Between 2000 and 2004, the Government of Tanzania undertook a transformative public health mission through its Expanded Programme on Immunization (EPI). Anchored within the Ministry of Health and aligned with global immunization goals, the EPI aimed to dramatically reduce childhood illness and death caused by vaccine-preventable diseases. The initiative focused on strengthening routine immunization, accelerating disease control, and expanding surveillance systems across the country’s diverse and often remote regions.
At the heart of this effort was a commitment to universal access, vaccine safety, and system-wide integration. This strategic plan not only prioritized the introduction of new vaccines, such as hepatitis B, but also targeted the eradication of polio, the elimination of neonatal tetanus, and the containment of measles outbreaks.
With over 1.2 million infants and 6.5 million children under five in the target population, the plan represented both an ambitious public health endeavor and a logistical feat. Coordinated action, strong donor partnerships, and nationwide mobilization laid the foundation for Tanzania’s progress toward a healthier, more resilient future.
Population and Target Groups
Tanzania’s immunization strategy between 2000 and 2004 was rooted in a deep understanding of the country’s population profile and healthcare delivery landscape. Reaching every eligible child and mother required a clear grasp of both demographic size and geographic complexity. The Expanded Programme on Immunization (EPI) was tailored to ensure that services extended to infants, children under five, and women of childbearing age—especially in rural and underserved regions.
Key demographic and healthcare delivery figures:
- Total national population (2000 estimate): 32,860,585
- Target population (0–11 months): 1,260,000
- Target population (0–59 months): 6,572,117
- Children under 15 years: 14,008,843
- Surviving infants: 1,200,000
- Growth rate: 2.8% annually
- Health facilities nationwide: 4,500 (75% government-owned)
- Facilities providing immunization: 3,544
- Outreach-based immunization coverage: 10%
- Population per health facility: 1 per 7,431
- Population per physician: 1 per 23,188
- Urban vs. rural distribution: 85% rural, 15% urban
- Primary target groups: Infants (0–1 year) and women of childbearing age
Despite these logistical hurdles, the program was built to adapt. From mountainous terrain and scattered island communities to urban settlements and agricultural villages, Tanzania’s immunization infrastructure sought to create reliable, year-round access to life-saving vaccines. The EPI’s focus on inclusive coverage underscored its broader mission of health equity, even in the most remote districts.
Main Objectives
The core objectives of Tanzania’s Expanded Programme on Immunization (EPI) for 2000–2004 reflected both the urgent need to control disease and the country’s growing technical capacity. The plan focused on expanding vaccine access, reducing wastage, and eliminating diseases through a mix of routine services and targeted campaigns. These objectives were carefully aligned with global health milestones while remaining grounded in the realities of local health delivery.
Routine Immunization
The EPI aimed to introduce the hepatitis B vaccine into the national infant immunization schedule by 2001. By that same year, it also planned to improve safety by supplying auto-disable (AD) syringes for 100% of BCG, DPT-Hep B, Measles, and Tetanus Toxoid (TT) vaccinations. Another target was to reduce vaccine wastage for DPT-Hep B to no more than 20% by 2004. A key performance milestone was achieving 90% immunization coverage for all antigens among children under one year of age at the district level by 2004, including new additions such as hepatitis B. Lastly, the plan aimed to achieve 90% protection of children at birth from the risk of neonatal tetanus by immunizing their mothers with TT vaccines.
Accelerated Disease Control
Tanzania set a national goal of eradicating polio by 2002. Additionally, it aimed to eliminate neonatal tetanus by 2004, with a target of reducing incidence to fewer than one case per 1,000 live births. The program also committed to investigating and controlling 90% of reported measles outbreaks by the year 2004, reinforcing its response mechanisms for epidemic-prone diseases.
Disease Surveillance
The plan included maintaining a non-polio Acute Flaccid Paralysis (AFP) surveillance rate above 1 per 100,000 children under 15 years of age. It also emphasized the need to integrate enhanced surveillance systems for polio, measles, and neonatal tetanus cases. To ensure the quality of reporting, EPI aimed for 80% completeness and timeliness in the submission of all reports on EPI-targeted diseases.
