Strengthening immunization systems in a decentralized health system: Availability and readiness of primary healthcare services in the Federation of Bosnia and Herzegovina

Title : Strengthening immunization systems in a decentralized health system: Availability and readiness of primary healthcare services in the Federation of Bosnia and Herzegovina

Abstract:

Suboptimal immunization coverage remains a major public health concern in middle-income countries, particularly in decentralized health systems. Recent measles outbreaks in the Federation of Bosnia and Herzegovina (FBiH) highlight critical gaps in service delivery and continuity of vaccination. Generating operational evidence on system performance is essential to support effective disease prevention and control strategies.

A cross-sectional assessment was conducted in 2025 across all 77 primary healthcare centers (87 immunization services) in FBiH. Data were collected using a WHO SARA-based tool, combining structured interviews and direct observation. Indicators included service availability, workforce capacity, cold chain management, data systems, and immunization coverage.

Immunization services were widely available, with 77% of facilities providing daily vaccination. However, significant system constraints were identified. Nearly one in five services (17.2%) operated without a permanently employed physician, and 31% relied on external staff. While basic cold chain equipment was universally available, only 62.1% of facilities had standard operating procedures, and 73.6% had backup power supply. Electronic immunization registries were implemented in only 40.2% of facilities, with marked regional disparities. Vaccine availability was generally high, but intermittent shortages were reported, particularly for measles-containing vaccines.

Coverage analysis revealed critical drop-offs: ≥90% coverage was achieved in 54.8% of facilities for the first pentavalent dose, declining to 32.9% for the third dose and 38.4% for MMR, indicating gaps in follow-up and completion of vaccination schedules.

Despite good structural access to immunization services, system readiness and continuity remain insufficient to ensure optimal coverage. Strengthening workforce capacity, cold chain resilience, digital immunization registries, and active follow-up mechanisms is essential to prevent outbreaks and improve vaccination outcomes. These findings provide actionable evidence for strengthening immunization systems in decentralized settings and are directly relevant to global infectious disease control efforts.

Biography:

Sinisa Skocibusic is a healthcare practitioner by profession. The individual embarked on a postgraduate program in "Medical Care and Public Health" with a particular focus on infectious diseases. He performed a crucial role during the COVID-19 epidemic as a subspecialist in intensive care medicine. Aside from his clinical practice, he imparts knowledge to aspiring physicians at the Medical School in Mostar. The individual in question has held the position of director at the Center for Addiction Prevention and Outpatient Treatment in Mostar since 2015 and subsequently assumed the role of director at the Institute of Public Health of the Federation of Bosnia and Herzegovina since 2021. He has authored or co-authored an additional 11 scientific papers that have been published in journals that are indexed in relevant databases. Furthermore, he has contributed to the publication of five scientific publications in other journals and has made contributions to two edited volumes.