Ethiopia National Expanded

Program on Immunization
COMPREHENSIVE MULTI-YEAR PLAN (2021-2025)

Federal Ministry of Health

Addis Ababa
July 2021
List of Participants in cMYP Development

No. Name of participants Organization No. Name of participants Organization

1 Mr. Yohannes Lakew MOH 41 Dr. Kumie Alene CHAI
2 Mr. Zinabu Temesgen MOH 42 Mr. Andamlak Asfaw CHAI
3 Mrs. Netsanet Berhanu MOH 43 Mr. Tahir Mohammed CHAI
4 Mr. Temesgen Lemma MOH 44 Dr. Ciara Sugerman CDC Ethiopia
5 Mr. Mengistu Bogale MOH 45 Dr. Samuel Teshome CDC Ethiopia
6 Mrs. Mastewal Kerebih MOH 46 Mr. Diriba Bedada PATH
7 Mr. Melkamu Ayalew MOH 47 Mr. Ashenafi Berihun PATH
8 Mr. Kibrom Abraham MOH 48 Mr. Shawul Tesema B.G.RHB
9 Mr. Yosef Tariku MOH 49 Mr. Workneh Mammo Amhara RHB
10 Mrs. Tseganesh Gedlu MOH 50 Mr. Tekalign Morka Harari RHB
11 Mr. Biruh Tesfaye MOH 51 Mr. Sisay Tefera Gambela RHB
12 Mr. Mulat Nigus MOH 52 Mr. Abyot Biru DD RHB
13 Dr. Miheret Elias MOH Mr. Mohammed
53 Somali RHB
14 Mohamoud
Mrs. Nafkot Abadura MOH
54 Mr. Kassa Eshetu Oomia RHB
15 Dr. Zelalem Tadesse MOH
55 Mr. Awol Gudalie Afar RHB
16 Mr. Gulilat Tefera MOH
56 Mr. Agaro Godana Sidama RHB
17 Dr. Teklay Kidanie MOH
57 Mr. Nigussie Terefe SNNPR
18 Mr. Girma Hailemariam MOH
58 Mrs. Betelhem Taye AA RHB
19 Mr. Sileshi Solomon MOH
59 Mrs. Abiyot Biru DD RHB
20 Mr. Habtamu Gashaw EFDA
60 Dr. Zemaw Adam JSI
21 Mrs. Meron Kiflie EFDA
61 Dr. Amare Bayih JSI
22 Dr. Adugna Abera EPHI
62 Mrs. Bezawit Getachew JSI
23 Mr. Mesfine Berhe EPSA
Mr. Tewodros
24 Mr. Tolera Geremew HRDD 63
Alemayehu JSI
25 Mr. Yohannes Kenne MOH(HSSD) 64 Dr. Belete Getahun MOH/PCD
26 Mr. Tewabe Manaye PPMED 65 Mr. Tarko Issa MOH/PCD
27 Mr. Tamirat Awoli PPMED 66 Mr. Solomon Zeleke THDR
28 Dr. Mekonnen Admasu WHO 67 Mrs. Tadelech Sinamo TPHC
29 Dr. Dereje Belew WHO 68 Mr. Andamlak Asfaw CHAI
30 Mr. Wondimu Bekele WHO 69 Mr. Melaku Tsehay CORE GROUP
31 Dr. Abay G/Kidan WHO 70 Mrs. Miraf Solomon Save the children
32 Dr. Yared Agdew THDR
33 Mrs. Almaz Merdekios UNICEF
34 Mr. Amsalu Shiferaw UNICEF
35 Ms. Hnin Su Mon UNICEF
36 Mr. Wassye Mengste UNICEF
37 Mr. Tesfaye Simireta UNICEF
38 Dr. Tariku Berhanu UNICEF
39 Dr. Yunis Mussema USAID
40 Dr. Habtamu Belete CHAI
Table of Contents

List of Figures i
List of Tables ii
List of Abbreviation iii
Acknowledgment iv
Preface v
Executive Summary 1
Chapter One - Country Information 2
1.1 Governance and demography 2
1.2 Socio-economic Situation 3
1.3 Health Problems of Mothers and Children in Ethiopia 3
1.4 Health System Organization 3
1.5 EPI Service Delivery 5
1.6 Rationale for the development of new cMYP (2021-2025) 5
Chapter Two - Situational Analysis 6
2.1 Expanded Programme on Immunization in Ethiopia 6
2.2. National Immunization Implementation Guideline 6
2.3 Immunization Service Delivery 7
2.3.1 Implementation of cMYP 2016 -2020 7
2.3.2 Achievements of Child, Infant and Neonatal Mortality Reduction 7
2.3.3 Performance of Routine Immunization during EFY 2008-2012 (2016-2020) 8
2.3.4 Immunization data quality 9
2.3.5 Routine Immunization Service Provision Platforms and Strategies 12
2.3.6 Reaching Every District/Child/ (RED/REC) Approach 13
2.3.7 Periodic Intensification of Routine Immunization (PIRI) 13
2.3.8 Urban Immunization 13
2.3.9 Catch- up vaccination 14
2.3.10 Impact of COVID-19 on Immunization Programme 14
 2.3.11 New Vaccines Introduction 14
2.3.12 Polio SIAs and Progress in Polio Eradication Initiative 15
2.3.13 Measles SIAsW 17
2.3.14 Maternal and Neonatal Tetanus SIAs 19
2.3.15 Meningitis A vaccination campaign 20
2.4 Disease Surveillance 20
2.4.1 Vaccine-Preventable Diseases Surveillance 20
2.4.1.1 AFP Surveillance 21
2.4.1.2 Measles surveillance 22
2.4.1.3 Rubella Surveillance 25
2.4.1.4 Neonatal tetanus surveillance 26
2.4.1.5 Paediatric Bacterial Meningitis/Hib Surveillance 26
2.4.1.6 Rotavirus Surveillance 28
2.4.2 Laboratory 28
2.4.2.1 Polio Laboratory 28
2.4.2.3 Rota Laboratory 28
2.4.2.4 Bacteriology Laboratory 29
2.5 Immunization Supply Chain Management 29
2.5.1 Effective Vaccine Management 29
2.5.2 Cold Chain Equipment Management 33
2.5.3. Vaccine Direct Delivery 36
2.5.4 Injection safety and waste disposal 37
2.5.5 Vaccine, Supply and Quality 38
2.5.6 Adverse Event following immunization (AEFI) 38
2.6. EPI Advocacy, social mobilization and program communication 39
2.6.1 Advocacy 39
2.6.2 Community Engagement and Social Mobilization 39
2.6.3. Program Communication 40
2.6.3.1. Evidence Generation 40
 2.6.3.2 Risk Communication 40
2.6.4. Challenges and gaps 40
2.7 Program Management 41
2.7.1 Planning 41
2.7.2 Administration and Coordination 41
2.7.3 Health Information system /Immunization data Management 42
2.7.4 Monitoring, Supervision and Evaluation 42
2.8 Strengthening human and institutional resources 44
2.8.1 Staffing 44
2.8.2 Capacity Building for EPI 44
2.8.2.1 Pre-service Training 44
2.8.2.2 In-service Training 44
2.8.3 Research and development 44
2.9 Partnership and financial sustainability 45
2.9.1 National EPI Stakeholder Analysis 45
2.9.2 GAVI support 47
2.9.3 Government Contribution 49
2.9.4 Other Donors: 49
2.9.5 Community participation 49
Chapter Three - Vision, Mission, Goals, Programme Objectives, Strategic Approaches, 57
Key Activities, Indicators and Milestones
3.1. Introduction 57
3.2. Vision 57
3.3. Mission 57
3.4. Goals of the cMYP (2021- 2025) 57
3.5 Program Objectives 57
3.6 Strategic Approaches 61
3.7 Anticipated Coverage Targets 64
3.8 Planning by immunization system component 80
Chapter Four - Costing, Financing and Financing Gaps 100
4.1 Macroeconomic Information 100
4.2 Methodology for costing the cMYP 100
4.2.1 Costing Assumptions 100
4.3 Costing of cMYP 20221-2025 101
4.3.1 Vaccines and Injection Equipment 101
4.3.2 Personnel Costs (EPI specific and shared) 101
4.3.3 Cold Chain Equipment Procurement and Maintenance 101
4.3.4 Operational Costs for Campaigns 101
4.3.5. Financial Sustainability 103
Chapter Five - Implementation, Monitoring and Evaluation 104
5.1 Implementation 104
5.2 Monitoring and Evaluation 104
Refrences 108
List of Figures