These goals outlined a comprehensive national commitment, not only to reduce illness and deaths, but to create a system that could respond faster, manage vaccines more efficiently, and ensure equitable access to immunization services.
EPI Strategic Pillars
To achieve its ambitious goals, Tanzania’s Expanded Programme on Immunization (EPI) was built on three strategic pillars: strengthening routine immunization, accelerating disease control, and enhancing disease surveillance. These strategies were supported by training, supervision, logistics planning, and extensive community engagement efforts across all levels of the health system.
Routine Immunization
The program prioritized continuous training and supportive supervision for healthcare workers to reinforce skills, identify gaps, and ensure consistency in service delivery. Advocacy and health education were essential for increasing vaccine uptake, especially in communities with limited access to health facilities. The strategy also included the implementation of a multi-dose policy to minimize vaccine wastage and improve stock management. Outreach services played a critical role, extending coverage beyond static facilities. Additionally, the government coordinated discussions around safe disposal of injection waste, recognizing the importance of environmental and occupational safety in immunization practices.
Accelerated Disease Control
To fast-track disease elimination, Tanzania implemented sub-national immunization days (SNIDs) and large-scale campaigns, particularly for measles and tetanus toxoid (TT) coverage. These campaigns targeted high-risk areas with intensive vaccination activities, monitoring TT coverage among women of childbearing age to ensure newborn protection. Measles campaigns were scheduled to coincide with known risk periods and were reinforced by health education campaigns to boost turnout.
Disease Surveillance
Improving disease surveillance involved targeted training and field supervision for health workers involved in data collection and reporting. The Ministry of Health provided communication tools and transport resources to improve real-time reporting and investigation capacity, especially for hard-to-reach districts. Surveillance activities were also aligned with broader health reforms, ensuring integration with Tanzania’s evolving Health Management Information System (HMIS).
Together, these strategic pillars provided the operational framework for the EPI to function as a nationwide health intervention. By reinforcing infrastructure, expanding outreach, and embedding surveillance, Tanzania aimed to deliver not just vaccines, but long-term resilience in public health delivery.
Monitoring and Evaluation
Monitoring and evaluation were essential components of Tanzania’s immunization strategy between 2000 and 2004. These functions were designed not only to track coverage and vaccine distribution but also to identify implementation challenges early and guide corrective actions. A mix of real-time supervision, annual performance reviews, and integration with national reporting systems formed the backbone of EPI’s accountability framework.
To ensure consistent tracking, the program employed a set of process indicators used to inform both government stakeholders and international partners about the program’s status and progress. Regular supervisory visits were conducted using standardized checklists to assess everything from vaccine stock levels and cold chain functionality to health worker performance and reporting accuracy. This hands-on approach ensured that problems were identified and addressed at the point of care, rather than after the fact.
At the national level, performance was reviewed during annual meetings held specifically for EPI and Maternal and Child Health (MCH) services. These forums brought together regional health management teams to analyze progress, share best practices, and revise implementation strategies based on data-driven insights.
While the Health Management Information System (HMIS) was introduced in 1996 to streamline data collection, the transition from vertical to integrated reporting systems proved challenging, particularly in maintaining timeliness and completeness of reports. Nevertheless, the EPI’s commitment to regular evaluations and field supervision helped sustain momentum and guide improvements across the immunization landscape.
Budget Overview
The financial backbone of Tanzania’s Expanded Programme on Immunization (EPI) was as ambitious as its health goals. From 2000 to 2004, the government and its partners committed substantial resources to support routine immunization, supplemental campaigns, disease surveillance, and the introduction of new vaccines such as hepatitis B. Budget planning was meticulous, with annual breakdowns to ensure transparency, efficiency, and alignment with program milestones.
In 2000, the total EPI budget stood at approximately $23.3 million, with significant investment in supplemental immunization activities and surveillance. As the program expanded, so did the financial commitment—culminating in a $35.9 million allocation in 2004. Cumulatively, the five-year budget reached an estimated $181.9 million, covering vaccines, logistics, outreach operations, and health worker support. Notably, $1.47 million was allocated specifically for the introduction of the hepatitis B vaccine, starting in 2001.
