A decade of progress and challenges in government support for routine immunization in East and Southern Africa (2015-2024)

¹WHO Intercountry Support Team office for East and Southern Africa, Harare, Zimbabwe

^&Corresponding author
Daudi Manyanga, WHO Intercountry Support Team office for East and Southern Africa, Harare, Zimbabwe

Introduction    

The Expanded Programme on Immunization (EPI) was officially launched by the World Health Organization (WHO) following the adoption of World Health Assembly Resolution (WHA) WHA27.57 on May 23, 1974. This initiative aimed to provide immunization for all children worldwide by 1990, as detailed in Resolution WHA31.53, which was adopted in May 1978, and further emphasized in the Declaration of Alma-Ata in September 1978 [1]. The EPI was designed to build on the success of the global smallpox eradication campaign, which was led by the WHO from 1967. It sought to address the challenges reported in countries like India and Ethiopia [2,3]. In Ethiopia, the eradication of smallpox faced significant challenges due to rugged terrain, limited infrastructure, and political instability. Health workers had to reach remote communities with minimal resources. In India, the campaign encountered obstacles related to a large, mobile population, vaccine hesitancy, and underreporting of cases. These issues were addressed through intensive surveillance and containment strategies. The current immunization challenges in some East and Southern Africa (ESA) countries are not much different from these historical issues. The WHA resolutions aimed to ensure that all children, regardless of their location, received life-saving vaccines. At that time, it was estimated that only 5% of children were vaccinated, and nearly two-thirds of the global population lived in developing countries [4,5]. The EPI programme represented a significant shift in global public health, as it sought to establish routine immunization services in all countries, especially those with limited healthcare infrastructure.

At its inception, the EPI focused on preventing six major childhood diseases through vaccination: tuberculosis (via BCG), diphtheria, tetanus, pertussis (via DTP), poliomyelitis (via OPV), and measles (via MCV) [6,7]. These vaccines were selected based on the high burden of disease they represented and the availability of safe, effective, and affordable options. The inclusion of tetanus toxoid (TT) also aimed to prevent maternal and neonatal tetanus, a significant cause of infant mortality in many low-resource settings. The programme emphasized not only vaccine delivery but also the development of cold chain systems, the training of health workers, and community mobilization to enhance vaccination coverage. In the ESA sub-region, most countries began implementing the EPI by 1975, quickly integrating it into their national health strategies. Initially, the program faced challenges such as limited infrastructure, and immunization coverage was estimated to be less than 5% in many developing countries. However, with international support from organizations including WHO, UNICEF and other partners, the program gained momentum [8-10]. Over the decades, EPI has expanded to include additional vaccines and target age groups. Nevertheless, its fundamental role in reducing childhood morbidity and mortality continues to be a cornerstone of public health in the region.

Following the launch of the Child Survival and Development Revolution, immunization coverage in low- and middle-income countries increased significantly, rising from approximately 20% in 1982 to nearly 76% by 1990. This progress was largely driven by funding and operational support from international organizations, particularly the WHO and UNICEF, along with contributions from donor countries [11-13]. At that time, many low-income countries lacked the infrastructure and resources necessary to implement immunization programs independently, making external assistance essential. UNICEF played a critical role in the early years by financing vaccine procurement, training health workers, and establishing cold chain systems to preserve vaccine potency. Additionally, WHO provided technical expertise, standardized immunization schedules, and surveillance frameworks. Together, these agencies coordinated resource mobilization from bilateral donors and philanthropic organizations. The financing model primarily relied on project-based funding, which faced challenges related to funding predictability and equitable access to life-saving vaccines, particularly in the ESA countries [14-16].

In response to these challenges, the WHA adopted key resolutions encouraging countries to take on greater financial responsibility for their national immunization programs. Notably, WHA39.30 (1986) urged Member States to commit to achieving universal childhood immunization and to allocate domestic resources to support EPI activities [14]. This marked a strategic shift from donor dependency to national ownership, urging governments to integrate immunization into their national health budgets and planning frameworks. The resolutions also emphasized the development of national immunization plans and the strengthening of health systems to ensure sustainable vaccine delivery [17]. This focus on domestic financing laid the groundwork for long-term sustainability, allowing countries in the ESA subregion to begin institutionalizing immunization as a core public health service.

