The COVID-19 pandemic interrupted immunisation programs globally, undoing previous progress that had brought vaccine-preventable diseases under significant control. This research investigated how the pandemic influenced the uptake of routine child immunisation services in South Africa. A qualitative study was carried out through in-depth interviews with 51 parents or caregivers of children under five who had missed or postponed one or more scheduled immunisation doses between 2020 and 2022. Additionally, 12 healthcare providers who administered public immunisation services during this period were interviewed. During lockdown periods, most caregivers viewed the threat of their child contracting COVID-19 at a health facility as more immediate than the dangers of missing immunisation. Caregivers noted limited access to routine immunisation information and reported vaccine shortages at public clinics. Healthcare providers also experienced stress and exhaustion. Following the pandemic, many caregivers began making more deliberate choices about immunisation, a departure from the previously habitual acceptance of RI. Some delayed vaccinating their children due to increased caution. There were also instances of caregivers associating negative perceptions from COVID-19 vaccines with routine childhood vaccinations, fostering concerns about vaccine safety. This movement from default to deliberate immunisation decisions raises concerns that RI uptake could decline in future pandemics. Strengthening health system resilience and ensuring consistent, transparent messaging about routine immunisation and vaccine safety are essential, along with addressing supply challenges. In South Africa, routine immunisation is broadly supported due to generational practices and health provider guidance. However, during the COVID-19 crisis, many caregivers faced the difficult choice between avoiding virus exposure and protecting children from vaccine-preventable diseases, which led to missed immunisation appointments. The shift toward active decision-making suggests potential risks in future pandemics. Governments must prioritize resilient health systems and address the needs of hesitant or delaying caregivers. Effective communication on the benefits of routine immunisation and vaccine safety is vital to counter misinformation and prevent erosion of public trust.