The vaccine cost structure shifted over time. In 2000, vaccine procurement excluded hepatitis B, focusing instead on DPT and others. From 2001 onward, vaccine budgets incorporated the combined DPT-Hep B formulation. Additional expenditures supported targeted tetanus vaccinations for women in high-risk areas and the strengthening of disease surveillance. Despite financial constraints and occasional stockouts, particularly with oral polio vaccines, the program remained largely on track, thanks to strong donor backing and detailed financial planning.
This careful alignment of funding with program needs ensured that financial gaps did not become bottlenecks in immunization delivery. By budgeting across operational areas, from cold chain infrastructure to outreach campaigns, Tanzania’s EPI maintained a clear path toward its coverage and disease control targets.
Health and Socio-Economic Context
Understanding the health and socio-economic realities of Tanzania was crucial for designing an immunization strategy that was both practical and equitable. In 2000, the country faced a complex mix of limited healthcare resources, geographic barriers, and a largely rural population dependent on subsistence agriculture. Despite these challenges, the government committed to delivering life-saving vaccines through both fixed and outreach health services, anchored by community-level leadership.
At the time, the Gross National Product (GNP) per capita stood at just $130, with only $4 spent per capita on health. Approximately 85% of the population lived in rural areas, where access to medical services was limited and infrastructure often underdeveloped. The remaining 15% lived in urban centers, engaging in a wider range of economic activities. Healthcare access was uneven, with a physician-to-population ratio of 1:23,188, and each health facility serving roughly 7,431 people. Despite the country operating over 4,500 health facilities, only 3,544 were equipped to offer immunization services, most of which were static units with limited mobile outreach.
Health indicators reflected these systemic constraints. Life expectancy was 49 years for males and 51 for females, with an infant mortality rate of 100 per 1,000 live births and an under-five mortality rate of 155 per 1,000. The EPI’s target population included children aged 0–59 months and women of childbearing age, with a special focus on surviving infants, estimated at 1.2 million. The strategy also incorporated a high-risk approach for neonatal tetanus, centering on maternal TT vaccination and measles campaigns targeting children aged 9 to 59 months.
By aligning immunization delivery with the broader socio-economic realities of the country, Tanzania’s EPI was able to design an inclusive and responsive strategy—one that aimed not just for high coverage numbers, but for real-world accessibility and impact.
Disease Surveillance
A critical component of Tanzania’s immunization strategy between 2000 and 2004 was the establishment of a robust disease surveillance system. The Expanded Programme on Immunization (EPI) aimed not only to deliver vaccines but also to track, verify, and respond to outbreaks in real time. Surveillance efforts were increasingly integrated with the broader Health Management Information System (HMIS) after 1996, though early challenges with timeliness and data completeness persisted.
To improve the national response system, health workers were trained to identify cases, complete field reports, and collect diagnostic specimens for diseases like polio, measles, and neonatal tetanus (NNT). Supervision and logistics support—such as transport for outreach and communication tools—were emphasized at district and regional levels. Annual program performance meetings provided a space for health teams to compare trends, share lessons, and adjust strategies based on reported data.
Measles Morbidity Trends (1980–1999)
While the early years of EPI significantly reduced measles cases, data showed a worrying resurgence during the mid-1990s. This table captures the year-over-year changes in reported measles cases:
Table A: Measles Morbidity Trends
| Year | Measles Cases |
|---|---|
| 1980 | 63,100 |
| 1985 | 46,032 |
| 1990 | 14,920 |
| 1991 | 27,188 |
| 1992 | 13,040 |
| 1993 | 16,471 |
| 1994 | 3,558 |
| 1995 | 13,040 |
| 1996 | 10,698 |
| 1997 | 7,287 |
| 1998 | 10,023 |
| 1999 | 5,887 |
This fluctuation revealed gaps in coverage and underscored the need for follow-up measles campaigns and improved routine immunization.