In the ESA sub-region, several countries such as South Africa, Madagascar, Namibia, and Rwanda have increasingly prioritized domestic financing as a crucial element for sustaining their immunization programs [18,19]. However, many ESA countries still rely heavily on donor support from organizations like Gavi, WHO, GPEI and UNICEF to mention few [20,21]. As immunization programs have matured and health systems have strengthened, governments are beginning to recognize the importance of allocating national resources to ensure consistent vaccine delivery and the resilience of these programs, particularly during donor transitions or times of global funding uncertainty. Government contributions, both financial and policy-driven, have significantly impacted vaccine procurement, delivery infrastructure, and coverage rates. Countries like Rwanda and South Africa have shown strong political commitment by integrating immunization into national health strategies and budgeting processes [22]. This commitment has facilitated timely vaccine procurement, the expansion of cold chain systems, and improved training for health workers. Supportive policy frameworks have also enabled the introduction of new vaccines and the scaling up of outreach services, particularly in hard-to-reach areas like rural Madagascar and the islands of Comoros and Seychelles. Today, the EPI programs in the region have evolved to adopt a life-course approach, extending beyond just childhood immunization. With the increasing availability of new and underused vaccines, prioritizing antigens and ensuring financial sustainability remain critical to achieving equitable access and long-term impact.

As several countries in the ESA sub-region approach or undergo the polio and Gavi transitions, there has been an increased emphasis on national ownership of immunization programs. Transition planning has encouraged governments to gradually raise their co-financing contributions and enhance their capacity to manage immunization services. However, in many ESA countries, there remains a critical gap in documenting government contributions, which is essential for understanding and sustaining the immunization ecosystem. Since its inception by the WHO in 1974, the EPI has significantly transformed global public health, especially in the ESA subregion. This publication traces the evolution of the EPI from providing six basic childhood vaccines to becoming a vital component of national health systems. It highlights key milestones, such as the shift from reliance on donor funding to domestic financing and underscores the importance of national ownership and strategic planning particularly as countries begin to transition away from GPEI and other partnership supports.

The article presents practical lessons from countries like Kenya, Rwanda, and South Africa to guide policymakers and public health professionals. It also examines important policy shifts that occurred during the 1980s, particularly the WHA resolution WHA39.30, which urged governments to assume financial responsibility for immunization programs. By exploring both the technical and financial evolution of the EPI, the article emphasizes the increasing importance of domestic commitment to sustain immunization initiatives throughout the region. Our study is based on a conceptual framework that examines the interconnected relationship between donor transitions, national ownership, budget transparency, and the sustainability of routine immunization programs in the ESA subregion, as observed in Europe and Asia [23]. As countries in this subregion experience a gradual reduction in external funding, the framework suggests that a successful transition to nationally led immunization systems depends on three key pillars: increased domestic financing for immunization, transparent and accountable budgeting processes, and strategic program planning and monitoring [24].

Donor transitions often act as a catalyst for national ownership, encouraging governments to assume greater responsibility for financing and delivering immunization services. However, without strong mechanisms for budget transparency such as dedicated budget lines and public expenditure tracking national ownership may remain superficial [25,26]. Additionally, the sustainability of programs depends not only on financial inputs but also on the capacity to plan, implement, and effectively monitor immunization services. In the context of ESA, where health systems vary significantly in maturity and resilience, this framework helps explain the inconsistent progress in immunization coverage and surveillance performance across countries. By utilizing this framework, the study aims to analyse how changes in funding dynamics influence national policy responses and the long-term viability of immunization programs. It also offers a lens for interpreting data from the electronic Joint Reporting Form (eJRF), national health budgets, and immunization performance indicators providing insights into the structural and strategic factors that support sustainable immunization systems.

Methods     

Study design: we conducted a descriptive mixed-method secondary analysis that combined qualitative and quantitative approaches. This study utilized data compiled through the electronic WHO-UNICEF Joint Reporting Form (eJRF) to assess government support for routine immunization in the ESA subregion. Rather than collecting new primary data, we systematically reviewed existing financial datasets and indicators reported by the countries involved. Our analysis covered 20 countries: Botswana, Comoros, Eritrea, Eswatini, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Rwanda, Seychelles, South Africa, South Sudan, Tanzania, Uganda, Zambia, and Zimbabwe. The quantitative component focused on identifying statistical trends, assessing the completeness of reporting, and detecting discrepancies in the submitted records. Meanwhile, the qualitative analysis explored the contextual and systemic factors that influence the quality and completeness of financial and expenditure data, reflecting the broader environment in which immunization information is generated and shared. By combining these methods, the study aimed to provide a comprehensive evaluation of immunization financing trends across the ESA subregion. We selected a 10-year period from 2015 to 2024 for our analysis, as earlier data contained significant gaps and were considered more historical than useful for future decision-making. We analysed the quantitative data using Microsoft Excel to identify trends, evaluate reporting completeness, assess government contribution trends, and highlight inconsistencies. The qualitative component examined the factors affecting information sharing, contributing to a deeper understanding of government contributions to immunization programs across the ESA subregion.

