A qualitative analysis exploring barriers and enablers to distribution, delivery, and access to COVID-19 vaccines in Botswana

John Thato Tlhakanelo^1*John Ele-Ojo Ataguba^2,3,4,5Vincent Pagiwa⁶Nankie Ramabu¹Khutsafalo Kadimo⁷Grace Njeri Muriithi²Daniel Malik Achala²Elizabeth Naa Adukwei Adote²Chinyere Ojiugo Mbachu⁸Senait Alemayehu Beshah⁹Nyasha Masuka¹⁰Chijioke Osinachi Nwosu¹¹James Akazili^12,13Ifeanyichukwu Chikezie¹⁴Dintle Molosiwa¹

• ¹Department of Family Medicine and Public Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
• ²African Health Economics and Policy Association, Accra, Ghana
• ³Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada, Winnipeg, Canada
• ⁴Partnership for Economic Policy (PEP), Nairobi, Kenya, Nairobi, Kenya
• ⁵School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
• ⁶Okavango Research Institute, University of Botswana, Gaborone, Botswana
• ⁷Department of Library and Information Science, University of Botswana, Gaborone, Botswana, Gaborone, Botswana
• ⁸Department of Community Medicine, University of Nigeria, Enugu Campus, Nigeria, Enugu, Nigeria
• ⁹Ethiopian Public Health Institute, Addis Ababa, Addis Ababa, Ethiopia
• ¹⁰Zimbabwe College of Public Health Physicians, Harare, Zimbabwe
• ¹¹University of the Free State, Bloemfontein, Free State, South Africa
• ¹²C.K Tedam University of Technology and Applied Sciences, Navrongo, Upper East Region, Ghana
• ¹³Bergen Centre for Ethics and Priority Setting, Faculty of Medicine, University of Bergen, Bergen, Hordaland, Norway
• ¹⁴Health Systems and Development Research Group. Veritas University Abuja, Abuja, Nigeria

Introduction: The COVID-19 pandemic highlighted pre-existing weaknesses, revealing deep-rooted issues in infrastructure, access, and resource allocation that have long impeded African countries' ability to effectively meet population health needs. It also became evident during the pandemic that there were discrepancies in how vaccines were distributed, delivered and accessed in these countries. We aimed to identify vaccine distribution, service delivery processes and related barriers in Botswana to contextually explore practices that either enhance or hinder access and equity in vaccine distribution and delivery. Methods: We conducted in-depth interviews, using a semi-structured interview guide, with a purposive sample of 18 key informants, including health sector officials, non-state actors, policy makers, regulatory bodies and other stakeholders. Interviews were audio-recorded and, transcribed verbatim., Thematic analysis was conducted following a deductive approach according to the six-step analysis framework by Braun and Clarke. Attention was given to aspects of credibility, dependability, and transferability of the findings through key strategies, including team data review, coding, consensus on themes and review of both secondary and grey literature on vaccine roll-out in the country.and analyzed using thematic analysis to identify recurring patterns and insights. Results: Seven primary themes emerged from the findings. COVID-19 vaccines distribution and delivery in Botswana followed the existing primary health care system structures for routine vaccine delivery. Traditional mechanisms such as static public health facilities, private facilities, outreach campaigns, and mobile stops, , were augmented through different roles played by stakeholders in the private sector, civil society organizations and nongovernmental organizations. Religious and cultural norms were reported to affect vaccine uptake centered around smaller population groups that are historically known to be anti-vaccines. There is no deliberate gender and the disabled population programming for vaccine distribution and delivery in Botswana. The private sector improved access to vaccines by supporting supply chain logistics with transportation, especially to hard-to-reach areas. Discussions: Achieving equitable vaccine access involves not only logistical and infrastructural considerations, but also coordination and collaboration across several sectors, enhancing gender diversity and inclusivity in planning, coordination, and decision making and implementation of strategies tailored to the needs of a wide range of vulnerable population groups.