Research | Open Access | Volume 9 (Suppl 13): Article  6 | Published: 18 Sep 2026

Functionality of the vaccine cold chain in a rural district in Western Uganda: A qualitative inquiry

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Table 1: Demographics of the participants

Keywords

  • Vaccine cold chain
  • Cold chain functionality
  • Facilitators and barriers

Amuzah Nshabaruhanga1,&, Moses Walijjo1,2, Julius Ssebaketta1, Connie Nait1, Alex Mulyowa1, Elizabeth Ekirapa-Kiracho1

1Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda, 2Kalisizo Hospital, Kyotera District Local Government, Kyotera, Uganda

&Corresponding author: Amuzah Nshabaruhanga, Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala, Uganda, Email: anshabaruhanga@musph.ac.ug ORCID: https://orcid.org/0009-0005-3350-965X

Received: 29 Oct 2025, Accepted: 15 Sep 2026, Published: 18 Sep 2026

Domain: Vaccine Management

Keywords: Vaccine cold chain, cold chain functionality, facilitators and barriers

©Amuzah Nshabaruhanga et al. Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Amuzah Nshabaruhanga et al., Functionality of the vaccine cold chain in a rural district in Western Uganda: A qualitative inquiry. Journal of Interventional Epidemiology and Public Health. 2026; 9(Suppl 13):6. https://doi.org/10.37432/jieph-d-25-00261

Abstract

Introduction: A functional vaccine cold chain (VCC) preserves vaccine potency by ensuring optimal conditions during storage and transport. However, frequent outbreaks of vaccine-preventable diseases raise concerns about vaccine potency, often linked to cold chain failures. We explored the facilitators of and barriers to VCC functionality in Rukungiri District, Western Uganda.
Methods: We employed a qualitative approach, involving seven key informant interviews with district and facility immunization managers. A key informant interview guide, developed based on the World Health Organization’s Effective Vaccine Management framework, was used.  Thematic analysis was performed manually, following both deductive and inductive approaches.
Results: Key facilitators of VCC functionality included dedicated and knowledgeable staff, supportive supervision from district health teams, the presence of solar-powered refrigerators, effective maintenance systems, and rigorous temperature monitoring. Barriers included reliance on outdated gas-powered refrigerators in some health facilities and gaps in transport and human resources.
Conclusion: Facilitators, including solar refrigeration, knowledgeable staff, and supportive supervision, improve VCC functionality, while barriers such as inadequate storage, transportation challenges, and human resource gaps hinder optimal performance. These insights emphasise the need for targeted investments in infrastructure, workforce development, and sustainable technologies.

Introduction

Immunization is a successful and cost-effective intervention for preventing vaccine-preventable diseases, having averted 154 million deaths worldwide over the last 50 years [1,2].  The success of an immunization programme depends on a robust vaccine cold chain (VCC) system, which maintains vaccines at optimal conditions, usually a temperature of +2 to +8 degrees Celsius (°C) to preserve their potency [3,4]. An optimally functioning VCC from the manufacturer through to vaccine administration is the most effective way of ensuring that vaccines reach recipients in their most potent form [5]. Short of that, vaccine potency is compromised, which affects the development of immunity against vaccine-preventable diseases in vaccinated individuals [4].

In recent years, some countries have reported resurgences of vaccine-preventable diseases, even with established immunization systems [6,7]. The resurgences are attributed to several factors, including disruptions to routine immunization services, vaccine hesitancy, or health system shocks [6,8]. Particularly, sub-optimal vaccine cold chain performance has increasingly been recognised as a critical factor, as exposure of vaccines to inappropriate temperatures reduces their potency and may result in reduced immune protection despite reported vaccination [9].

In 2010, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) launched the Effective Vaccine Management (EVM) initiative, providing materials and tools used to assess and monitor VCC. The EVM assesses the performance of nine criteria of the VCC at the national, district, and health facility levels and benchmarks it against the global standard of 80% for an optimally functioning VCC. The criteria assessed include vaccine arrival procedures; temperature; capacity; buildings, equipment, and transport; stock control; vaccine management; distribution; maintenance; and information systems [10,11]. Despite the efforts from WHO, UNICEF, and national governments, EVM assessments have shown that VCC still underperforms, especially in low- and middle-income countries. Africa and Asia are the most affected, with scores across most criteria averaging around 70% [10,12].