Routine Vaccine Coverage (1991–1999)
Tanzania maintained strong vaccine coverage in the early 1990s, but saw a decline starting in 1995. The table below shows national coverage levels for BCG, DPT3, and OPV3:
| Year | BCG (%) | DPT3 (%) | OPV3 (%) |
|---|---|---|---|
| 1991 | 93 | 76 | 70 |
| 1992 | 99 | 83 | 80 |
| 1993 | 94 | 83 | 83 |
| 1994 | 92 | 84 | 84 |
| 1995 | 88 | 81 | 79 |
| 1996 | 80 | 72 | 73 |
| 1997 | 82 | 79 | 79 |
| 1998 | 83 | 74 | 75 |
| 1999 | 87 | 76 | 74 |
The decline in DPT and OPV coverage from 1995 to 1999 signaled issues in routine immunization performance, which likely contributed to the spike in measles cases during the same period.
Measles & TT2+ Coverage (1991–1999)
This table focuses specifically on measles vaccine coverage and tetanus toxoid (TT2+) coverage among women of childbearing age:
| Year | Measles (%) | TT2+ (%) |
|---|---|---|
| 1991 | 75 | 19 |
| 1992 | 81 | 22 |
| 1993 | 81 | 24 |
| 1994 | 79 | 27 |
| 1995 | 76 | 30 |
| 1996 | 70 | 31 |
| 1997 | 73 | 32 |
| 1998 | 72 | N/A |
| 1999 | 72 | 77* |
Note: The 1999 TT2+ coverage refers specifically to pregnant women.
Polio National Immunization Days (1996–1999)
In response to polio eradication goals, Tanzania organized annual National Immunization Days (NIDs) with consistently high turnout:
| Year | 1st Round (%) | 2nd Round (%) |
|---|---|---|
| 1996 | 98 | 102 |
| 1997 | 95 | 98 |
| 1998 | 97 | 100 |
| 1999 | 99 | 99 |
With all campaigns exceeding 90% national coverage, these NIDs were instrumental in pushing Tanzania closer to its 2002 target for polio eradication.
Injection Safety and Cold Chain Infrastructure
Delivering vaccines safely and effectively requires more than just vials and needles—it demands a reliable infrastructure that ensures vaccine potency and injection safety from central warehouses down to the most remote clinics. Tanzania’s Expanded Programme on Immunization (EPI) invested heavily in cold chain systems and promoted safe injection practices as essential pillars of its immunization strategy from 2000 to 2004.
Injection Safety
The national policy mandated the use of auto-disable (AD) syringes for mass campaigns and sterilized syringes for routine immunization. To support this, each health facility received two “Kit B” supplies per year, containing syringes and waste disposal tools. Efforts to reduce injection-related risks were complemented by advocacy for proper waste management, including safe disposal of used materials, especially in outreach and campaign settings.
While the policy infrastructure was in place, actual implementation faced challenges. The Adverse Events Following Immunization (AEFI) monitoring system, introduced in 1994, remained weak by 2004. Although guidelines were reviewed and training was rolled out across districts, the number of actual AEFI reports remained limited, pointing to gaps in both reporting practices and community awareness.
Cold Chain Infrastructure
Tanzania’s cold chain system was structured across four tiers, from a central vaccine store in Dar es Salaam to district-level units and static health facilities. At the top, the Central Vaccine Store, managed by the Medical Stores Department (MSD), featured walk-in coolers and freezers with generator backup. Vaccines were distributed through:
- 1 Zonal Store (equipped with compression-based refrigeration),
- 15 Regional Stores (using compression and ice-pack freezers), and
- 116 District Stores (with kerosene/electric absorption refrigerators and compression freezers).
At the grassroots level, 3,544 health facilities conducting immunization services were equipped with small-scale fridges powered by kerosene, electricity, LP gas, or solar energy. Solar fridges were particularly important in off-grid areas. However, maintaining this equipment was an ongoing concern, as many units were aging and public health budgets were limited.
Complicating matters further, Tanzania was under international obligation to phase out CFC-based refrigerators by 2005 under the Montreal Protocol. Transitioning to CFC-free equipment required not only new procurement but also specialized training for cold chain technicians. Plans were underway to equip central and regional repair teams with updated toolkits and spare parts to support this shift.