Figure 1.1 Map of Ethiopia 3

Figure 1.2 Population structures by age and sex 3
Figure 1.3 Ethiopian Health Tier system 5
Figure 1.4 immunization service structure in Ethiopia 6
Figure 2.1 Trends in childhood mortality rates, 2005 – 2019 9
Figure 2.2 Trends of Penta 3 coverage by different data sources from 2000 to 2019 10
Figure 2.3 Trend of MCV1 coverage by different sources from 2000 to 2019 11
Figure 2.4 Ethiopia (DHS2000-2019) Immunization Inequity Trend 12
Figure 2.5 Proportion of incomplete immunization for the three EDHS periods Melaku et.al BMC 13
Figure 2.6 Measles immunity profile for population ≤19 years, Ethiopia, 2020. 19
Figure 2.7 Comparison of Confirmed Measles Cases by High and Low Contributing Regions, 25
Ethiopia, Jan-Dec 2019
Figure 2.8 Trend of Confirmed Measles Cases by age Distribution, 2010–2019, Ethiopia) 25
Figure 2.9 Lab confirmed Rubella Cases by Year, Ethiopia, 2010-2020 26
Figure 2.10 Age distribution of Confirmed Rubella Cases by Region, Ethiopia, Jan to Dec 2020 26
Figure 2.11: Number of Suspected Pediatrics Bacterial Meningitis Cases per Year from 2015- 28
2020
Figure 2.12 Etiologies identified for PBM, 2015-2020, Ethiopia; 28
Figure 2.13 Assessment results EVMA 2013 & 2019 – Composite and Criteria score 31
Figure 2.14 EVM performance per supply chain level for 2013 and 2019 31
Figure 2.15 EVMA performance in supply chain level by EVM criteria 2019 EVMA 33
Figure 2.16 Regional distribution of health facilities accessed by direct delivery, 2020. 38

Comprehensive Multi-Year Plan (2021-2025) i

List of Tables

Table 1. Routine Immunization antigens, site administration and schedule 8

Table 2. Administrative vaccination coverage of Penta 3 and MCV1 by region, cMYP EFY 2008 10
to 2012

Table 3. Immunization coverage for selected antigens and dropout by region, Ethiopia EMDHS 11
2019

Table 4. Polio (bOPV) SIAs coverages, 2016-2019, Ethiopia 17

Table 5. mOPV2 SIAs coverages, 2018-2020, Ethiopia 18

Table 6. Measles Supplementary Immunization Activities, Ethiopia, 2011-2020 20

Table 7. Summary of AFP surveillance indicators in Ethiopia, 2016-2020 (Source EPHI VPD 22
weekly update)

Table 8. Measles case-based surveillance performance indicators, 2010-2020 (Source: measles 23

surveillance update 2020)

Table 9. Summary of Measles Outbreaks, by Year, Ethiopia, 2010 – 2020 24

Table 10. Measles Incidence Rate by Region, Ethiopia, comparison between 2018 & 2020 24

Table 11. Rota Virus Positivity Rate, sentinel surveillance indicators, 2015-2020, Ethiopia 29

Table 12. Model type and manufactures of equipment 36

Table 13. Functionality Status of the equipment by facility type 37

Table 14. Reasons for the non-functionality of the equipment 37

ii Ethiopia National Expanded Program On Immunization

List of Abbreviation

AD Auto Disabled Syringes ISS Immunization Service Support

AEFI Adverse Events Following Immunization ITN Insecticide-Treated Bed Net
AFP Acute Flaccid Paralysis JRF Joint Reporting Form
BCC Behavioural Change Communication KABP Knowledge, Attitude, Behaviour and
BCG Bacillus-Calmette-Guerin Practice
BPR Business Process Re-engineering MDG Millennium Development Goals
CDC Centres for Disease Control and Prevention MDVP Multi-dose Vial Policy
CMYP Comprehensive Multi Year Plan MLM Mid-level Managers
CSO Civil Society Organization MNT Maternal and Neonatal Tetanus
DHS Demographic and Health Survey FMOH Federal Ministry of Health
DPT Diphtheria-Pertussis-Tetanus vaccine NGO Non-Governmental Organization
DQA Data Quality Audit NIDs National Immunization Days
EPI Expanded Programme on Immunization NIP National Immunization Program
GAVI Global Alliance for Vaccines and NNT Neonatal Tetanus
Immunisation OPV Oral Polio Vaccine
GIVS Global Immunization Vision and Strategies PAB Protection At Birth
Hep B Hepatitis B PCV Pneumococcal Conjugated Vaccine
HEW Health Extension Workers PFSA Pharmaceuticals Fund Supply Agency
HF Health Facility RED Reaching Every District
Hib Haemophilus influenza type b SIAs Supplemental Immunization Activities
HMIS Health Management Information System SNIDs Sub-National Immunization Days
HPV Human Papilloma Virus Vaccine SOS Sustainable Outreach Services
HSDP Health Sector Development Program TFI Task Force on Immunization
HSEP Health Service Extension Program TOT Training of Trainers
HSS Health Service Support TT Tetanus Toxoid
HW Health Worker UCI Universal Child Immunization
ICC Inter-Agency Coordinating Committee UNICEF United Nations Children Fund
ICST Inter-country Support Team VMA Vaccine Management Assessment
IDS Integrated Disease Surveillance VPD Vaccine-Preventable Diseases
IEC Information Education and Communication VVM Vaccine Vial Monitor
IIP Immunization in Practice WFP World Food Program
IMR Infant Mortality Rate WHO World Health Organization
IPC Inter-personal Communication WPV Wild Polio Virus
IPV Injectable Polio Vaccine WRRT Woreda Rapid Response Team

Comprehensive Multi-Year Plan (2021-2025) iii

Acknowledgment

Immunization Comprehensive Multi Year Plan

(cMYP) is a key strategic and management document
for National immunization programs that provide
national goals, objectives and strategic directions
which address all components of immunization
system relevant to the country. The new cMYP
(2021-2025) is the result of the collaborative work
of the Ministry of Health and partners working in
health.

In spite of the gains made during the previous multi-year plans, several challenges in the delivery of EPI services
including the COVID-19 global pandemic need a collaborative effort of all stakeholders to sustain the previous
gains and optimally reaching zero doses children, under vaccinated children and missed communities.

The current cMYP (2021-2025) document has strategies conforming to the vision of the global Immunization
Agenda/IA2030/ which envisioned as “a country where everyone, everywhere, at any age should fully benefit
from all vaccines for good health and well-being”.

The Ministry of Health would therefore like to express its special thanks for the tireless efforts of the technical
team supporting the National Immunization program for the successful preparation of the document in the
shortest possible time. Our appreciation goes also to those partners for their financial as well as technical
support without which it would have not been possible to prepare this document.

Dereje Duguma, MD, MIH

State Minister, Ministry of Health

iv Ethiopia National Expanded Program On Immunization

Preface

Immunization is a key priority of the basic package

of Essential Health Services in Ethiopia. The
implementation of the 2016-2020 comprehensive
multi-year plan (cMYP) for EPI accelerated
government’s efforts to achieve better health for
the children and women of Ethiopia through the
reduction of morbidity, mortality and disability
from vaccine preventable diseases (VPDs), thereby
contributing to the enhancement of the quality of
life and productivity.