Variables: the variables used in this study were obtained from the electronic WHO-UNICEF Joint Reporting Form (eJRF) and focused on essential financial indicators related to routine immunization. These indicators included: the percentage of total expenditure on routine immunization financed by government funds, the total spending in routine immunization from all sources, including vaccines, the government expenditure specifically allocated for vaccines used in routine immunization, the percentage of total vaccine expenditure financed by government funds, overall government expenditure on routine immunization, including vaccines, and the presence of dedicated line items in national budgets for vaccine procurement. Additionally, the study analysed total expenditure on vaccines from all sources. These variables provided a comprehensive overview of the financial landscape of immunization programs across the ESA subregion.

Data source: we gathered financial data related to the EPI from the 20 ESA countries, covering the years 2015 to 2024, through the electronic WHO-UNICEF Joint Reporting Form (eJRF). This data is publicly accessible and is routinely checked and verified by the WHO and UNICEF secretariats for the eJRF reports. It is worth noting that while the EPI was established in some countries earlier such as in South Africa before 1975, and in others by 1990, relevant financial information for our study was only available from 1997 for one country. Most countries did not report the necessary variables until 2015. Therefore, we used secondary data from 2015 onwards, which we retrieved from the WHO-UNICEF Joint Reporting Form repository. No primary data was collected or gathered, and any information from outside the study period or from other sources was excluded from the analysis.

Results     

Progress in government financing and reporting for immunization

We observed that reporting of WHO-UNICEF eJRF immunization financing indicators has generally improved over time across the ESA subregion, with some indicators showing progress, others stagnating, and one showing a decline (Table 1). For instance, the proportion of ESA countries reporting on the presence or absence of dedicated line items in national government budgets for the purchase of vaccines used in routine immunization ranged from 90% to 95% during the study period (2015-2024), with the lowest at 90% in 2021 and reaching 100% in 2024. The proportion of countries reporting the percentage of total expenditure on routine immunization financed by government funds increased from 65% in 2021 to 75% in 2024, although it was higher at 85% in 2015. Reporting on government expenditure on vaccines used in routine immunization remained stable at 85% in both 2015 and 2024, peaking at 95% in 2016, 2017, 2019, and 2023. However, a decline was noted in the proportion of ESA countries reporting total expenditure (from all sources) on vaccines used in routine immunization, dropping from 95% in 2016 to 70% in 2024. On a positive note, the proportion of countries with dedicated line items in national government budgets for vaccine procurement improved from 75% in 2015 to 90% in 2024, reflecting increased attention to domestic financing mechanisms.

Trends and disparities in routine immunization expenditures

We observed that the total reported expenditure on routine immunization, including vaccines, in ESA countries increased significantly over the study period. In 2015 and 2017, it accounted for only 1.79 billion USD of the overall reported 1,148.8 billion USD, rising to 246 billion USD in 2021 and settling at 142 billion USD in 2024 (Table 2). Among the countries, Uganda and Tanzania reported the highest contributions, accounting for 49.4% and 39.5% of the subregional total, respectively. In contrast, Comoros (0.0002%) and Lesotho (0.0022%) reported the lowest expenditures. Madagascar contributed 6.9%, while South Africa reported 1.5%. Before 2019, higher expenditures were consistently reported by Rwanda, Kenya, South Africa, and Ethiopia. Challenges in fund disbursement and comprehensive data reporting.

Regarding the reported percentage of routine immunization expenditure financed by government funds in ESA countries during the study period, the highest value was recorded in 2024 at 58.1%, while the lowest was in 2016 at 41.5%. Government contributions to routine immunization in the ESA subregion increased to 55.8% in 2022 but declined to 46.4% in 2023 (Table 3). This drop may reflect shifts in fiscal priorities, reporting inconsistencies, or changes in donor dynamics, though the exact causes are unclear. This decline raises concerns that warrant further investigation, particularly regarding post-pandemic recovery and health financing. In terms of country averages, South Africa reported full government financing at 100%, followed closely by Mauritius (99.8%), Namibia (96.8%), Botswana (95.7%), Eswatini (91.6%), and Seychelles (87.5%). On the other hand, countries with the lowest average government financing during the study period include South Sudan (7.2%), Eritrea (14%), and Mozambique (15.6%), possibly indicating continued reliance on external funding sources.

