After slow start, Tanzania becomes a leader in COVID vaccinations

Over the course of four months, from June to September 2022, COVID-19 vaccination rates among adults in Tanzania surged from an average of 15% to 70%. By December, 98.9% had received at least one dose. Since that time, the COVID-19 vaccination rate has continued to climb. Today, Tanzania has reached 104% of adults with at least one dose of a COVID-19 vaccine.

We spoke with Dr. Mahesh Swaminathan, an infectious disease specialist who has led the U.S. Center for Disease Control’s partnership with the Tanzanian Ministry of Health to accelerate the pace of COVID-19 vaccinations.

To achieve the rapid rollout of COVID-19 vaccine, Tanzania “de-medicalized” vaccine delivery – offering it both inside and outside of health facilities, such as at community events, sports matches, and workplaces – and relied on thousands of vaccination champions to mobilize communities across the country.

The vaccine champions “were healthcare workers or people who have influence in the community. In some cases they were religious leaders, in some places it was local political leaders or teachers,” said Dr. Swaminathan. “Training these local vaccine champions was key.”

Vaccine delivery is often understood as dependent on three distinct factors: access, intent, and readiness. How did Tanzania, once Samia Suluhu Hassan was sworn in as President in March 2021, use these levers to improve its COVID-19 vaccination rates?

Dr. Swaminathan: In Tanzania, political will was the first step and opened the door to access. In using the term political will, I’m not just referring to government. It includes business leaders and community leaders.

Tanzanian President Samia Suluhu Hassan set up a presidential task force weeks after entering office. The task force was a technical team that included respected scientists and Ministry of Health officials, animal and human vaccinologists, and some members of the judiciary. The task force interviewed donors and met with religious, business and community leaders, academics, and researchers. I think that multidisciplinary approach helped ensure the appropriate decision was made. With a decision like this there is a technical element: what should we do? But then there's also a political element. The government made sure that whatever recommendation the task force made it was taken seriously and the process was transparent.

The task force recommended that Tanzania aggressively pursue COVID-19 vaccination in addition to other mitigation measures. Once that happened, the US government through the Initiative for Global Vaccine Access, COVAX, and the American Rescue Plan Act, were able to provide vaccines and support for vaccinations to Tanzania. The US CDC stepped in because it was the right thing to do, and we had the expertise and were fortunate to receive extra funding. We were already working to provide COVID-19 vaccinations to Tanzanians living with HIV. The CDC felt an urgency since Tanzania was starting COVID-19 vaccinations later than other countries.

How did President Hassan and other leaders demonstrate and communicate that political will?

Dr. Swaminathan: At the top level, President Hassan, after the presidential task force recommendation, publicly said: 'This is something we have to take seriously.' She embraced it. She got vaccinated in public, as did her minister of health. And she made the resources available to ensure that it could be done. But that was only the first step towards providing access.

Government leaders were joined by a lot of business leaders who also pushed to support vaccination and hosted vaccination days for their staff. The tourism industry was particularly supportive. There was a feeling that if we're not able to vaccinate people and show that we can keep people safe we're not going to get tourists.

Was vaccine hesitancy a big challenge?

Dr. Swaminathan: People tend to think about vaccine hesitancy or confidence as binary – I would like to get vaccinated, or I would not. That's not really how it works. It is more of a continuum. Yes, there are people who are at one extreme, who are going to say, 'Hell no, you won't vaccinate me. In fact, I'm going to spend energy not getting vaccinated.' Then they're people on the other end of the spectrum who say, ‘I will do whatever it takes to get vaccinated.’ But most people are in between. And they might accept the vaccine if you lower barriers.

And, in a country like Tanzania, there are many barriers. Many people here live day to day. If they don't work that day, they may not eat. Also, this is a big country. Many people don’t have cars or even access to public transport. Traveling 10 or 15 kilometers or more without motorized transportation takes a very long time.