The Uganda National Expanded Programme on Immunization oversees the functionality of the VCC, including cold chain maintenance, supervision, and staff capacity building [13]. Vaccines procured by the National Medical Stores are first stored in central warehouses before being distributed to district vaccine stores [13]. From the district vaccine store, vaccines are delivered to health facilities, which monitor storage conditions and maintain proper temperatures to ensure vaccine potency during storage and use [13].   Thus, the district and health facilities play a crucial role in ensuring the VCC is functioning optimally.

Assessment done in Uganda found average EVM scores of 61.6% at the national, 64.3% at district, and 59.3% at health facility level in 2011[13,14].  By 2014, the EVM scores had risen to 79.0% nationally, 67.6% at the district level, and 62.5% at the health facility level [13,14]. These scores remained below the 80% minimum standard at all levels, highlighting gaps in the VCC. In an assessment conducted in some districts in Uganda in 2018, improvements were observed, although some criteria still scored below 80% [15]. In fact, between 2018 and 2023, there was limited data about EVM scores.  It is thus not known whether the functionality of the VCC is still optimal or not. Furthermore, there is limited information on the barriers and facilitators of the VCC functionality. Rural areas have previously reported low functionality of the vaccine cold chain (VCC) due to inadequate infrastructure and limited equipment [16]. We explored the barriers and facilitators to the functionality of the VCC in Rukungiri District, Western Uganda.

Methods

Study design

This cross-sectional study was conducted from 27 November 2023 to 8 December 2023 in Rukungiri District, Southwestern Uganda. The study involved key informant interviews with district and health facility immunization managers to explore VCC functionality at a point in time.

Study setting
Rukungiri is one of the districts in the Kigezi sub-region, located in South-Western Uganda, approximately 390km from Uganda’s capital city, Kampala. The district has four health sub-districts, forty-six health facilities with vaccine storage capacity, and one district vaccine store. The district is predominantly rural, hard to reach, and characterized by hilly terrain. Rukungiri District was purposively selected for this study based on practical considerations, including accessibility and feasibility for field assessment, and is also characteristic of districts in Southwestern Uganda. The selection was not based on performance in previous assessments, as district-specific data are not publicly available, but on the feasibility of conducting an in-depth evaluation of VCC functionality within the available resources. As a predominantly rural local government district with a decentralised health system structure similar to other districts, Rukungiri’s findings may reflect the functionality of the VCC in the district and in comparable districts. Moreover, Uganda’s immunization and cold chain systems are centrally guided by the national Ministry of Health policies and Uganda’s national expanded programme in immunization standards, which provide uniform structures for equipment, maintenance, and human resources, among others, across all districts. However, district-specific contextual challenges should be considered when interpreting the findings.  Southwestern Uganda has a total of 18 districts distributed across the Ankole and Kigezi subregions.

Study population and Sampling technique
The study population comprised the district and health facility immunization managers.  Seven key informants were purposively selected, including three members of the district health team, two facility in-charges, and two Expanded Programme on Immunization (EPI) focal persons. Participants were chosen based on their direct involvement in and knowledge of vaccine cold chain management. The selection of participants across district and health facility levels provided diverse perspectives on vaccine cold chain management, and the interviews provided sufficient depth and richness of information to address the focused study objectives.

Data collection
A key informant interview guide was developed from the WHO EVM framework [10,11], a validated tool for assessing VCC functionality. The guide was adapted for a qualitative approach. It included constructs on temperature monitoring; cold chain capacity; buildings, equipment, and transport; stock control; vaccine management; distribution; and maintenance. Probes were inserted into each of the questions to ensure that the questions were answered fully and comprehensively. Interviews were conducted in English and audio-recorded. On average, interviews lasted 40 minutes.  Interviews were conducted by two trained data collectors with health-related backgrounds and prior experience in qualitative research, who received study-specific training before fieldwork.

