Infant immunisation is currently a focus of national and global policy attention in relation to Africa as a key means to address ill-health and contribute to the Millennium Development Goals. Yet vaccination coverage is stagnant or falling in many African countries. Redressing such declines, and ensuring the effectiveness and sustainability of proposed expansion of immunisation programmes, requires a sound understanding of the factors shaping vaccine delivery and acceptance in contemporary African health systems. This paper explores these issues through an anthropological approach. It considers how vaccine delivery is influenced by the wider context of the health care system; how vaccination demand is shaped by socially-differentiated knowledges and political identities, and how interactions with delivery institutions and their frontline health workers unfold. It focuses on urban and rural sites in the Republic of Guinea, where dominant policy perspectives often see increasing immunisation coverage as a matter of (a) improving demand through educational approaches that enhance people’s biomedical understandings of the reasons for vaccination, and quell misguided ‘anti-vaccination’ rumours, and (b) redressing supply difficulties through improvements to vaccine delivery system infrastructure, financing and management.

In contrast, our ethnographic findings suggest that high demand already exists, although underlain by socially- embedded forms of knowledge and reasoning that fail to match, and often contradict, biomedical views. Yet people frequently cannot realise effective access to vaccines, less because of inherent problems in vaccine delivery systems, but because of the ways these are embedded in the multiple, pluralised processes through which health services are now provided in the Guinean context. As health workers struggle to cope with provision dilemmas, interactions arise which mothers often experience as negative, and which can deter their future demand. Such an analysis, and its implications for policy, emerge only through detailed ethnography of what vaccination practices actually mean to Guinean parents in the context of everyday child care and social relations.