A thorough situation analysis, comprehensive EPI and surveillance review conducted in 2018 provided useful
information on best practices, weaknesses, opportunities, and lessons learned over the previous years that
formed the basis for development of this cMYP (2021-2025). The current cMYP(2021-2025) document preparation
process has taken in to account the Governments’ second Health Sector Transformation Plan/HSTP II/, experience
gained during the past years of implementing routine and supplemental immunization activities, new vaccine
introduction and the global Immunization agenda 2030/IA2030/, GAVI 5.0, and WHO technical immunization
guidelines for program use at all levels.
Establishment of the structures for immunization program management at the national and regional levels; all
vaccines, injection materials and equipment used at all levels conform to WHO standards/specification and
strong support and collaboration from Development Partners for EPI.
The process of development of the new comprehensive multi-year plan for 2020-2025, has accorded the
stakeholders and partners an opportunity to reorganize approaches to address the current/future challenges and
to explore opportunities for more effective and efficient delivery of services.
Focus will be made to improve immunization coverage through reaching all un-immunized and under immunized
children in every district/Woreda/community; introduction of new and underused vaccines like Hepatitis B birth
dose, Yellow fever, MenA etc. and maintaining a high quality and sensitive disease surveillance system at all
levels in order to detect and respond timely to any Vaccine Preventable Diseases outbreaks.
Lastly, the Maternal and Child Health Directorate pledge full commitment in implementation of the plan and
look forward to attainment of the set objectives and targets. The directorate would also like to express its
appreciation for the unreserved efforts of the EPI case team, other Directorates of the FMoH, EPI stakeholders
and partners for their invaluable contributions.

Meseret Zelalem Tadesse, MD, Pediatrician

Maternal, Child Health and Nutrition
Directorate Director, Ministry of Health

Comprehensive Multi-Year Plan (2021-2025) v

Executive Summary

The comprehensive multiyear plan (cMYP) is the through time-tested mechanisms such as annual EPI
medium term or strategic plan for the Expanded review meeting.
programme on Immunization (EPI) in Ethiopia,
prepared in consonance with the 5 year strategic The role of the ICC in ensuring that the plan is on the
plan of the health sector for the year 2021 to 2025. proper track. It is expected that this national plan
will serve as a guide and template for regional and
The goals of the cMYP are: district annual plans during 2021-2025.

■ Reduce morbidity and mortality from vaccine- The current plan is presented in five chapters
preventable diseases for everyone through the described briefly as below:
life course.
Chapter One: Country Information
■ Leave no one behind by increasing universal This describes the country profile and demographic
and equitable access and use of new and information, administration and politics, the
existing vaccines. macroeconomic environment, the health status, and
■ Ensure good health and wellbeing for everyone the Expanded Programme on Immunization (EPI) in
by strengthening immunization within primary Ethiopia.
health care and contribute to universal health Chapter Two: Situation Analysis
coverage and sustainable development.
This chapter provides information on the current
■ Achieve vaccine-preventable diseases issues and challenges of the immunization
elimination and eradication goals. programme in Ethiopia. It further provides detail
description of the strengths and weaknesses of all
This strategic plan will be guided by the the components of the immunization system in the
above goals and consistent with the goals of country.
immunization agenda 2030.
Chapter Three: Goals, Objectives, Key
There are enabling and impeding factors that affect Activities, Indicators and Milestones
the effective implementation of all components of This chapter focuses on the goals and objectives of
the immunization system in the country. Improved the cMYP for each of the strategic components, key
access and quality immunization services have been activities, indicators, and milestones.
major challenges because of difficult topography
in the most hard‐to-reach areas and resource Chapter Four: Costing, Financing and
constraints. Despite these challenges there is Financial Gaps
government commitment, dedicated service staff This chapter elaborates on the plans for financing
and effective collaboration from partners like GAVI, and sustainability of the plan.
WHO, and UNICEF and so on to support and provide
immunization services. Chapter Five: Monitoring, Evaluation and
Implementation
Great amount of work has been done for developing This is the final chapter describing the monitoring
the cMYP starting from the situational analysis to and evaluation mechanisms which are put in place
costing, monitoring and evaluation. The progress to ensure effective and efficient implementation of
of implementation of the cMYP will be monitored the plan.

Comprehensive Multi-Year Plan (2021-2025) 1

 01
CHAPTER
Country
Information

1.1 Governance and demography Regional States (NRSs), also called Regions (ክልል/
Kilile) and two city administrative councils under a
Ethiopia is the second most populous country in constitutional federal system. The regions and city
Africa, with a unique cultural heritage, diverse administrations are further divided into 108 Zones,
population, mixed ethnicity, and different religions. 1054 Districts and 32,000 urban dwellers and
Administratively, Ethiopia comprises of 10 National farmers association commonly known as ‘kebeles’.

Figure 1. 1 Map of Ethiopia

According to projections from the 2007 National fertility rate of 4.6 births per woman (2.3 urban and
Census, the estimated total population for the year 5.2 rural) and a corresponding crude birth rate of 32
2020 is about 101 million in Ethiopia, ranking as per 1000 in 2016. As demonstrated in the contrasting
second in Africa and 12th in the world. Ethiopia is population pyramids for 2020-2029 shown below
home to more than 80 ethnic groups with the same (Fig. 2), the younger population will keep growing in
number of languages and dialects. The population the next decade.
is characterized by a rapid growth (2.6%), high total
Population structures by age and sex (Percent)

2020 2029
HSTP II Master file 2019-12-30 HSTP II Master file 2019-12-30
80+ 80+
Male Female Male Female
75-79 75-79
70-74 70-74
65-69 65-69
60-64 60-64
55-59 55-59
50-54 50-54
45-49 45-49
40-44 40-44
35-39 35-39
30-34 30-34
25-29 25-29
20-24 20-24
15-19 15-19
10-14 10-14
5-9 5-9
0-4 0-4
6 4 2 0 2 4 6 6 4 2 0 2 4 6

Figure 1. 2 Population structures by age and sex

2 Ethiopia National Expanded Program On Immunization

1.2 Socio-economic Situation about 8.4 million people were affected and needed
humanitarian assistance. Women and children were
Ethiopia has been implementing a number of disproportionately affected by the humanitarian
macroeconomic policies, including a market-based crisis. For the health sector, about 5.9 million
and agriculture-led industrialization, and has people were reported to have humanitarian needs
classified as a Low-Income Economy Country (LIEC). among which women and children constituted
In 2018, the gross domestic product (GDP) per capita larger proportion. Thus, it needs for urgent RMNCH
was US$ 790, an increase from US$ 340 in 2010. interventions and strengthening of primary health
Annual per capita health expenditure during 2016- care services including routine and supplementary
2017 was US$ 33.2 showing increment from US$ immunization services.
28.5 in 2013/14 but still falls short of the WHO
recommended US$ 86. According to the Ethiopian 1.3 Health Problems of Mothers and
Poverty Assessment, households have experienced Children in Ethiopia
a remarkable reduction in the poverty rate from 39%
of the population living below US$ 1.25 purchasing About 80% of morbidities in mothers and children
power a day in 2004/05 to 29% in 2010. The poverty are attributable to communicable diseases including
level fell by around 20% between 2011 and 2016 vaccine-preventable diseases and sickness
(World Bank, 2019). Despite rapid economic growth, associated with nutritional disorders. The country
the country remains one of the world’s poorest has shown significant improvements in prevention
countries. Poverty and income inequality remain and control of communicable diseases by integrating
persistent challenges in Ethiopia. health service deliveries such as immunization and
other maternal and child health services. The UN
Ethiopia’s economic growth led the country to the 2019 Report showed that life expectancy was at
early attainment of the Millennium Development 67.85 years while IMR and under-five mortality rates
Goals (MDG), particularly in hunger, gender parity were respectively 37/1000 and 44/1000 live births/
in primary education, child mortality, HIV/AIDS, and year. Though mortality rates have been declining,
malaria. Between 2000 and 2017, Ethiopia’s HDI deaths of children from preventable diseases such
(Human Development Index) value increased from as pneumonia, diarrhea, malaria, neonatal problems,
0.283 to 0.463, an increase of 63.5 per cent still it is malnutrition and HIV/AIDS are still very high.
below the average which is 0.504.
1.4 Health System Organization
Ethiopia experiences cyclical hazards leading to the
humanitarian crisis including disease outbreaks, The Ethiopian health service delivery system is
recurrent droughts, flooding, and insecurity which structured into three-tier systems. This includes
resulted high morbidity and mortality, people primary, secondary, and tertiary levels health care
displacements (IPDs), health care interruptions, tier systems (Fig. 03).
and other social and economic disruptions. In 2020,

Comprehensive Multi-Year Plan (2021-2025) 3

 Ethiopian Health Tier System

Specialized Hospital
3.5-5.0 Million Tertiary level health care

General hospital
Secondary level health care
(1-1.5 million) People

Primary hospital
(60,000-100,000) People
Health Center
Health center Primary level
40,000 (15,000-25,000) People health care
People
Health Post
(3,000-5,000) People