Data management and analysis
Audio recordings were transcribed verbatim. Transcripts and audio recordings were securely stored.  A codebook was created with predetermined codes categorised into a priori themes guided by WHO EVM assessment criteria and converted into a Microsoft Excel matrix. The codes were categorised into two overarching themes of facilitators and barriers. AN read the transcripts twice to familiarize himself with the data while assigning codes.  Similar codes were grouped into sub-themes, and each sub-theme was linked to a parent theme. The analysis also allowed for the emergence of new themes beyond the pre-determined EVM-based framework, capturing context-specific insights from participants. Results were presented as quotes to support the reporting of findings.

Ethical considerations
Approval was obtained from the Makerere University School of Public Health Research and Ethics Committee and assigned protocol number 291 (MakSPH REC 291). Administrative clearance was granted by the District Health Officer before collecting the data. Written informed consent was obtained from all participants before the interviews. All participants were assured of confidentiality. No identifying information of the participants is presented.

Results

The majority of participants were male (n = 6). Most participants were aged 40–49 years (n = 3). In terms of professional roles, three were members of the district health team, while four were health facility staff. The demographics are summarised in Table 1. The study followed two key themes: facilitators and barriers.

Facilitators for the functionality of the vaccine cold chain
The following are the findings on possible facilitators for a functional VCC

Availability of appropriate storage infrastructure: The majority of the key informants mentioned that the presence of appropriate storage facilities was critical to the functionality of the VCC. The transition from gas-powered refrigerators to solar direct-drive refrigerators ensured continuous functionality even in off-grid areas. Additionally, the facilities that still used gas-powered fridges benefited from gas refills.

“Availability of functional refrigerators, availability of power, of course, availability of human resources; we are glad the district is well coordinated in cold chain management and maintenance. We got a boost from the Ministry of Health, and most of our facilities were moved from gas-powered fridges to the solar-powered fridges. So, a number of our facilities have solar-powered fridges for the cold chain, but for those which are still not transitioned, we provide gas that comes from National Medical Stores” (KII02RD, medical officer)

Maintenance and repair of cold chain equipment:  Participants mentioned that refrigerators, vaccine carriers, cold boxes, and ice packs were well-maintained. Maintenance, like defrosting and repairs, was handled by cold chain technicians or assistants, while complex problems were reported to the Ministry of Health.

“You see, every facility has a fridge, and every fridge has its own temperature monitoring thermometer. Whenever they are faulty, the cold chain technician, and the cold chain assistants usually see how to handle those ones. If they are beyond, then they communicate to the ministry. Facility staff may do things like defrosting and ensure the fridges are protected. What they cannot manage they report to someone capable usually the cold chain assistant or DCCT…” (KII03RD, public health officer)

Human resources for the vaccine cold chain: All the key informants mentioned that the district and all health facilities had staff responsible for overseeing the VCC. At the district level, there was a cold chain technician; cold chain assistants at the health sub-district, while at the health facility level, there were EPI focal persons.

“At facility level, the EPI focal persons are the ones who are responsible for reporting any fault in the fridge to ensure that temperature is monitored as expected. We have the health sub-district; before they [EPI focal persons] reach the district, they are supposed to report to the health sub-district cold chain assistant, and when that thing is beyond the health sub-district, then they inform the district cold chain technician, then we move in.” (KII01RD, clinical officer)

Through onsite mentorships and ongoing training, staff learn the latest best practices in vaccine storage, handling, temperature monitoring, and cold chain management. This ensures that staff remain proficient in using equipment, managing temperature excursions, and following protocols.

“We also have training and continuous education. Sometimes when we have the campaigns, we have to pass through all the requirements we need, so we always update our health workers about the new innovations as far as vaccines, cold chain, and immunization are concerned. We do this on-site during visits, but at times some staff are taken for classroom training, especially the cold chain team and EPI” (KII03RD, public health officer)

Support supervision: Routine supervision is always done by the district health team to provide ongoing guidance, training, and troubleshooting of any challenges related to VCC management at health facilities. The supervision focuses on vaccine handling, equipment maintenance, temperature monitoring, and adherence to cold chain protocols.  Structured and planned supervisions are conducted quarterly, while ad hoc supervisory visits are undertaken as needed.

