Confronting 'chaos': a qualitative study assessing public health officials' perceptions of the factors affecting Tanzania's COVID-19 vaccine rollout.

Objectives: Mass COVID-19 vaccination in Africa is required to end the pandemic. In low-income settings, street-level bureaucrats (SLBs), or public officials who interact directly with citizens, are typically responsible for carrying out vaccination plans and earning community confidence in vaccines. The study interviewed SLBs to assess their perceptions of the factors affecting COVID-19 vaccination rollout in Tanzania.

Methods: We interviewed 50 SLBs (19 rural; 31 urban) responsible for implementing COVID-19 vaccination microplans across four diverse regions and districts of Tanzania in September 2021. Moreover, we conducted six in-depth interviews with non-governmental organisation representatives and seven focus group discussions with health facility governing committees. We asked for their perceptions of factors facilitating and challenging vaccine rollout according to three preidentified domains: political, health system and community. We analysed translated transcripts using a thematic analysis approach.

Results: Political factors facilitating mass vaccination included the executive leadership change from a denialist president to a president who accepted vaccines and promoted transparency. Global integration, commercially and politically, also motivated vaccine acceptance. Political challenges included community confusion that emerged from the consecutive presidents' divergent communications and messaging by prominent religious antivaccination leaders. Health system factors facilitating vaccination included scaling up of immunisation sites and campaigns. Urban district officials reported greater access to vaccination sites, compared with rural officials. Limited financial resources for paying healthcare workers and for transport fuel and a lack of COVID-19 testing compromised mass vaccination. Furthermore, SLBs reported being inadequately trained on COVID-19 vaccine benefits and side effects. Having community sources of accurate information was critical to mass vaccination. Challenges at the community level included patriarchal gender dynamics, low risk perception, disinformation that the vaccine has satanic elements, and lack of trust in coronavirus vaccines.

Conclusion: Mass COVID-19 vaccination in Tanzania will require greater resources and investment in training SLBs to mitigate mistrust, overcome misinformation, and engage communities.