We noted that the reported government expenditure on vaccines used in routine immunization in ESA countries was estimated at 276.67 billion USD over the study period (Table 4). Government spending on routine immunization increased from 0.16% of the total in 2015 and 2017 to 21.42% in 2021, with a slight decline to 12.41% in 2024. Among the countries, Tanzania (42.67%) and Uganda (40.5%) contributed the highest shares of total government expenditure in the subregion, while Comoros and South Sudan reported the lowest (0.0002%). In Tanzania, major government investments were observed between 2021 and 2024, ranging from 16% in 2023 to 31% in 2024. Uganda showed a steady increase starting in 2018 (18%), reaching 27% in 2023. Notably, Madagascar reported a peak investment of 100% in 2022, indicating strong national commitment during that year.

Qualitative insights and strategic recommendations for sustainable financing

In our study, we conducted a qualitative analysis that included a thematic review of the contexts of different countries and the challenges in reporting. This review was based on patterns identified in the WHO-UNICEF eJRF and was cross-referenced with insights from peer-reviewed literature and regional policy reports. The WHO-UNICEF eJRF, co-managed by WHO and UNICEF, serves as a standardized platform for monitoring the performance of immunization systems across Member States. It includes key indicators related to financing, coverage, and program sustainability. The WHO-UNICEF eJRF systematically captures annual data on government health expenditures, budget allocations for immunization, and external donor contributions. This provides essential evidence for assessing the financial sustainability of national immunization programs, a gap that continues to exist in the African Region [27]. We also noted that data for self-financing or non-Gavi priority countries were either underestimated or unavailable, as funds were often disbursed at subnational levels, managed by a different directorate from the one EPI is laid in the Ministry of Health. In some cases, the procurement of vaccines and related supplies was not conducted annually for all EPI antigens, depending on the target population and the shelf life of the vaccines.

We observed that, in the ESA subregion, government contributions to routine immunization have made uneven progress. While some countries have increased overall health spending on an annual basis, specific allocations for immunization often remain stagnant or have decreased [28]. This longstanding underinvestment poses a significant risk to health security, especially into the ESA subregion that experiences frequent outbreaks of vaccine-preventable diseases and has a growing population of zero-dose children those who have not received any routine vaccinations. The WHO African Region directly links disparities in domestic financing to inconsistent immunization coverage and weakened surveillance systems, particularly in fragile and low-resource settings such as South Sudan, Madagascar, and parts of Ethiopia to mention few [29]. These findings highlight the urgent need for targeted policy interventions that prioritize sustained domestic investment, enhance budget transparency and tracking, and promote strategic long-term planning. Strengthening national ownership and reducing dependency on external funding are essential for achieving equitable and sustainable access to vaccines across the ESA subregion.

Discussion     

Across the East and Southern Africa (ESA) subregion, countries have made commendable progress in reporting immunization financing indicators through the WHO-UNICEF Joint Reporting Form (WHO-UNICEF eJRF). The number of countries documenting dedicated budget line items for vaccine procurement has steadily increased, reflecting growing awareness and commitment to domestic financing. This trend aligns with WHO's strategic focus on strengthening health systems through transparent budgeting and financial accountability. Similar experiences have been observed in other WHO regions. For example, a multi-country analysis in the South-East Asia Region found that institutionalizing standardized reporting tools like the WHO-UNICEF eJRF was instrumental in improving budget transparency and initiating policy discussions on sustainable immunization financing [30]. However, studies also noted that while the establishment of dedicated vaccine budget lines is a positive step, it does not guarantee timely or adequate fund disbursement an issue also prevalent in the ESA Region. These insights suggest that the progress made in the ESA Region to strengthen immunization reporting systems is an essential milestone. It lays the groundwork for more effective advocacy and can support efforts to mobilize increased domestic resources, aligning with WHO's strategic objectives for sustainable immunization financing.

In ESA, total expenditure on routine immunization, including vaccines, has grown significantly over the years. Countries such as Uganda and Tanzania have emerged as leaders, demonstrating strong national investment in immunization programs. This increase follows WHO's guidance encouraging countries to prioritize immunization within national health budgets and especially using the National Immunization Strategy approach. Nevertheless, fluctuations in expenditure levels in recent years may reflect fiscal pressures, competing priorities, or weak budget execution, underscoring the need for sustained advocacy and strategic planning. Evidence shows that reductions in immunization spending often correlate with setbacks in coverage and surveillance outcomes [31]. A key finding during the study period was the variation in the percentage of routine immunization expenditure financed by governments. The highest percentage was recorded in 2024, while the lowest was in 2016. This trend showed a progressive increase until 2022, followed by a decline in 2023, probably attributed to disruptions caused by the COVID-19 pandemic or issues related to reporting anomalies where further studies is advised. At the country level, South Africa reported full government financing, while Mauritius, Namibia, Botswana, Eswatini, and Seychelles also demonstrated high levels of domestic funding. In contrast, South Sudan, Eritrea, and Mozambique reported the lowest average government contributions, indicating continued reliance on external funding. These disparities highlight the need for tailored financial transition strategies to promote equity and sustainability, especially in light of the ongoing Gavi transition [32].