Donor Support and Vaccine Procurement
The success of Tanzania’s immunization program between 2000 and 2004 was deeply intertwined with strong, long-term partnerships from global donors. These collaborations supported everything from vaccine procurement and cold chain expansion to disease surveillance and social mobilization. While the Ministry of Health provided strategic leadership, donor agencies brought in essential funding, technical expertise, and operational resources.
Key Donor Contributions
Two of the most consistent and foundational partners were DANIDA (Danish International Development Agency) and UNICEF. DANIDA supported logistics, supervision, training, and the procurement of vaccines like DPT and BCG, while UNICEF focused on measles and tetanus toxoid (TT) vaccines, as well as cold chain equipment, sterilization kits, and public awareness activities.
Additional partners included:
- JICA (Japan International Cooperation Agency): Supported cold chain expansion and procured vaccines such as OPV.
- USAID: Focused on disease surveillance system strengthening.
- Rotary International: Played a major role in oral polio vaccine procurement and community outreach, especially in the earlier years.
- Irish Aid: Contributed solar refrigerators and vaccine support, especially during periods of emergency shortage.
- DFID (UK): Supported surveillance and National Immunization Days (NIDs).
- WHO: Provided technical guidance and policy support.
While each donor contributed based on its mandate, coordination among them allowed Tanzania to create a fairly stable immunization supply system even in the face of financial uncertainty.
Vaccine Procurement and Stockouts
Vaccine forecasting was conducted annually by the EPI using demographic data and target coverage rates. Procurement responsibilities were donor-specific: DANIDA handled BCG and DPT, while UNICEF handled TT and measles vaccines. OPV procurement rotated among partners, including Rotary, Irish Aid, and later, KfW (Germany).
Despite these coordinated efforts, Tanzania experienced a national OPV stockout from June to December 1999, caused by delays in funding and a broader global shortage. Emergency OPV procurement was managed by UNICEF that year to keep campaigns on track.
The procurement cycle followed a formal chain: districts submitted their vaccine needs to the regions, which forwarded consolidated requests to the EPI headquarters. Once verified, orders were processed by the Medical Stores Department (MSD), which distributed supplies to regional and district stores. From there, Regional and District Health Management Teams (RHMTs/DHMTs) delivered vaccines to local health facilities.
This tiered system, while bureaucratic, provided a level of accountability and allowed the government to monitor supply gaps, distribution timelines, and usage rates. Through the support of its donor network and detailed planning mechanisms, Tanzania was able to maintain consistent immunization delivery across most of its national territory.
Program Management
Tanzania’s Expanded Programme on Immunization (EPI) operated under the Reproductive and Child Health Unit within the Ministry of Health’s Directorate of Preventive Services. At the national level, the program was managed by a dedicated team led by an EPI Manager, supported by officers responsible for disease surveillance, cold chain logistics, monitoring and evaluation, data management, and training. This structure enabled the central office to coordinate planning, resource distribution, technical guidance, and performance tracking across the country.
The national team worked closely with Regional and District Health Management Teams (RHMTs and DHMTs), who were responsible for implementing immunization services on the ground. They ensured proper vaccine storage, staff training, supervision visits, and integration of EPI data into health management systems. Vehicles, motorcycles, and cold chain technicians were deployed to support field operations—though outdated equipment and transportation gaps often strained daily coordination.
Despite these challenges, the program maintained routine supervision and used standardized checklists to monitor service delivery. Annual reviews brought together health leaders from across regions to analyze performance and update strategies. By combining structured oversight with decentralized execution, Tanzania’s EPI created a system capable of responding to public health needs while staying aligned with national priorities.
Reaching Every Child, Strengthening Every System\
Tanzania’s Expanded Programme on Immunization (2000–2004) demonstrated how a well-coordinated national strategy could drive meaningful improvements in public health. By aligning routine immunization, disease surveillance, cold chain logistics, and community mobilization under a unified framework, the country made significant strides toward reducing childhood illness and vaccine-preventable deaths—even in the face of financial and logistical hurdles.
The program’s success was built on strong partnerships, detailed planning, and a commitment to reaching every child and mother, regardless of location. With consistent support from donors and active engagement from local communities, Tanzania created an immunization model that balanced technical execution with grassroots connection—offering valuable insights for other countries working toward similar goals.