Stakeholder perceptions of political and economic factors influencing vaccination in two States with a high burden of zero-dose children in Nigeria

Globally, an estimated 22.7 million children are unimmunized or 'zero-dose' (ZD), with 3.1 million in Nigeria. The political and economic environment plays a critical role in influencing the number of ZD and under-immunized children. We explored stakeholder perceptions of the political and economic context of vaccination services in Kano and Lagos States, two Nigerian States with a high number of ZD children. We conducted stakeholder mapping, followed by key informant interviews with 84 State, local, and community informants responsible for or influential in immunization. Transcripts were analyzed using a reflective thematic framework approach. We describe the multi-level network of domestic and international actors characterizing Nigeria's immunization policymaking and implementation landscape. Respondents perceived a strong and mutual political commitment by all actors involved in routine immunization. The pivotal role of local influencers further reinforced this commitment, from traditional to religious leaders, to improving uptake in challenging settings. Knowledge of national policies, and thus, perception of their adequacy in addressing under-immunization, was weakest among participants working at the local and community levels. Other reported barriers to policy implementation included bureaucratic delays in fund disbursement, outdated policies, slow dissemination of policies to local levels, and inadequate policy provisions for funding and staffing at the local level. To enhance equitable immunization coverage in Kano and Lagos, our findings suggest a need for meaningful engagement of community actors in policy development, timely policy revisions, and the establishment of mechanisms for expediting fund disbursements and addressing funding shortfalls at the local levels.