Table 3.

Examples of immunisation system leverage points classified according to Malhi et al. (2009) based on Meadows (1989).

Intervention level	IMS Leverage points and potential directions of change
1. Paradigm	Expanding the mindset behind the IMS: from the anthropocentric ethic of preventive health as an enabler for human wellbeing, to the One Health/Planetary Health concept: Multi-stakeholder health approach (human, animal, environment) (Whitmee et al., 2015) Emergence instead of centrally controlled system: Social cohesion as cornerstone of health-seeking behaviour (Ubuntu) (Barugahare, 2018)
2. Goals	Complement IMS targets based on SDG3, IHRs and national immunisation targets with targets addressing Vulnerable groups and geographic diversity Sustainability targets beyond financial sustainability Differentiation based on transdisciplinary thinking
3. System structure (across IMS loops and outside IMS)	Self-Organising power Country-specific IMS, adapted to local circumstances Self-Organisation at subnational level: counties, districts, health centres
	Rules of the system Planned and emergency immunisation as one holistic system Synchronisation at vaccination point: differentiation, effectiveness, efficiency Community engagement, CHWs connecting immunisation demand and supply National immunisation programme adequacy and funding sustainability
	Information flows Patient-based data, real-time vulnerability maps available to health workers Patient-based health information available to population for fostering personal and community health engagement Supply-related data available to relevant stakeholders
4. Feedback and delays	Reinforcing feedback loops Efficiency of vaccine supply loop: vaccine wastage reduction Efficiency and effectiveness of workforce and infrastructure loop Strength of wellbeing loop, linked to education and poverty Balancing feedback loops Outbreak prevention loop strength: ability of surveillance and response Interface between national and international response to epidemics Delays Immunisation delivery options with different dynamics: RI, campaigns Delays in outbreak prevention loop and outbreak response loop Synchronisation of vaccine supply and distribution delays to create stability in the system
5. Structural elements (within IMS loops)	Vaccine Supply chain network layout Size of warehouses and vaccine inventory levels Workforce capacity