workers showed that children scheduled for follow-up are not always reached as planned.

Health workers explained that outreach teams frequently face transport constraints, limited time, and difficult terrain, making it impossible to visit every household listed for follow-up during a single outreach exercise.

“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.”

Many children miss vaccine doses because follow-up visits could not be completed.

In Billiri LGA of Gombe State, the pattern is the same.

Health workers and volunteer mobilisers spend almost as much time searching for children who missed appointments as they do on administering vaccines.

Across these locations, one pattern persists: children often begin immunisation but fail to complete the schedule because of family challenges.

A system sustained by people

For Ignatius Essien, general manager of eHealth Systems Africa, the difficulty families face getting to health facilities helps explain the introduction of the Zero Dose Support Programme.

Mr Essien said the programme gives transport support to caregivers who bring their children for immunisation. It applies to children coming for either their first dose or subsequent doses.

“The funds are not tied to routine immunisation outcomes,” he stated.

He explained that the idea grew from what health workers repeatedly saw in the field: families who wanted to vaccinate their children but lived too far from health facilities or could not afford the fare to get there.

“Some say they cannot even afford transport fare to the clinic,” he said. “That is what stimulated the stipend.”

The support started at N500 but has since increased from N1000 to N2500 depending on the vaccine type as transport fares and the cost of living rose.

At Sansani PHC in Billiri LGA, routine immunisation sessions typically attract between 30 and 45 caregivers.

Behind those clinic days, however, lies another routine that is rarely captured in official reports —tracing children who do not return.

The facility’s Head of Immunisation, Elias Ezekiel, said health workers use immunisation registers to identify children who miss appointments from the catchment seven communities.

“From the register, if anyone misses, we follow up,” Mr Ezekiel told PREMIUM TIMES.

That work depends on outreach funding.

The health centre receives about N35,000 monthly for outreach activities, but the money is released quarterly by the State Primary Health Care Development Agency.

When PREMIUM TIMES visited, more than three months had passed without any release.

Mr Ezekiel said the delays are routinely reported through local government health authorities.

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

So, staff members buy fuel and pay transport costs from their own pockets while waiting for the fund.

His account echoed those of several frontline workers interviewed across Kano and Gombe.

Vaccines are generally available, they said, but getting them to children in remote communities often depends on health workers absorbing the cost whenever operational funding is delayed.

That challenge is more difficult for facilities serving scattered settlements.

A quiet crisis in the North

The challenges confronting health workers in Kano and Gombe reflect a much wider crisis across northern Nigeria, where hundreds of thousands of children remain unreached by routine immunisation.

In April 2025, UNICEF estimated that about 53,000 children in Gombe State had never received a routine vaccine. More than half of them were in five high-risk LGAs, including Akko, where health authorities were contending with poor access to healthcare, low awareness and vaccine hesitancy.

To address the problem, the Gombe State Primary Health Care Development Agency, with support from UNICEF, launched the Fathers’ Response Team in 2024 to encourage greater male involvement in decisions about child health and immunisation.

Even so, many children continue to miss life-saving vaccines.

The challenge is even greater in Kano.

UNICEF estimates that more than 300,000 children are zero-dose, accounting for half of the burden across Kano, Katsina and Jigawa states.

UNICEF’s Chief Field Officer in Kano, Rahama Farah, said more than 600,000 children across the three states have yet to receive their first routine vaccine dose.

Many of these children live in remote or underserved communities where access to healthcare remains inconsistent.

“This is a basic fundamental child right,” Ms Farah noted.

She also warned that missed vaccinations increase vulnerability to outbreaks of preventable diseases and urged caregivers to complete immunisation schedules.

Why Kano and Gombe tell different stories

Although Kano and Gombe face similar immunisation challenges, the underlying pressures are different.

In Kano, the greatest obstacle is scale. With a population of more than 17 million people and over 600,000 births every year, health facilities operate under constant pressure.