“The supervisions which are planned are quarterly supervisions, but in case of any emergency, then we immediately arrange for support. When we go, we focus on maintenance, that is preventive maintenance and corrective maintenance. Then we also do short vaccine use supervisions [ad hoc supervisory visits] to make sure that temperatures are being monitored as one of the key performance indicators” (KII07RD, cold chain technician)

Effective temperature monitoring: Most participants mentioned that health facility staff consistently monitor and record temperature readings on monitoring charts twice daily, in the morning and evening, including weekends and public holidays. This allows for early detection of temperature fluctuations, enabling timely corrective actions. In case of temperature deviations, fridge tags trigger an alarm indicating either a high or low temperature, which informs action.

“Anything may fail to be done, but with temperature monitoring, we don’t take it as a simple or a slight issue… people are monitoring temperatures well for sure. Morning, evening, including weekends and even public holidays. They are doing it well, and at least these fridge tags, leave alone the other thermometers which sometimes could not indicate the variation properly in temperature by showing you an alarm…most of the facilities now were given this new type of biomedical refrigerator; now the system is monitored even from the centre” (KII06RD, cold chain assistant)

Barriers to a functional vaccine cold chain
Gaps in storage facilities: Participants mentioned that although most health facilities have transitioned to solar direct drive refrigerators, a few still rely on gas refrigerators. At the time of the study, seven facilities in the district were still using gas refrigerators, and gas comes with its challenges. It was emphasised that, at times, gas leaks and is used up in a shorter time than expected. The availability of gas is inconsistent, with National Medical Stores and the District Vaccine Store often experiencing stockouts, leaving facilities without a reliable power source.

“Some facilities are still using gas refrigerators, and you know the challenges with gas refrigerators, so if that one can also be phased out. Sometimes there’s inconsistency in delivery. You may come here, maybe you need gas, these people will tell you we don’t have gas, it is out of stock, national medical store has not delivered” (KII06RD, cold chain assistant)

Gaps in transport facilities: Many of the vehicles and motorcycles used for the transport of staff and distribution of vaccine and related supplies were old and prone to frequent mechanical breakdowns. In some facilities, staff faced difficulties in moving in the remote, hilly, and hard-to-reach areas. This delayed vaccine delivery compromises the integrity of ice packs and risks temperature excursions beyond the recommended +2°C to +8°C range.

“Sometimes, transportation becomes very hard for these staff who go out for outreaches. So, you find some in outreach posts; they are in areas where there is no road. So, it becomes a barrier. It compromises the cold chain because sometimes, whenever there is, you may find that from the facility to the outreach post, it may take long for them to reach the outreach post, having the ice packs, which can be affected, and temperatures can go out of range, above 8 degrees Celsius” (KII03RD, public health officer)

Gaps in cold chain human resources: The EPI focal persons are usually nurses or midwives who are just assigned VCC management roles. However, they lack formal specialised training in cold chain management. Frequent staff transfers and high turnover, especially in public not-for-profit facilities, further disrupt operations as new staff require time to adapt and familiarise themselves with cold chain procedures.

“If someone is an EPI focal person, it is just an assignment whereby he can be there or not, because we know how they operate because they have offs at work. So sometimes you find that temperature has not been monitored because the EPI was not there, so the issue of human resources is a big challenge because they may not be having enough staff to handle all the issues…I think in NGO facilities, there is high turnover of health workers, whereby you orient this one, and when you go there the next day, you find another person, who may not be able to right away know the standards of EPI, like the importance of monitoring temperatures” (KII07RD, cold chain technician). 

Discussion

Facilitators of the VCC included the presence of appropriate storage facilities, maintenance and repair of cold chain equipment, availability of human resources, support supervision, and temperature monitoring. Conversely, key barriers included inadequate storage capacity, with some facilities still relying on gas-powered refrigerators; transport challenges due to ageing vehicles and motorcycles; and limited human resource capacity resulting from a lack of specialized training. Altogether, the study findings suggest the need to strengthen VCC systems through targeted improvements in infrastructure, transport, and human resource capacity, along with support supervision.