URBAN RURAL

Figure 1. 3 Ethiopian Health Tier system

As illustrated in Fig. 3, the primary health care unit or tertiary health care system consisting specialized
(PHCU) consists of health posts at the community hospitals that serves as a referral center for general
level, health center, and primary hospital. One hospitals and as training centers for medical doctors
health center is attached to five-satellite health and specialists. Furthermore, private health care
posts, aimed to provide services to a population facilities at different levels supplement the overall
of approximately 25,000. Health centers provide health care delivery.
both preventive and curative services and serve as
referral centers for health posts and as practical Regional Health Bureaus (RHB), Zonal Health
training sites for Health Extension Workers Departments (ZHD) and Woreda Health Offices
(HEW). Primary hospitals are organized to provide (WoHOs) provide a coordinated health management
ambulatory, inpatient, and emergency surgical and leadership services at their respective levels.
services to approximately 100,000 populations. The decision-making process is decentralized from
the regions and down to the district level (PHCU
At the second tier, general hospitals are organized level). According to FMOH 2018/19 report, there
to provide curative health services and serve as a are 338 hospitals, 4,063 Health Centers and 17,574
referral center for primary hospitals. It also plays Health Posts, which the latter is staffed by 42,000
vital role in the training of health officers, nurses, and Health Extension Workers (HEWs).
emergency surgeons. At the third tier is the highest

4 Ethiopia National Expanded Program On Immunization

1.5 EPI Service Delivery hard to reach areas. Introduction of new vaccines
such as Hep-B and Hib (as Pentavalent vaccine)
In Ethiopia, EPI was first launched in 1980 with six in 2007, PCV in 2011, Rotavirus Vaccine in 2013,
antigens but expanded tremendously over the years, Inactivated Polio Vaccine (IPV) in 2015, HPV in 2018
which the routine immunization (RI) program at and Measles second dose (MCV2) in 2019 were
present provide services with a total of 12 antigens. among the greatest achievements of the program.
Expansion of EPI has significantly contributed to the The administrative structure of EPI in Ethiopia is
prevention of maternal and child death, suffering and designed based on the administrative structure of
disability among populations including remote and the country.

Federal Ministry of health EPI case Team / EPI Manager

Regional Health Bureau EPI officer

Zonal Health Department EPI officer

Woreda Health office EPI officer

PHCU EPI Focal Person

Health Post Health Extension Worker

Figure 1. 4 immunization service structure in Ethiopia

1.6 Rationale for the development of years in alignment with the national immunization
new cMYP (2021-2025) program goals and objectives along with the second
Health Sector Transformation Plan (HSTP II) and in
The cMYP of the EPI program is a key strategic reference to the global strategic frameworks such
and management document covering the next five as Immunization Agenda 2030 and the Gavi 5.0.

Comprehensive Multi-Year Plan (2021-2025) 5

 02
CHAPTER
Situational
Analysis

In this section the immunization performance Increasing health infrastructure and human
situation over the previous five years (2016-2020) of resources over the past five years has also made an
multi-year plan is analysed focusing on immunization impact to improve access to quality immunization
system components of: services and increasing vaccine management and
storage capacity by installing significant number of
i. Service delivery
SDD refrigerators.
ii. Surveillance
2.2. National Immunization
iii. Vaccine supply and quality
Implementation Guideline
iv. Logistics
The Ethiopian immunization policy implementation
v. Communication/social mobilization and guideline was developed in 2004 and it has been
vi. Program management, capacity building and revised in 2015 and 2019. The revised immunization
finance. policy implementation guideline (2019) highlighted
the second year of life immunization platform and
2.1 Expanded Programme on adolescent girl vaccination from the introduction
Immunization in Ethiopia of measles second doses (MCV2) and human
In Ethiopia, the EPI programme was launched in 1980 papillomavirus vaccine (HPV) into the routine
with the objective of reaching universal coverage to immunization program. Children of the under-one
all children under 2 years of age by 1990, with a year of age, the second year of life, adolescent girls (9-
14 years) and women of reproductive age group (15-
review of the policy to reduce overage to 75% and
49 years) are the targets for the currently available
reduce target age of children to under one year old.
vaccines in the immunization program of Ethiopia
The Reaching Every Districts (RED) and Sustainable (BCG, Measles, DPT-HepB-Hib or Pentavalent,
Outreach Services (SOS) approaches were Rotavirus Vaccine, Pneumococcus vaccine (PCV),
introduced in 2003. As part of an effort in addressing OPV, IPV, HPV and Tetanus diphtheria(Td) vaccine).
the immunization inequity and increase coverage,
the Periodic Intensification of Routine Immunization The country’s immunization schedule for the
(PIRI) has been implemented since 2018 in selected below-listed vaccines strictly follows the WHO
poor-performing woredas of agrarian and pastoral recommendations for developing countries.
regions. Other strategies to increase immunization Although no booster doses recommended in routine
EPI for childhood immunization, there are periodical
coverage have also been implemented including
supplemental doses for measles and polio.
Child Health Day events, intensified outreaches, and
pulse campaigns.

6 Ethiopia National Expanded Program On Immunization

Table 1. Routine Immunization antigens, site administration and schedule

No. Vaccines Target diseases Age Route/Site of administration

1 BCG Severe forms of Tuberculosis At Birth or soon after Intradermal (ID), Rt deltoid

2 PCV Meningitis and pneumonia Weeks 6,10 & 14 Intramuscular (IM),

(streptococcal and Rt anterolateral thigh
pneumococcal)
3 OPV Poliomyelitis Birth (OPV0), weeks 6, 10 & 14 Oral
4 IPV Poliomyelitis Week 14 IM, Rt thigh 2.5 cm below
PCV injection site
5 DPT-Hib- Diphtheria, Pertussis, Weeks 6, 10 & 14 IM, Lt anterolateral thigh
HepB Meningitis & pneumonia
associated with Haemophilus
influenza and Liver disease
due to Hepatitis B virus.
6 TT/Td Tetanus/diphtheria At 0, 1 & 6 months, IM, Lt Deltoid
1st & 2nd year for TT
1st dose early as possible
2nd dose 4 week after 1st dose
3rd dose 6 months after 2nd dose
4th dose 1 year after 3rd dose
5th dose 1 year after 4th dose
7 MCV Measles 9 and 15 months Subcutaneous (SC),
Rt deltoid
8 Rotavirus Rotavirus-associated gastro- Weeks 6 & 10 Oral
vaccine enteritis
9 HPV Human papillomavirus, Age ------ 0, 6 months for IM, Deltoid muscle of upper
associated with cervical Quadrivalent arm
cancer and anogenital wart

2.3 Immunization Service Delivery 2.3.2 Achievements of Child, Infant and Neonatal
Mortality Reduction
2.3.1 Implementation of cMYP 2016 -2020
There has been significant reduction in infant (IMR)
The 2016-2020 cMYP aimed to achieve the national and under 5 (U5MR) mortality rates during the last
and sub national vaccination coverage targets set at two decades, shown in Fig. 6 below, and largely
HSTP I, a polio-free status, eliminate measles, and believed that increased access to immunization
MNT, introduce new vaccines IPV, MCV2, MR, Men and introduction of new vaccine has significantly
A, HPV and Yellow Fever in line with the GVAP goals contributed.
and improvement of vaccine supply management
and cold chain capacity at all levels.