The 2021 Multiple Indicator Cluster Survey (MICS) found that about 30.2 per cent of children in Kano are zero-dose, while only about 48 per cent complete the full routine immunisation schedule by their first birthday. National estimates indicate dropout rates of up to 31 per cent between the first and third doses of routine vaccines.

In Gombe, where the population is less than a third of Kano’s, geography plays a larger role. Communities are more dispersed, distances are longer, and access to health facilities often requires significant time and effort.

Estimates place Gombe’s zero-dose prevalence between 18 and 22 per cent, with only about 36 per cent completing full immunisation in some datasets.

Where the system weakens

The investigation found that the biggest weakness in routine immunisation is not getting children into the system.

It is keeping them in it.

Across health facilities in Kano and Gombe visited by PREMIUM TIMES, workers consistently described a system that performs relatively well at administering first doses but struggles to retain children through the full vaccination schedule.

Nationally, dropout rates between early and later vaccine doses range from about 12 to 30 per cent, depending on location.

At the Galadima PHC in Kano, Hauwa Isa, the assistant head of the facility, pointed to a solar-powered vaccine refrigerator stocked with vaccines.

“We have complete vaccines in the fridge,” she said. “We conduct immunisation three times a week and spend other days on outreach.”

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

That continuity depends on a governance system in which responsibility is shared but accountability is often blurred.

Primary health centres are under local governments, while state Primary Health Care Development Agencies oversee much of their staffing and operations. The federal government sets national policy and supports key immunisation programmes through partnerships with development agencies.

Health workers told PREMIUM TIMES that when outreach funding is delayed or operational gaps emerge, it is often difficult to determine where responsibility lies.

Money, priorities and the field reality

Over the past five years, both Kano and Gombe have recorded sharp increases in their budgets. 

 Official budget documents show Kano State’s spending plan rose from N221.24 billion in 2022 to N1.47 trillion in 2026, while Gombe’s grew from roughly N154.96 billion to N617.95 billion over the same period.

 Those figures suggest governments have greater financial capacity to deliver public services, including primary healthcare.

Yet interviews with frontline workers across both states tell a more complicated story.

For them, the size of the budget does not matter when operational funds do not arrive when they are needed.

Outreach funding illustrates that gap.

It is the money that helps vaccines to reach children in remote communities. Health workers say when those funds are delayed, outreach activities depend on staff members improvising.

In Fagge and Takai LGAs of Kano State, workers told PREMIUM TIMES that each PHC is allocated about N7,000 a month for outreach transport.

Several months’ allocations are often paid together in arrears at the end of a quarter, long after many of the outreach visits.

In Gombe State, PHCs receive N35,000 a month for outreach transport, but the money is likewise paid quarterly.

The situation is even more difficult at health posts.

Unlike PHCs, they receive no dedicated transport allocation, according to workers interviewed by PREMIUM TIMES. Yet they are responsible for tracing children who miss appointments and carrying vaccination services to remote settlements.

When priorities compete

Funding pressures extend beyond the health sector.

Budget documents reviewed by PREMIUM TIMES show that both Kano and Gombe have made substantial allocations to debt servicing in recent years.

In the 2026 fiscal year, Kano budgeted about N69.84 billion for debt repayment, while Gombe allocated roughly N37.23 billion.

Those obligations are met before many operational funds are released to sectors such as PHCs, reducing the fiscal space available for routine service delivery.

Health workers say they experience those pressures in delayed outreach, postponed field visits and reduced operational flexibility.

Government spending priorities are also visible elsewhere.

In Kano, the state approved the purchase of 41 sport utility vehicles (SUVs) for members of the House of Assembly in 2024 at a cost of about N2.6 billion, alongside other vehicle purchases for the executive and security agencies.

In Gombe, similar procurements included 41 SUVs for lawmakers and commissioners in 2023, while more than N2 billion was allocated for vehicles for the judiciary in 2025.

Government officials have defended such purchases as necessary for governance and movement across challenging terrains.

For health workers travelling across the same terrains, however, the contrast is difficult to ignore. Many outreach teams continue to rely on motorcycles, commercial transport, or long walks to reach remote communities.

