Manyara Region - Until recently, Tanzania was among a few African countries that have fully vaccinated less than 10% of their eligible target population. As of June 2022, Tanzania had fully vaccinated only 8% of the target population above 18 years, although COVID-19 vaccination was introduced in July 2021. Yet, several independent studies, including Anjorin et (2021) and Institute of Public Health, Kilimanjaro Christian Medical University College (2022), show that more than two-thirds of Tanzanians are willing or have the intention of getting vaccinated. Hence, closing the intension-action gap is a priority of the country. With the technical support of WHO and partners, Tanzania, therefore, set out to vaccinate at least 40% of its target population across all regions during an intensified campaign, which took place in June 2022. In addition to supporting all regions for improved vaccination campaigns, WHO focused on Manyara for apparent reasons, including that the Manyara region was consistently the least performing region since the beginning of the COVID-19 response in Tanzania. Across the regions, full vaccination coverages varied from 3.7% in Manyara to 39% in Ruvuma. With 3.7% full vaccination coverage, the Manyara region was the worst performing of the 31 regions of Tanzania. WHO's strategic leadership, technical guidance, and financial support enabled the Manyara region to triple its coverage since the beginning of COVID-19 vaccination in the country. Significant highlights of WHO's technical support include:

Advocacy for Political Leadership

Setting effective political leadership in the health care context enhances outcomes. To position the Manyara region's management in the region's driver's seat for COVID-19 response, WHO led high-level result-oriented advocacy to the region's management. Prior to the advocacy meeting, the team conducted a quick search on the region's performance in other areas of healthcare services and the reputation/integrity of the leadership under the Regional Commissioner. At the regional advocacy meeting presided by the Regional Commissioner were all seven district commissioners, the Regional Administrative Secretary, heads of security agencies and directors and members of the Regional Health Management Team (RHMT). Bulletized PowerPoint presentation enhanced focused discussion. Two critical strings were pulled in the power-point presentation to ensure a personal touch on the region's leadership. One, highlighting Manyara as the worst performing region among 31 regions of Tanzania was challenging and embarrassing to the region's management. "I simply cannot believe that Manyara is the worst performing region in the whole of Tanzania," exclaimed the Regional Commissioner, Charles Makogoro Nyerere. The second string, which was even stronger, was a link between the performance of the Mayara region vis-à-viz the standard of socio-economic development of Tanzania established by the father of the nation and sustained by the later leaders, including in health, education, agriculture, and rural development, which has not been upheld in Manyara as far as COVID-19 response was concerned. Thirdly, a specific appeal was made requesting the Regional Commissioner to lead an advocacy delegation to the five districts and two councils of Manyara. The outcome of the regional advocacy, which challenged the region's leadership and the regional commissioner's personal ego, was the conduct of seven district/council level advocacy engagements led by the Regional Commissioner. The district/council level advocacies witnessed the participation of district commissioners, district/council directors, honorable councilors, and community and political leaders. Again, at the district/council levels, specific performance evaluation presentations were made. Critical discussions on improving COVID-19 vaccination coverage were held, with tangible commitments extracted from all the stakeholders. "Now that you people have come to us for help, you will see that we represent and have the interest of our people at heart," says District Executive Officer, Simanjiro District Council.

Making COVID-19 vaccine available and accessible

Although COVID-19 vaccines are free and accessible, complacency, convenience and confidence remain significant determinants of uptake of COVID-19 vaccination, yet only 7.8% were vaccinated as of 26 June 2022. Therefore, WHO provided the urgently needed technical expertise to make the vaccines available and accessible to the target beneficiaries through the strategic delivery of COVID-19 vaccines from house to house, at events and through mobile outreach. The Regional Medical Officer led the initiative to increase vaccination coverage by inviting stakeholders to jointly develop a plan that defines the strategies to vaccinate all eligible beneficiaries. Collectively, local vaccination targets were set at all levels.

Branding Manyara campaign: Uviko bado ipo! Pata chanjo.