Comprehensive Multi-Year Plan (2021-2025) 7

 Trends of under 5, infant and neonatal mortality rate per 1000 live births
from 2005 to 2019 EDHS
150

100 123 88
67
59
77 48 59
50
29 47
39 37 33
0
2005 EDHS 2011 EDHS 2016 EDHS 2019 EMDHS

Neonatal Mortality Infant Mortality Under-five Mortality

Figure 2. 1 Trends in childhood mortality rates, 2005 – 2019

2.3.3 Performance of Routine Immunization during and Benishangul-Gumuz regions were relatively
EFY 2008-2012 (2016-2020) consistent by different data sources. The most
recent Penta 3 and MCV1 administrative coverage
Immunization performance assessed by Penta 3 estimates for EFY 2012 (2019/2020) showed 97%
and MCV1 coverage as indicators for the period and 93% respectively, with large variations between
2008-2012/2016-2020 shows that coverage was regions where coverage for Afar, Somali, and Dire
maintained at 95% for Penta 3 and 90% for MCV1 Dawa was 70-80% while Amhara, Gambella and
with uneven coverage levels among regions. Tigray achieved between 80-90%. Coverage for
Administrative coverage was higher in Addis Ababa, Addis Ababa, Benishangul-Gumuz, Oromia, Harari
Harari, Oromia and SNNP while data from Somali, and SNPPR regions remained high at more than
Afar and Gambella was low. The estimates in both 90% coverage. MCV1, follow similar pattern with
directions were inconsistent with what was shown Penta 3 with slight variations (Table 2).
by survey estimates. Coverage for Amhara, Tigray

8 Ethiopia National Expanded Program On Immunization

Table 2. Administrative vaccination coverage of Penta 3 and MCV1 by region, cMYP EFY 2008 to 2012

Region 2008 2009 2010 2011 2012

Penta3 MCV1 Penta3 MCV1 Penta3 MCV1 Penta3 MCV1 Penta3 MCV1

Addis Ababa 100% 100% 100% 85% 100% 85% 154% 145% 108% 146%
Afar 100% 94% 92% 88% 82% 69% 74% 67% 74% 72%
Amhara 92% 90% 93% 90% 93% 89% 88% 84% 87% 88%
B. Gumez 99% 93% 100% 96% 97% 93% 89% 84% 90% 85%
Dire Dewa 79% 78% 78% 76% 86% 79% 79% 71% 78% 72%
Gambella 77% 61% 85% 76% 85% 74% 88% 78% 85% 70%
Haraeri 100% 92% 100% 93% 100% 100% 111% 100% 111% 98%
Oromia 100% 99% 100% 97% 97% 93% 105% 96% 104% 99%
SNNP 99% 97% 100% 97% 96% 93% 75% 93% 100% 73%
Somali 76% 71% 80% 75% 77% 71% 80% 69% 78% 91%
Tigray 89% 86% 78% 85% 91% 85% 89% 85% 89% 86%
National 98% 94% 97% 94% 96% 90% 96% 90% 97% 93%

2.3.4 Immunization data quality four transformation agendas stipulated in the HSTP
I and HSTP II. The agenda embraces data generation
Immunization data in Ethiopia varies greatly by and digitalization, staff capacity building, motivation
sources such as administrative, WUENIC, and and practice in data management including analysis
surveys largely due to differences in methodology and data use for action. The overall discrepancy
in data collection, use of inaccurate and dissimilar where Penta 3 and MCV1 coverage estimates by
denominators, inadequacy in recording, and administrative, WUENIC and surveys between
reporting. The problem is so chronic and deep 2000-2019 is shown in Figures 2 and 3 below.
rooted that “information revolution” is one of the

100 96 96 96 95 96

90 86 87 87
81 83 82
79
80 73
72 73 73 73 72
69 69
70 66 65
61 62 61
58 59
% Coverage

60 56.3 54
51 51 52 66 60.9
50 59.5
50 44 46
42 53.2
40
40 35 37
32 30 36.5
30
31.9
20
20.7
10

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Year

Figure 2. 2 Trends of Penta 3 coverage by different

Survey data sources
EDHS from 2000 to 2019
Mini-DHS WUENIC Admin

Figure 2. 3 Trends of Penta 3 coverage by different data sources from 2000 to 2019
Comprehensive Multi-Year Plan (2021-2025) 9
 100 92 93 92 91
88
90 82 84
81 80
75 76
80 74
% Coverage

68 65 66 65
70 65 64 62
63 59 61
56 59 55 58
60 54 54
51.9 49
50 44 44
42 40
40
37 37 55.7 68.2 54.3 58.6
35 35
30 35 36 36
34.9 54.3
20
26.6
10
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Year
Survey EDHS Mini-DHS WUENIC Admin

Figure 2. 3 Trend of MCV1 coverage by different sources from 2000 to 2019

Figure 2. 2 Trend of MCV1 coverage by different sources from 2000 to 2019

Recent Mini-DHS survey findings (EMDHS 2019) 90%. The MCV1 coverage follow similar pattern.
demonstrated that Penta 3 and MCV1 coverages Using dropout as an indicator, the survey revealed
were very low and only one out of four children in Drop Out Rate (DOR) for Penta1-3 and Penta1-MCV1
Afar and Somali regions received the third dose were similarly high in Afar with 43% and 37%, and
of Pentavalent vaccine. Not far from that, data for Somali 38%, and 26%, SNNP with 30% and 20%,
Oromia and SNNP was 53% and 50% respectively and Oromia with 27% and 34%. Details are shown
and 70-79% for Dire Dawa and Gambella. Tigray, on Table 3 below.
Benishangul-Gumuz, Amhara achieved 80% to

Table 3. Immunization coverage for selected antigens and dropout by region, Ethiopia EMDHS 2019

Region Penta 1 Penta 3 MCV1 MCV2 DOR Penta DOR All Never been
1-3 Penta types of vaccinated
1-MCV1 vaccines
Addis Ababa 96.3 93.1 90.6 3.3 3 6 83.3 3.7
Afar 45.5 25.9 28.5 8.5 43 37 19.8 44.9
Amhara 84.4 80.2 71.3 13.3 5 16 62.1 14.8
B./Gumuz 89.2 81.2 77.4 1.6 9 13 66.7 9.8w
Dire Dawa 95.2 74.2 74.2 17.7 22 22 53 2.6
Gambella 76.3 65 57.6 21.2 15 25 38.3 14.2
Harari 65.3 52.8 58.7 7 19 10 45.8 20.4
Oromia 73.4 53.6 48.7 5.2 27 34 29.9 18.9
SNNP 72.7 50.8 58.2 15.3 30 20 38 24.2
Somali 42.2 26.2 31.1 1.4 38 26 18.2 48.8
Tigray 95.4 84.4 82.9 17.2 12 13 73 4.6
National 76.3 60.9 58.6 9.1 20.2 23.2 43.1 19.2

10 Ethiopia National Expanded Program On Immunization

The MEDHS findings also revealed that 1.25 million 322,566 (25.7%) unvaccinated children. Amhara and
children were unvaccinated with Penta 3, of which Somali regions had 136,824 (10.9%) and 134,383
95% were from five regions. Oromia Region was (10.7%) respectively.
home to 569,705 (47.6%) followed by SNNPR with

Number of Oromia Amhara SNNPR Somali Tigray AA Afar BG Dire Dawa Gambela Harari National
Unimmunized
(mini-EDHS 2019) 569,705 136,824 322,566 134,383 27,836 5,689 38,985 6,578 3,965 4,688 3,599 1,254,810

Similarly, marked differences of MCV1 coverage regional, and global targets as disparities across
and dropout rates between Zones and Districts geographic areas and population groups continue
indicating the build-up of unprotected children with to prevail. EDHS survey findings and recent inequity
potentials of increased risk for measles outbreaks assessment by UNICEF identified geographic
and jeopardizing the measles elimination goals. The area (pastoralist), household wealth, caregivers’
introduction of MCV2 and the extension services to education, and place of residence (urban) as
second year of life is hoped to improve coverage of determinants influencing access to and utilization of
not only MCV but also of other antigens. Coverage immunization services3. Details are shown on Fig.
has increased steadily but has not met national, 8 below.
Ethiopia (DHS2000-2019) Immunization Inequity Trend

Economic Status Education Residence

42.4
40 35.6
29.6 31.4 30.6 28.5 29.0
24.8 26.4
24.1 1. Penta 1
20 19.3 18.9 20.2 19.8

48.0
40 35.5
39.9
33.8
38.0
34.3 33.7 34.1 36.7
28.0 29.8
20 22.3 2. Penta 3
16.3 15.8

46.7
40.8
40 34.4
40.7 39.6
33.4 33.2
31.1 32.2 30.6
27.6 27.8 28.1
20
24.5 3. Measles

40.8 41.1
40 33.7
40.0
34.8 36.9
31.3 31.0 31.4 29.5
27.7
20 21.5 24.3
20.4 4. Fully Vaccinate

40
29.8
23.7
20 16.3 16.0
19.6 18.1 5. No Vaccine
12.8 13.6 13.3 13.8 13.6 13.6
11.1 9.8
0
2000 2005 2011 2016 2019 2000 2005 2011 2016 2019 2000 2005 2011 2016 2019

Immunization coverage in equality in children 12-23 months old by wealth, education and residence

Figure 2. 4 Ethiopia (DHS2000-2019) Immunization Inequity Trend

Comprehensive Multi-Year Plan (2021-2025) 11

The disparity can also be seen by examining dropout barriers but frequent appointments for multi-dose
rates (DOR) where DOR in Addis Ababa, Dire Dawa vaccines, stock out of vaccine supplies on the date
and Tigray reduced from 37-7%, 56-29% and 55-29% of visit are major players. Low level of awareness
respectively during 2005-2016 (Fig. 11). In contrast, on vaccination schedules, fear of multiple injections
Afar, Somali, Oromia, Gambella and SNNP regions and AEFI, illness of child or mother, distance and
had the highest number of defaulters during the same difficult terrain and lack of transportation are also
period. Therefore, equity analysis and reaching every identified as barriers to vaccination completion.
child (REC) planning and implementation monitoring, Absence and unfriendliness of health workers and
targeting high-risk communities should be the focus failure to provide key messages are also contributors
in the future planning. Multiple factors may play as to the high dropout rates.