Where the system holds

Despite its weaknesses, northern Nigeria’s routine immunisation system continues to function because thousands of frontline health workers, volunteers and community mobilisers return to the same communities, often with limited resources, determined to find children who have missed their vaccines.

But sustaining that effort requires more than commitment, according to public health expert Abdulhameed Adediran, who warned that children who miss subsequent vaccine doses remain vulnerable to preventable diseases.

“A child is supposed to have three doses but has only the first dose. That child is not 33 per cent protected. That child is not protected because the first dose is supposed to last for a particular period before the next one is administered to have a complete effect,” he told PREMIUM TIMES via phone interview.

Mr Adediran said inadequate financing for PHC undermines the entire immunisation system. According to him, when outreach activities are poorly funded, children in distant communities are more likely to miss vaccinations, leaving dangerous gaps in disease prevention.

He traced many of the problems to systemic weaknesses, including poor funding, shortages of health workers, weak accountability, and inadequate infrastructure. In many facilities, he noted, community health extension workers shoulder responsibilities beyond their intended roles because of years of limited recruitment.

Mr Adeniran said immunisation programmes must be designed around the realities of the communities they serve rather than through one-size-fits-all approaches.

“People sit in Abuja and take decisions for people in those villages, and those decisions don’t necessarily work for them or are not necessarily applicable to them,” he explained, adding, “We need to start looking at a tailored, people-centred approach to our health institutions.”

Government responds

Responding to the findings, the Gombe State Primary Health Care Development Agency acknowledged that delays in releasing outreach funds sometimes occur, attributing them to administrative procedures, financial reconciliation processes and the timing of support from development partners.

The State Immunisation Officer, Abdulkarim Aliyu, said routine immunisation outreach is funded through a combination of government resources and donor support, with disbursements passing through several approval and accountability processes before reaching health facilities.

While acknowledging the effect of delayed releases, Mr Aliyu praised frontline workers who continue to provide outreach services despite funding constraints.

“We also recognise and appreciate the dedication of frontline health workers who often go the extra mile to ensure that vaccination services continue even when resources are delayed,” he said.

He said the agency has strengthened defaulter-tracking systems, expanded community mobilisation through Ward Development Committees, Community Health Influencers, Promoters and Services (CHIPS) agents and the Mama-to-Mama initiative, while holding regular review meetings to identify communities with high dropout rates and deploy targeted interventions.

Mr Aliyu added that the agency was pursuing workforce training, supportive supervision, and strategic staff deployment to address staffing shortages, while routine data validation and quality assessments are used to monitor immunisation records and identify children who miss scheduled vaccinations.

Looking ahead, he said the agency would focus on strengthening outreach services, improving community engagement, and expanding efforts to identify and vaccinate zero-dose and under-immunised children.

In Kano, the Director-General of the State Primary Health Care Management Board, Salisu Ibrahim, said outreach stipends are paid through a performance-tracking system supported by Acasus, a routine immunisation partner that monitors outreach sessions conducted by service providers.

Mr Ibrahim explained that payment delays sometimes occur because service-delivery records must first be verified before payments are processed.

He said the state has adopted several measures to reduce vaccine dropout rates, including ensuring that planned immunisation sessions are conducted, expanding public awareness campaigns, and addressing practices that contribute to missed vaccination opportunities.

While acknowledging financial pressures, he said the current administration of Governor Abba Yusuf increased outreach stipends from N1,000 to N4,000 per session to help health workers cope with rising transportation and operational costs.

He added that the board also conducts monthly data validation exercises, review meetings and independent surveys to identify service gaps and strengthen routine immunisation in underserved communities.

Whether those efforts will be enough to reduce the number of children missing vaccines remains uncertain. 

What is clear, however, is that across communities in Kano and Gombe, routine immunisation continues to depend heavily on the persistence of health workers, volunteers and caregivers who keep showing up despite funding delays, staffing shortages and the difficulties of reaching remote settlements. 

For many children, completing vaccination depends on that fragile chain.