CHAPTER 3: RESULTS The results are presented in two sections; the first part is based on the health system, socio-economic, access and cultural factors (variables) influencing immunization services, summary analysis (see Appendix V, figure 1) and the second part focuses on innovative practices available to improve immunization in Benin, Burkina Faso and Ivory Coast. 3.1.2 Health system factors. Most decision makers cited vaccine stock-out or occasional stock-out as the main factor driving mothers not to adhere to the vaccination schedule. Participants at the health center level identified lack of equipment and its maintenance as a barrier to providing community services, for example lack of fuel for community services and lack of equipment (motorcycles). A surprising concept, also mentioned at the health center level, was that it was long overdue times. When mothers travel long distances and wait long at a health center due to busy health workers or staff shortages, they are unlikely to return for future services. 3.1.3 Socio-economic factors. Social factors were identified as primarily related to the demand side of immunization. Although immunization services in the three countries are free at the point of contact. However, staff at one health center noted that “there is a hidden cost that families pay to avail of vaccination services. The cost of purchasing a health vaccination card and the cost of transportation to go to the vaccination site were associated with low participation in the vaccination session''. Another factor mentioned by decision makers was ignorance: ''mothers are not aware of the need for vaccination and may not know the actual dates of the next appointment... half of the document... ted. Local political and religious leaders are involved to gain support from the community they are involved in, with the aim of instilling local ownership and empowerment of health services, including immunization services, to ensure that every child is vaccinated. Announcements about the availability and dates of immunization services are also announced in churches. 3.2.7 Flexible hours of immunization services. Flexible hours were mentioned as one of the innovative solutions to improve immunization. In addition to providing routine immunization on specific days, immunization targets specific communities and locations. The choice of target location is based on an analysis of the situation to find out who the cases are, where and why they are not vaccinated. Markets constitute one of the places where children are targeted with the provision of immunization services