Maintenance of the cold chain equipment was found to facilitate the functionality of the VCC. Findings from Ethiopia showed that maintenance of cold chain equipment was significantly associated with performance of the VCC [17,18]. Our findings reaffirm WHO and UNICEF recommendations on maintenance of VCC and are consistent with results from the previous studies that emphasised the importance of maintenance and repairs in ensuring optimal functioning of the VCC [18,19].  More effort needs to be put into ensuring that maintenance is always planned for and any emergencies are promptly handled.

Availability of skilled, knowledgeable, and experienced human resources to manage the VCC was crucial for its optimal functioning.  Facilities often have staff responsible for cold chain management. Cold chain staff are important because their absence implies that the cold chain will not function optimally [20]. Therefore, staff should be well-trained in general storage and handling practices and standard operating procedures (SOPs) to ensure vaccine potency and patient safety [3]

One of the critical determinants of the sustainability and effectiveness of cold chain integrity and immunisation programmes is cold chain handlers’ knowledge of the cold chain system and continuous professional development [21]. It has been found that experience and technical capacity are significantly associated with a well-functioning cold chain system [22,23], which aligns with our findings. The capacity to manage the VCC can further be improved through routine support supervision [24,25]. These findings, therefore, underscore the need for investment in training, mentorship, and retention of skilled workers in VCC management.

Temperature monitoring, once well controlled, gives the assurance that vaccines have been well protected from extreme conditions and that their potency is likely to be retained [10,11]. The CDC and WHO recommend temperature monitoring twice daily, including on weekends and public holidays [3,4]. The ability of VCC equipment to maintain recommended temperatures is due to a combination of improved responsiveness to temperature excursions at the facility level and improved ability at the management level to recognize and address recurring problems [26]. Therefore, temperature monitoring should be treated with utmost importance to ensure vaccines retain their potency across all levels of the cold chain.

However, there were also some barriers to the functionality of the VCC.  Although most facilities have transitioned to solar direct drive refrigerators, a few still rely on gas refrigerators, which need frequent refills and experience an unreliable supply of gas. Evidence has shown that an unreliable supply of gas at health facilities affects the functionality of VCC [27]. Gas-driven refrigerators, although used, are plagued by problems of gas supply interruptions, low efficiency, poor temperature control, and frequent maintenance needs [28]. These findings suggest the urgent need to replace gas refrigerators with other options, including solar refrigerators, across facilities. In the event that solar power may be unreliable or insufficient, complementary options such as hybrid systems that combine solar power with grid electricity may be considered.

We found that vehicles and motorcycles frequently broke down, disrupting the VCC in Rukungiri district, making the movement of staff and transportation of vaccines and related supplies of vaccines difficult. This is in line with a previous study, which found that managing effective distribution systems at health facilities was negatively affected by inadequate vehicles for distribution, especially in lower-level and remote facilities [27]. Frequent breakdowns and untimely maintenance of vaccine distribution vehicles may reflect broader health system challenges, including limited funds for routine fleet maintenance, competing budgetary priorities at the district level, lengthy public procurement procedures for spare parts, or reliance on external service providers [29,30]. This may lead to prolonged vehicle downtime, particularly in hard-to-reach areas [29].  Numerous vaccine-related adverse events have been reported across the world, especially in low- and middle-income countries, due to exposure of vaccines to inappropriate temperatures during their transportation, emphasising the need to ensure that the cold chain is not broken during the transportation of the vaccines [31]. For transport to be effective, it should be robust, with functional and well-maintained vehicles, as well as a well-developed transport network to be able to reach every site where vaccines are stored. This would ensure vaccines are transported swiftly, maintaining temperatures and preventing spoilage.