Proportion Of incomplete immunization for the three EDHS periods

100 97
93
90 88
86 EDHS - 2005
82
80 79 EDHS - 2011
80 78 78
76
74 75 EDHS - 2016
72 72 73
Percentage of Incomplete immunization

70
70 69 69

62
60 56 56
55 54 54
50
43 42
40 39
35 35

30 29 29

20
20

10 7

0
Tigray Afar Amhara Oromiya Somali B/Gumuz SNNPR Gambela Harari Addis Dire dawa
Ababa
Regions

Figure 2. 5 Proportion of incomplete immunization for the three EDHS periods Melaku et.al BMC

2.3.5 Routine Immunization Service Provision According to Service Availability and Readiness
Platforms and Strategies Assessment (SARA) 2018, about 81% of health
facilities offer child immunization services ranging
In Ethiopia, routine immunization service is available from 17% in Addis Ababa and 88% in Oromia
at almost all government health facilities through Region. MOH administrative data report (2012 EFY),
one or a combination of static, outreach, and has shown that 67.1% children received vaccination
mobile (extended outreach) strategies depending from health posts while 28.4% and 4.4% of
on the distance between the health facility and children received from health centres and hospitals
community’s settlement. respectively. Immunization services is by and large

12 Ethiopia National Expanded Program On Immunization

(98.5%) provided by government health facilities 2.3.7 Periodic Intensification of Routine
as private facilities and NGOs contribute for only Immunization (PIRI)
1.0% and 0.5% respectively. The distribution of
services in Addis Ababa City was slightly different In 2018, MOH initiated Periodic Intensification of
as contributions by government, private and NGO Routine Immunization (PIRI) strategy to improve
health facilities were 82.9%, 14.4% and 2.7% immunization coverage, reduce dropouts and the
respectively. Infants may start vaccination at the transmission of vaccine-preventable diseases. PIRI
facility of their birth but are likely to shift to their is tailored to improve the immunization inequity
nearest government facility for completion. and to reach every child with available and new
vaccines using a combined routine immunization
2.3.6 Reaching Every District/Child/ (RED/REC) and campaign-style strategies in 140 low
Approach performing woredas, including all woredas in the
developing regional states and in selected zones of
The RED strategy approach is a five-component agrarian regions. PIRI is instrumental in increasing
strategy aimed at reaching all eligible children in coverage but has a limitation that the approach
all districts and was first introduced in 2004. It was lacks the system to track achievements particularly
implemented in phases to reach current level of in measuring additional number of children reached
nationwide implementation. Since the introduction by the PIRI approach.
of the approach, there has been increased effort to
train health workers and use guidelines. The RED 2.3.8 Urban Immunization
guide has also been revised and contextualized as
recently as 2018, reprinted and distributed to the Immunization programme in urban areas is often
regions. As the result of RED implementation, the masked by the notion of better access to services
EPI program has generally improved and DPT 3 has and increased utilization leading to high vaccination
increased but it was also realized that its practical coverage. The true picture is, however, to the contrary
application of RED components was sub-optimal due to multiple factors including large number
to achieve the intended provision of equitable of undocumented and underserved populations.
and quality immunization services. The MOH has Urban population has seemingly better geographic
continued its effort to enhance and maximize the access to health services, service utilization is less
operationalization of the RED strategy and currently known. Urban population is rapidly growing as rural
leading an effort to roll out of the strategy to woreda populations and migrants are attracted to seek
and health facility levels through the development better opportunities and end up settling in slums
of a simplified and user friendly version of the RED with difficulty accessing services.
guide for use at PHCU level. At present the PHCU Undocumented migrant populations distort the
level RED guide which was field tested is in the denominator with which vaccination coverage
process of printing in different languages and will is calculated sending an inflated coverage data.
soon be ready for use by the lower level health The problem is a lot more complex and the health
facilities to enable them to reach every child with system alone cannot solve. Particular attention
quality services. and strategies are urgently required to address the

Comprehensive Multi-Year Plan (2021-2025) 13

problem, especially to reduce disparities and missed “National Facility Assessment for Monitoring the
opportunities. Besides, strengthening community Continuity of Essential RMNCAH Services during
health facility linkage, communication, and referral COVID-19” commissioned by UNICEF and conducted
system among health facilities in urban are essential by Development Research and Training (dab) in
to ensure children complete the required doses. Amhara, Oromia, SNNP, and Somali regions of
the country reported that outreach services were
2.3.9 Catch- up vaccination interrupted in 1.6% of the surveyed facilities. In
46% of health facilities reported that demand for
Catch-up vaccination refers to vaccinate children
health care services had declined. Highly affected
who missed doses for any reasons (e.g. delays,
health care facilities were primary hospitals (60%)
security, stock outs, access, hesitancy, service
followed by health centres (49%) and health
interruptions, etc.) and for which they were eligible
posts (34%). The reported reasons for the decline
as per the immunization schedule. Providing catch-
in demand were fear of exposure to COVID-19
up vaccination at fixed, outreach, mobile and/or
among service seekers while visiting the facilities
PIRI mini campaigns or local innovative strategies
(77%), fear of being labelled as having contracted
are part of immunization programs. Immunization
COVID-19 (58%), mixed messages - i.e. stay at
services are interrupted due to various reasons
home message conflicting with expectation to
including security incidence, public unrest, flooding,
seek essential health services - (55%), and lack of
and COVID-19 pandemic. The missed children should
information on availability of services (41%). It is
be reached with specific catch-up plans. As catch-
essential to prepare scale-up plans for intensifying
up vaccination is not frequently practiced program,
immunization activities to close the gaps and
it is critical to prepare catch-up guidelines.
prevent of VPDs outbreak.
2.3.10 Impact of COVID-19 on Immunization
2.3.11 New Vaccines Introduction
Programme
In the previous cMYP (2016-2020), it was planned to
Following a report of the first case in March 2020,
introduce six new vaccines, Inactivated Polio Vaccine
COVID-19 pandemic has affected the health system
(IPV), measles second dose, MR, Men A, Human
in many ways. The pandemic diverted the attention
Papilloma Virus, and Yellow Fever vaccines into the
of policy makers, political leaders, and public health
national immunization program. The introduction of
professionals. In Ethiopia, some health facilities
IPV, HPV and MCV2 was conducted in 2015, 2018
have been designated as solely COVID-19 isolation
and 2019 respectively. Post introduction evaluation
and treatment sites by leaving out other essential
for HPV and MCV2 vaccines indicated the successful
health services provision. Health sector monthly
implementation for HPV and MCV2 vaccines into the
analytic report in April 2020 by MOH showed
routine immunization system. Additional efforts are
that immunization coverage in the country has
needed to reach out-of-school girls and improve
declined with an average of 6% with variations
rollout of MCV2.
among regions. The draft report from the recent

