Zambia's COVID-19 vaccine rollout: a conversation with the head of the national immunisation programme

AMP Health has partnered with the national Expanded Programme on Immunisation (EPI) team in the Zambia Ministry of Health since 2018. We recently supported the team with a three-day planning workshop to help the team develop the Zambian COVID-19 vaccine rollout strategy. We spoke to Dr Francis Dien Mwansa, Zambia’s National EPI Manager, to find out more about the work his team is doing.

Dr Francis Dien Mwansa, National EPI Manager, Zambia

I wanted to start with you telling us about who you are and what you do.

I am Francis Dien Mwansa, national EPI manager at the Ministry of Health in Zambia. I am based in the Child Health unit.

You are running the national immunisation program in Zambia. Tell us a bit about that.

Immunisation programmes are different than a lot of other health programmes. First, the goals of an immunisation programme are constantly changing. Here is what I mean: If I was running the volunteer male circumcision program, the goal is clear – every year we have a target for the number of men circumcised. There’s nothing else.

But in the immunisation programme, every year, there is talk of a new vaccine to be added. And for existing vaccines, targets are changing. That makes the work interesting, but challenging.

Another challenge is patient demand. TB patients, for example, know that they need treatment. They don’t need the Ministry of Health to tell them. So when you tell them that a treatment is available, they queue up for it. In the immunisation space, we often run programmes where people don’t know that they are at risk. An example is HPV. I doubt that people in our community knew of the vaccine before we introduced it. So, we introduce a vaccine, and we have to tell people what it is and how good it is. And these are not sick people that we are telling.

What is your team’s role in Zambia, when it comes to the COVID-19 response?

At the outset of the pandemic, immunisation was not part of Zambia’s response strategy. I think many people did not foresee a vaccine being available this fast. The initial focus was on testing, tracing, surveillance, and treatment. So we came on board quite late.

We learned some difficult lessons in this country from the 2015 cholera outbreak and the 2016 yellow fever outbreak, when separate teams were set up to handle the mass vaccination efforts. We realised how important an integrated approach is and that the national EPI team must be involved in everything to do with immunisation. This means my whole team is part of this: we are doing the planning and coordination, and we’ll do the implementation of the activity. That is our role.

Can you tell me a little bit about some of the challenges that you are facing as a team when it comes to introducing the COVID-19 vaccine?

There are challenges in just about every area of operations. We are dealing with a much broader group of people than children under the age of five, which is the main group that our existing infrastructure is set up to reach. We are looking now at immunising every adult in the country – that is 46% of the population. The highest target we have had previously is 20%.

Then there is the training of health workers. We will not get this vaccine in bulk all at once, so how do we prepare the people who will be doing the vaccination? We have to take a phased approach to training these health workers so that we don’t arrange people in March, for instance, who will only be useful in December.

At the same time we have to make sure we keep up routine service provision so that we don’t fall behind on other key vaccination programmes. With diseases like measles, the moment you have a drop in vaccine coverage, you have problems.

Monitoring people that have been immunised will also be a new challenge – the way we monitor programmes for children under-five won’t suffice.

And then there is advocacy, communication, and social mobilization. This will be the biggest problem. I know because already I have heard reports from the field of people running away from health workers, because there is rumour that our health workers are transporting the COVID-19 vaccine. So we are already seeing evidence of vaccine hesitancy before the programme even starts.

The fact that it’s a vaccine for adults makes this more complex. For children it’s a bit easier, because you tell the parent “I’m giving you Pentavalent, because it prevents some of the diseases that can cause pneumonia, and it will keep your child healthy.” And because it’s not them receiving the injection, they easily say “Yes, I want my child to be well”.

Now, when you approach the same parent and say “I’ve got an injection for you”, you have to do a lot of talking to them to convince them.

Of course, each of these areas require money and not small amounts of money. The vaccine procurement cost alone requires something north of $135 million.

Can you tell me a bit about your team’s work with AMP Health?

We’ve had the pleasure of working with a Management Partner. I think this has really accelerated the progress of our team. Without this support, it would have required much more time for us to get to the point where we are today – and we don’t have that time during COVID-19! The way we’ve approached planning, both for our routine service provision and for the COVID-19 vaccine, has been strengthened by the support of the Management Partner.

We now have better systems in place, and I think we are now in a position where even if all of us were to leave and a new team comes in, they just have to sit with somebody for an hour to get oriented to the plan and everything is in good shape.

AMP Health recently worked with the team to support your planning for the COVID-19 vaccine rollout strategy. Can you tell me about that?

I think that the exchange we had over the course of a three-day workshop really highlighted some of the challenges that we have as a team, particularly with regard to planning and communication. There are some things that we have started doing as a team, and it was gratifying to understand that the AMP Health team saw these as a step in the right direction. The workshop allowed us to build on what we had started and what we had learned. It has helped and now the hope is that we don’t revert to our old ways in the future.

The session also helped us to think about how to be more deliberate about being a team that looks for opportunities to improve and learn. That instead of just moving from Activity A, to Activity B, to Activity C, we look for opportunities to say “before we go to Activity C, what did we learn from Activity A and B that we can apply?”.

This interview has been edited for clarity and brevity