Lack of specialised training in the cold chain and staff transfers remain a barrier to an optimally functioning VCC. Cold chain performance largely relies on staff; therefore, qualified and experienced staff should be designated as primary vaccine coordinators at the facilities, responsible for ensuring all vaccines are stored and handled correctly in accordance with SOPs [3]. Studies have found that some personnel involved in vaccine handling and storage have no specialised training in VCC and vaccine handling, and some even lack on-the-job training [27]. This leads to delays in reporting the cold chain faults and affects the performance of routine tasks [32]. Therefore, health facilities and other storage locations should employ skilled, knowledgeable, and experienced staff with specialised training in vaccine cold chain management.

Study limitations
The study involved only seven key informants, which may limit the breadth and diversity of perspectives captured, potentially affecting the generalizability of the findings. The study does not provide empirical comparative district-level data; therefore, transferability should be interpreted cautiously.

Conclusion

Presence of appropriate storage and transport facilities, maintenance and repair of cold chain equipment, availability of human resources, support supervision, and temperature monitoring are some of the facilitators for functionality of the VCC. Inadequacies in storage facilities, human resources, and transportation remain key barriers to a functional VCC. This ought to be addressed to further improve the functionality of the VCC in the district.

Recommendations
The study recommends that the Uganda National Expanded Programme on Immunization, under the Ministry of Health, with support from partners such as Gavi and UNICEF, prioritise replacement of gas and electric refrigerators with solar direct-drive refrigerators in facilities where reliability challenges were identified. This would ensure a more reliable and cost-effective power supply. Gas and electric refrigerators may be retained as contingency backup options to mitigate system failure risks.

The government and partners should invest in additional vehicles and motorcycles dedicated to immunization and cold chain activities. This would ease the movement of cold chain teams involved in collecting vaccines from the district to facilities, as well as movements to communities during outreaches. Preventive maintenance budgets should be ring-fenced at district and health facility levels to minimize vehicle breakdowns and ensure uninterrupted vaccine distribution and outreach services.

The Ministry of Health should recruit and deploy dedicated staff for VCC management at health facilities in line with the revised staffing norms. The current practice of assigning this role to nurses and midwives alongside clinical duties limits effectiveness. Pharmacy staff, where available, should be formally assigned to oversee VCC management to enhance accountability and technical oversight.

The staff currently manning the VCC, that is, the EPI focal persons, cold chain assistants, and cold chain technician, should continuously receive training since the field is ever evolving with new technology and vaccines being introduced. Structured refresher training programmes should be institutionalized at the national and district levels. The training should be organized and delivered by the Uganda National Expanded Programme on Immunization to district teams, and the district teams would trickle down the knowledge to facility staff. This would ensure standardized technical competence across all levels of the system

What is already known about the topic

  • A functional VCC is essential for maintaining vaccine potency and effective immunization.
  • In low-resource settings, particularly rural areas of Uganda, gaps persist in infrastructure, equipment maintenance, transport, and human resources, compromising VCC performance.

What this  study adds

  • This study provides empirical evidence on context-specific facilitators and barriers to VCC functionality in a predominantly rural Ugandan district.
  • Key facilitators include solar-powered refrigerators, skilled and dedicated staff, routine supervision, and rigorous temperature monitoring.
  • Barriers include reliance on outdated gas-powered refrigerators, inconsistent transport, and limited specialized training amid high staff turnover. These findings inform targeted strategies to strengthen VCC systems in rural, low-resource contexts.

Competing interest

The authors of this work declare no competing interests.

Availability of data and material
Data supporting the findings of this study are available from the corresponding author upon reasonable request.

Funding

This work was fully funded by the corresponding author as part of the requirements for the Master of Public Health dissertation.

Acknowledgements

We thank the Rukungiri District Health Office, participating key informants, and Makerere University School of Public Health for their support and guidance throughout the study.

Authors’ contributions

AN conceptualized the study, developed the methodology, conducted data collection and analysis, and drafted the manuscript. MW, JS, EEK, CN, and AM contributed to study design, tool development, supervision, and critical manuscript revision. All authors read and approved the final manuscript.

Tables & Figures

Table 1: Demographics of the participants

VariableFrequency (n=7)
Sex
Male6
Female1
Age (years)
30-392
40-493
50-602
Role
District health team3
Facility team4
 

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