While reporting on government expenditure for vaccines has remained relatively stable, there has been a noticeable decline in the number of countries reporting total vaccine expenditure from all sources. This gap could hinder regional and global efforts to monitor immunization financing comprehensively. WHO policies advocate for consistent and complete data reporting to inform decision-making and resource allocation. Addressing barriers to full reporting and improving data systems across the subregion is essential for strengthening accountability and guiding future investments. Investment patterns vary widely across ESA countries. Notable examples of strong national commitment such as those in Madagascar, Tanzania, and Uganda serve as models for peer learning and policy dialogue. These variations emphasize the importance of context-specific strategies and technical support, guided by WHO frameworks, to help countries strengthen immunization financing mechanisms and reduce dependence on external aid. Ongoing monitoring and collaboration will be crucial for ensuring equitable and sustainable immunization programs across the subregion. Furthermore, triangulating data based on vaccine costs and the number of children vaccinated could help estimate expenditures in countries that do not report, enhancing comparability and supporting regional planning.

Study limitations: the main limitation of the study is its exclusive use of secondary data from the electronic WHO-UNICEF Joint Reporting Form (eJRF), which may contain gaps and inconsistencies in reporting. The lack of primary data collection restricts the ability to validate findings and to explore deeper contextual factors that influence immunization financing. Additionally, by excluding data prior to 2015, the study restricts long-term trend analysis. The absence of stakeholder perspectives also limits insights into the policy and operational dynamics within countries. For future research, incorporating primary data through interviews or surveys with EPI managers and health ministry officials could enrich understanding of national budgeting processes and financing challenges. Comparative policy analysis across ESA countries would help identify best practices and barriers to domestic resource mobilization. Furthermore, a longitudinal study assessing the impact of Gavi transition on immunization coverage and sustainability would provide valuable insights for planning and advocacy.

Conclusion     

In conclusion, countries in the ESA sub-region have made significant progress in financing immunization programs, evidenced by increased government contributions and improved reporting practices. However, the disparities in domestic financing levels and the recent decline in government-funded expenditures expose vulnerabilities in sustainability. As Gavi and the Global Polio Eradication Initiative (GPEI) phase out direct support, and as funding from WHO and UNICEF is reduced, these countries are advised to strengthen their financial planning and institutionalize budget allocations for immunization. It is recommended that governments prioritize immunization within national health budgets, enhance coordination with their finance ministries, and adopt multi-year financing strategies for the national immunization strategies to mitigate the impact of these donor transitions. Further studies should examine the effects of reduced external funding on the performance of immunization programs, especially in countries that have historically invested less domestically. Research should also investigate how prepared ESA countries are to absorb program costs that were previously covered by Gavi, GPEI, WHO, and UNICEF, and identify any policy or operational gaps that could hinder financial sustainability. Comparative analyses of successful transition models and country-specific case studies will be essential to guide regional strategies and inform WHO technical assistance in the post-transition era.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Daudi Manyanga and Maryanna Ochieng and conceptualized and designed the study, and constructed the background information, data collection, study analysis, interpretation, discussion, review and organization of the entire manuscript for publication. Charles Byabamazima, Brine Masvikeni and Sarah Wanyoike reviewed the manuscript and contributed to the discussion and conclusion. All authors have read ang agreed to the final manuscript.

Acknowledgments     

We acknowledge the efforts of all EPI managers from Ministries of Health, WHO, and other partners in the ESA countries for their unwavering commitment to delivering safe vaccines to all children.

Tables     

Table 1: proportion of ESA countries reporting WHO-UNICEF eJRF immunization financing indicators (2015-2024)

Table 2: total reported expenditure on routine immunization, including vaccines, in ESA countries (2015-2024)

Table 3: reported percentage of routine immunization expenditure financed by government funds in ESA countries (2015-2024)

Table 4: reported government expenditure on vaccines used in Routine immunization in ESA countries (2015-2024)

References