14 Ethiopia National Expanded Program On Immunization

2.3.12 Polio SIAs and Progress in Polio Eradication cases were reported along the border of Sudan and
Initiative in 2008. Besides, a total of 10 confirmed WPV cases
were reported from Dollo Zone of Somali Region
In 1988, the WHO endorsed a resolution to in 2013. The last WPV case was reported from the
eradicate poliomyelitis by the year 2000, which then same zone and region on 5th January 2014.
the Global Polio Eradication Initiative (GPEI) was
established. Ethiopia has adopted the Global Polio Several rounds of polio SIAs at national, sub
Eradication Initiative since 1996. Since then, several national and high risk targeted were conducted
polio vaccination-campaigns have been conducted since the start of PEI in Ethiopia. The following table
at national and sub-national levels. Case-based shows selected SIA conducted during the last cMYP
AFP surveillance was established in 1998. Ethiopia period (2016-2020). Ethiopia has been certified as
introduced Inactivated Polio Vaccine (IPV) into the polio free status in 2017. WPV3 was eradicated in
routine immunization schedule in 2015. The trivalent Ethiopia and the world in 2017. Africa WHO/AFRO
oral polio vaccine (tOPV 1, 2, 3) was switched to declared polio free in August 2020 and awarded a
bivalent (bOPV 1, 3) in 2016 based on epidemiological certificate in October 2020.
evidences and global directions. The country has
been conducting a series of successful national and Polio SIA has been continuously conducted at
sub-national polio SIAs. national and sub-national covering 19-33% of the
under-five population in selected zones based on
Ethiopia was considered a polio endemic country risk analysis. Case based AFP surveillance is still in
until 2001 when the last indigenous confirmed wild place at all the regions. A summary of the polio NIDs
poliovirus was isolated from a child in the SNNP and mOPV2 SIAs in the country during the period
Region. However, the country experienced multiple 2013 through 2020 with administrative coverage are
polio outbreaks following five separate importations shown in below table.
from neighbouring countries. There were 22 reported
WPV cases in 2004, 17 WPV cases in 2005, three
WPV cases were reported in 2006, and other three

Comprehensive Multi-Year Plan (2021-2025) 15

 Table 4. Polio (bOPV) SIAs coverages, 2016-2019, Ethiopia

16
2016 2017 2019 2020

No REGION 1ST Round SIAs 2ND Round SIAs 1ST Round SIAs 2nd Round SIAs 1st Round SIAs 2nd Round SIAs 3rd Round SIAs Vaccinated %

Vaccinated % Vaccinated % Vaccinated % Vaccinated % Vaccinated % Vaccinated % Vaccinated %

1 Amhara 493,801 96.8 487,971 97 499,489 96 499,671 96 513,257 96

2 Oromia 2,531,921 105.9 2,460,982 103 2,795,361 114 2,531,385 104 1,450,642 103 1,473,317 103 2,666,079 104

3 SNNPR 252,012 105.3 251,381 100 259515 103 267,046 106 274,064 101

4 Tigray 75,344 102 74,398 103 73,063 98 74,420 102 74,133 99

5 Gambella 101,724 94.5 114,846 100 116,601 97 126,103 98 142,794 103 144,528 96 147,655 99

6 B/Gums 184,119 97.3 185,868 102 190,473 98 192,243 108 184,601 92

7 Afar 273,500 98 253,910 100 250,853 99 251,090 99 268,855 98

8 Dire Dawa 59,516 97.2 60,791 99 60,698 103 63,564 104 72,184 114

9 Harari 46,113 95.6 46,241 97 49,237 99 49,338 101 51,554 104

10 Addis Ababa

11 Somali 1001325 96.3 1,022,712, 98 1,062,709 98 1,056,775 98 1,176,428 99 1,163,897 98 1,230,955 99 1,414,120 100%

Total 5,019,375 101.6 4,959,135 100 5,357,999 106 5,111,635 102 2,769,865 101 2,781,742 100 5,482,337 101 1,414,120 100%

Remark: Target for 2019 in 1st and 2nd rounds was 19% of the national target

Ethiopia National Expanded Program On Immunization

Ethiopia is currently affected by circulating vaccine six rounds of SIA with mOPV2 vaccines in each
derived polio viruses type 2 (cVDPV2) since 2019. affected and other risk zones in the three regions
The first cVDPV2 case was reported from Dolo Zone between June 2019 to March 2020 (Table. 5).
of Somali Region on 20 May. Ethiopia has conducted

Table 5. mOPV2 SIAs coverages, 2018-2020, Ethiopia

2018 2019 2020

1 Round SIA
ST
2 Round SIA
ND
1 Round SIA
ST
2 Round SIA
nd
2 Round SIA
nd

No. REGION Vaccinated % Vaccinated % Vaccinated % Vaccinated % Vaccinated %

1 Oromia 738,808 106 736,808 108

2 SNNP 975,771 106 1,027,710 111

3 Somali 497,953 99 509,049 102 281,336 101 588,839 100

Total 497,953 99 509,049 102 1,995,915 104 588,839 100 1,764,518 108

2.3.13 Measles SIAsW (follow up vaccination campaigns) and children of

age 6/9 months to 14 years (catch-up vaccination
Despite implementation of measles elimination campaigns), mostly achieving coverage of above
strategies including conducting measles SIAs 95%. The first phase “catch-up” vaccination
and introducing MCV2, Ethiopia is not on track to campaigns, targeting children 6 months to 14 years,
achieve measles elimination targets. Thus, the were conducted from 2003 to 2005 and covered all
country developed a measles elimination plan for regions, zones and woredas. Following the catch-
2018-2022 to accelerate implementation of the up measles SIAs, Ethiopia has been conducting
elimination interventions. follow up measles SIAs almost every 2-3 years
Ethiopian routine immunization coverage data targeting children 6/9-59 months depending on the
indicates there are close to 1.2 million children analysis of measles epidemiology and susceptible
unvaccinated for measles vaccine with MCV1 population profiles. Despite of the efforts to improve
coverage of 58%, suboptimal population immunity. routine immunization and frequent measles SIAs,
In addition, since the introduction of MCV2 in rampant measles outbreaks still has continued to
routine immunization in 2019, coverage progressed occur in the country, particularly every 2-3 years
to 53% for 2012 EFY. Ethiopia has conducted after each measles SIA because of accumulation of
several measles SIAs in the past 17 years, susceptible population due to persisting low routine
primarily targeting children age 6/9-59 months measles vaccination coverage.

Comprehensive Multi-Year Plan (2021-2025) 17

 Measles immunity profile, Ethiopia
As of December 31,2022

100%
7% 7% 7% 8% 8% 8% 7% 7% 6% 5% 5%
17%

38%
75% 47% 45%
41% 39% 40% 46% 65%
30 % 46% 43% 46% 47% 46%
58%
12 %

50% 5% 6% 4%
Percent

25% 50% 49% 49% 49% 46% 49% 47% 52% 55% 54% 49%
45% 46%
34% 30%

0%
2022(0)

2021(1)

2020(2)

2019(3)

2018(4)

2017(5)

2016(6)

2015(7)

2014(8)

2013(9)

2012(10)

2011(11)

2010(12)

2009(13)

2008(14)
Birth Year (age)

% protected by maternal antibody % immune by MCV1 % immune by MCV2

% immune by SIAs % not protected

Figure 2.6 Measles immunity profile for population ≤19 years, Ethiopia, 2020.