Given the socioecological context of the COVID-19 response in Tanzania, which was hitherto not favorable, branding a renewed approach was imperative. There was a need to reactivate a positive impression, establish an emotional connection and give the campaign identity. Mwalimu Mkanda, a 58-year-old farmer in Simanjero, typified the belief among millions who had concluded that the COVID-19 pandemic was over, needless getting a jab anymore. "Although I had wanted to get vaccinated before I made up my mind to visit any of the health facilities, the earlier hype about the disease waned off; so I thought that the pandemic was already over," says Mwalimu Mkanda, a 58-year-old farmer in Simanjero, Manyara region. Thanks for bringing the vaccine closer to us. My family members above 18 years and I are protected from COVID-19 as we have all been vaccinated," says Mwalimu.

 So, Uviko bado ipo. Pata chanjo, as a campaign slogan, was adopted and locally publicized during advocacy meetings, town hall meetings, compound meetings and sensitization activities in schools, prisons, marketplaces, religious gatherings, etc., both in local and Kiswahili languages.

Technical leadership

To deliver on its core mandate and performance standards, including technical assistance appropriate to the health needs of the people affected, WHO provided solid technical leadership to the region. It adapted and localized Standard Operating Procedures for the COVID-19 vaccination campaign and coordinated pre-campaign planning during and post-campaign activities. In collaboration with the RHMT, WHO led the process of microplanning, developed the curriculum for the training of health workers and community champions, developed standard data collection tools, vaccine distribution plan and management, and supportive supervisory plans to guide the campaign. WHO deployed public health experts in all areas, including technical coordination, risk communication and community engagement, finance and administration, data management, monitoring and evaluation to provide technical direction for a result-oriented campaign.             

Results-based supportive supervision and monitoring

WHO supported the region in developing a supportive supervisory plan to ensure close monitoring of the processes before, during and post-campaign review meetings, data capturing, and analysis and documentation of lessons learnt. Each member of the Regional Health Management Team (RHMT) was assigned two councils to supervise, mentor, and ensure timely daily reporting about the number of people vaccinated. The Council Health Management Team (CHMT) headed and mentored health facilities to ensure timely daily reporting on the number of people vaccinated. The DIVO compiled data and shared daily updates. Resources were mobilized to facilitate mobile outreach services since there was evidence that it was more effective than fixed facilities. Data transmission was smooth as data was captured on google sheets at health facility levels and transferred electronically to the regional level the same day during the campaign. With that, it was possible to monitor daily performance at the ward and district levels. Daily monitoring showed which health facilities or wards performed below expectations and needed extra support. Overall, rapid daily programmatic decisions were taken based on monitoring data from the field.  

Partners' Coordination

Partners' coordination enhances WHO's ability to engage all health sector actors critical for achieving COVID-19 response targets in Tanzania. For effective resource utilization, WHO initiated partner mapping to avoid fragmentation and duplication of efforts. Two partners, Johns Hopkins Program for International Education in Gynecology and Obstetrics, now referred to simply as Jhpiego and Clinton Health Access Initiative (CHAI) were coordinated in the Manyara region to ensure harmonization and alignment of programmes toward achieving the set goal. As a result, WHO facilitated technical and financial support for the implementation of the campaign for four days (27 -30 June 2022), while Jhpiego, under WHO's technical assistance, funded the extension of the Manyara campaign from 01-05 July 2022. CHAI leveraged WHO's technical leadership in Babati District council to ensure that the committee meets its target. At the end of the 9-day campaign, Manyara, which hitherto was the worst performing among 31 regions in Tanzania, rose from 3.7% to 20% in just days.  

Conclusion

Tanzanians are willing to get vaccinated, as evidenced in several studies and typified in the Manyara experience, but it requires political, community and religious leadership by example. As a hierarchical society, the average Tanzanian's COVID-19 related behavior is determined by the inter-action of his socioecological environment, which encompasses intrapersonal, interpersonal, community, institution, and policy levels. Therefore, a system thinking approach is imperative to explore the variables that affect COVID-19 uptake in Tanzania. System thinking, which is the process of understanding how things influence one another within a whole, argues that it is difficult to isolate an individual from the environment in which he operates. It is impossible to understand the determinants of COVID-19 uptake among Tanzanians without considering the inter-paly of variables of the socioecological environment. Indeed, social work theories insist that we do this for effective interventions.