What you have to do then is you have to say, 'I'm going to figure out a way to get the vaccine to you.' This requires what is called ‘de-medicalizing’ the vaccine. Instead of having to travel one or two hours to a health facility and then wait three hours at the facility for a vaccine, Tanzania made it easier for people to accept the vaccine by bringing the vaccine to them including outside of medical facilities. This included giving vaccinations in communities, either door-to-door or at fixed temporary vaccination sites in the community.

Can you walk us through the steps Tanzania took in bringing the vaccine to communities?

Dr. Swaminathan: Tanzania started with a lot of mass marketing campaigns. This was through radio, television, and newspapers. These campaigns just provided information, so someone's heard of the vaccine.

Tanzania was flexible and responded to opportunities, such as leveraging sporting events. For example, they set up vaccination booths and tents at football games and local festivals. Tanzania also had vaccine trucks that traveled around the country to get people vaccinated.

And at health facilities, we would have people stationed at the entrance and at various clinics, saying, 'Have you been vaccinated?' If they agreed to being vaccinated the volunteer would accompany them to the vaccine point in the facility.

The real grunt work though, to take someone from, 'OK, this is something I have heard of' to ‘this is something that is important to my health that's desirable and I would like to get vaccinated’ required intense engagement and community mobilization.

How did Tanzania mobilize communities?

Dr. Swaminathan: Tanzania trained vaccine champions. When you're talking about a community, and this is true across the board, it's very hard to get that community’s confidence without having someone who is trusted by the community to endorse you.

It's not necessarily that they're trusted for their expertise. But that does help too. But it's more important that people see someone who is part of your team, who is speaking for you and can say, ‘You're part of us. You care about us.’

The vaccine champions were healthcare workers or people who have influence in the community. In some cases, they were religious leaders, in some places it was local political leaders or teachers.

With really vulnerable or disadvantaged groups, it becomes an even bigger deal. Unless you have a local community member working with you, it's very hard to reach these groups.

Training these local vaccine champions was key. The vaccine champions were provided with standard messaging in a few languages. The Ministry of Health’s training provided sample scripts, talking points, and techniques for engaging with people, thinking on their feet and answering questions. A lot of work went into ensuring the messaging made sense in a local context. There were thousands of vaccine champions, so this was a lot of work for a lot of people across the country.

There's also some improvisation involved. Sometimes, you go to a community and find out as you're vaccinating that you're not reaching everyone. The team might say, ‘Maybe we need to talk to these other people in order to get access to this particular segment of the community.’ Tanzania did that community engagement ahead of time, and then, continued it while they brought the vaccine to each community.

Why engage in community mobilization concurrently with vaccinations?

Dr. Swaminathan: The vaccine champions are wonderful volunteers who provide great information and are very persuasive. The person they are educating may walk away from a conversation with the vaccine champion saying, ‘Oh, absolutely. This is great. I'm going to get vaccinated.’ But, if the vaccine is not available right then and there, you have a problem. Because a few hours later they may say, ‘I'm not against getting vaccinated, but is it worth spending all this time getting vaccinated? It's going to be very difficult for me. I got to miss work.’

As time passes, it is less and less likely that they are going to get vaccinated. So, the government of Tanzania made sure the vaccine was available immediately. That community outreach and vaccination happened together. This required a great deal of organizational expertise.

Tanzania recognized that it is really bad if you've done all this work to get someone to agree to vaccination and then there’s no vaccine available for them either at their local clinic or at whatever event they're attending. Maybe, they were already a little hesitant before. But if and when the vaccine runs out, or can’t be administered when they are ready, they are going to say, ‘You guys are incompetent. I can't trust you.’

Tell us about the role data played in this success?

Dr. Swaminathan: That's where I think our global health security program really helped. We worked with Tanzania to help them develop timely and reliable data systems to track who's been vaccinated. It's not an easy thing to do. But it enables you to help ensure people get their second dose, by reminding them and going back to vaccination sites.

It also helps you to determine which geographic areas need your attention and which ones don’t, ‘I vaccinated this number of people here and I've achieved a pretty high coverage. I don't need to keep coming back here. I can take those resources and go somewhere else.’ The data system also helped the government start monitoring vaccine effectiveness as they had data on both vaccination status and who was hospitalized for COVID-19.