The planned measles follow up SIA for 9-59 months by undertaking all the necessary precautions to
old children in April 2020 was postponed to July prevent further spread of COVID-19 during the
2020 because of the COVID-19 pandemic. Because campaign. This most recent campaign achieved
of the continued progressive measles outbreaks 97% administrative coverage.
in many parts of the country, the MOH decided to
conduct the measles vaccination campaign during
the early transmission of COVID-19 in the country

18 Ethiopia National Expanded Program On Immunization

Table 06 Measles Supplementary Immunization Activities, Ethiopia, 2011-2020

Year Number of Zones/ Target population Coverage Remarks

Woreda 6/9-59 6/9 month- Vaccinated Admin RCS1/
months 14 years (%) Coverage
survey (%)
Dec 146 woredas 7,034,264 7,034,264 96 96.4 Covered total 32 Zones:
2011 (potential risk of all Zones in Somali and
measles outbreak selected zones in Oromia,
and high-risk SNNP, Amhara. Tigray and
drought hot spot), Afar.
targeting age group
6 months-14 years
June All woredas in all 11,873,928 11,609,484 98 91
2013 regions, targeting
age group 6-59
months
2015 368 woreda 4,795,622 56,637 5,046,349 104 Emergency SIAs in
selected from all drought affected
regions except woredas.
Addis Ababa
It was 9–59 months
in Benishangul Gumuz
Region.
2016 All except Addis 25,706,550 24,935,354 97 94 545 woredas in 62 zones
Ababa – Woredas covered
2017 All woredas in all 24,814,965 24,070,516 97 93 All woredas
regions
2020 All woredas in all 14,950,084 14,501,581 97 All woredas
regions

Ethiopia is now planning for a measles SIA in is believed to be prevalent in pocket areas of the
2022 targeting all children 9-59 months old and country due to low routine tetanus toxoid vaccination
implementing innovative strategies to reach zero- coverage coupled with the high number of deliveries
dose and under-immunized children. handled by untrained personnel. In an effort to
sustain MNTE, Ethiopia developed sustaining
2.3.14 Maternal and Neonatal Tetanus SIAs strategies including:
Ethiopia was declared free of Maternal and Neonatal 1. Reduce to less than one case of neonatal
Tetanus by the WHO and UNICEF expert validators tetanus per 1,000 live births by 2010,
in June 2017 and it is a significant achievement
2. Increase Penta 3 coverage >80% in all woredas,
for the country. However, Neonatal Tetanus death

Comprehensive Multi-Year Plan (2021-2025) 19

3. Increase access to skilled attendants at birth were achieved in all three phases of the Men A
and clean cord care practices to >80% in all mass vaccination campaigns with above 97.6% and
woredas,
post campaign coverage survey report for the third
4. Achieve high Td2+ coverage or Td protection phase mass vaccination campaign showed coverage
among pregnant women to >80% in every of 94%.
woredas, achieve Td vaccination of school
children, achieve 100% timeliness, accuracy, 2.4 Disease Surveillance
and completeness including zero-dose
reports from all reporting health facilities and 2.4.1 Vaccine-Preventable Diseases Surveillance
strengthening programme communication on Td In Ethiopia, VPD surveillance is implemented
immunization and MNCH services. within the framework for the Integrated Disease
Surveillance and Response (IDSR) strategy; the
2.3.15 Meningitis A vaccination campaign
strategy was adopted by the FMOH in 2001. After
Ethiopia has had outbreaks of meningococcal the restructuring of the FMOH in 2009, the country
meningitis occurring every 8-12 years. A risk adopted IDSR as part of Public Health Emergency
assessment in 2012 showed that 5 regions were Management (PHEM) and VPD surveillance became
at high risk and the remaining 6 regions were at a component of the PHEM core process at the federal
low to moderate risk for meningitis A outbreaks. level within the Ethiopian Public Health Institute
Accordingly, the country planned to conduct Men A (EPHI). The VPD surveillance infrastructure (human
mass vaccination campaigns for individuals of age and logistics) have provided the platform on which
1-29 years (70% of total population) in three phases IDSR implementation was rolled out nationwide.
over a three-year period from 2013 to 2015. The
PHEM guidelines was developed in 2012 for the 21
geographical meningitis epidemic risk levels and
diseases under surveillance and specific guidelines
risk-based phases of the Men A SIAs is shown in
for diseases and disease conditions such as AFP,
Figure 18.
measles, MNT and cholera have been finalized and
Phase I Men A SIA was conducted in October 2013 PHEM trainings have been conducted. Recently,
in the most high-risk areas of the country that are Maternal Death Surveillance and Response (MDSR),
found at the African meningitis belt. During phase scabies, and perinatal death have also been included
I Men A SIA, a total population of 18,926,853 in into reportable diseases.
the age 1-29 years living in 30 zones in six regions
Since PHEM’s establishment, there has been a
(Tigray, Amhara, Gambella, Benishangul-Gumuz,
steady increase in completeness of PHEM reporting.
SNNP, and Oromia) were targeted. Phase II Men A
Community level data is captured by Health
SIA was conducted in October 2014 targeting a total
Extension Workers (HEWs) through community-
population of 26,910,795 in the age 1-29 years living
based surveillance volunteers. Recently, the
in in 45 zones in three regions (Addis Ababa City
establishment of the HDA has provided an additional
Administration, Oromia, and SNNP). The third phase
source of community-based data. Other community-
of Men A campaign was conducted in October/
based surveillance structures have been established
November 2016 targeting a total population of
by PHEM and partners (including Core Group, JICA
15,910,620 who are 1-29 years old living in 257
and WHO). Case based surveillance of AFP, Measles,
woredas, 27 zones in seven regions (Afar, Amhara,
NNT, YF and sentinel surveillance for new vaccines,
Harari, Oromia, Somali, Tigray, and Dire Dawa City
such as, pediatric bacterial meningitis (PBM) and
Administration). High administrative coverages

20 Ethiopia National Expanded Program On Immunization

Rotavirus gastroenteritis are also undergoing. Currently, cVDPVs have emerged as a global key
Ethiopia has achieved 91.7% national completeness challenge in the final stage of eradication efforts.
and 90.2% timeliness for disease surveillance in Ethiopia is currently affected by circulating vaccine
2020. derived polio viruses type 2 (cVDPV2) starting
from 2019 to 2020, with first onset of paralysis
2.4.1.1 AFP Surveillance in 20 May 2019 occurred in Somali Region/Dolo
Zone. Cases of cVDPV2 have been then confirmed
Nationally, AFP surveillance has been sensitive in several regions, namely Somali (Dollo Zone),
enough to identify polio cases including ambiguous Oromia (West Arsi Zone), SNNPR (Wolayita Zone),
and circulating vaccine derived poliovirus (cVDPV). and in Amhara region (Oromo special zone). In
The two most important AFP surveillance indicators; addition, three cVDPV2 have been isolated from
non-polio AFP (NP-AFP) and stool adequacy rate three environmental sample from Addis Ababa
have been achieved at national level; however, in 2019. As response to the cVDPV2 outbreaks,
sub national gaps have been identified. The other Ethiopia has been conducting a series of SIAs with
concern is the laboratory indicator of Non-polio monovalent oral polio vaccine type two (mOPV2), in
enterovirus isolation rate which has been declining, each affected and risk areas between June 2019 to
for the past four years to levels below the target of March 2020(Table 5).
10%.

Table 7. Summary of AFP surveillance indicators in Ethiopia, 2016-2020 (Source EPHI VPD weekly update)

Indicators Target 2016 2017 2018 2019 2020

NP-AFP rate per 100,000 < 15 Yrs. 2.0 3.1 2.5 2.3 2.6 2.5
Stool adequacy 80% 91% 92% 93% 90% 90%
Timelines and completeness of reporting 80% - 86.2% 89.6% 89.12% 90.2%
of priority diseases
90% 88.4% 93.1% 93.4% 91.7%
Investigated < 2 days of notification 80% 93% 92% 93% 89% -
Specimen arriving at lab < 3 days 80% 99% 99% 99% 98% 79.8%
Specimen arriving in good condition 90% 85% 92% 89% 95% 98%
Non-polio enterovirus isolation rate 10% 9.10 7.20 7.00 3.90 6.8
Timely Lab result within 14 days of receipt 80% 89% 90% 91% 90% 67.4%

Proportion of AFP cases with zero/ 0 9% 10% 5% 6% -

unknown doses
Number of cases with wild polio virus 0 0 0 0 0 0
Proportion of polio cases with zero/ 0 0 0 0 0 -?
unknown/ doses

Comprehensive Multi-Year Plan (2021-2025) 21

2.4.1.2 Measles surveillance where measles virus may still be circulating is
detected in a timely manner and no imported case
In Ethiopia, measles is a major health problem and is detected late. Though measles surveillance has
common cause of morbidity and mortality in children. identified outbreaks and cases each year and major
Ethiopia initiated measles case-based surveillance surveillance indicators are achieved nationally,
in 2003, integrated with the AFP surveillance which some surveillance indicators were not achieving the
was supported by laboratory investigation starting target. Trends of measles surveillance performance
from 2004. The measles case-based surveillance indicators for the previous years is indicated in
has been established to ensure that any area Table 6.

Table 8. Measles case-based surveillance performance indicators, 2010-2020 (Source: measles surveillance update 2020)

Measle Surveillance Quality Indicators, Ethiopia, 2010 - 2020

Indicators Target 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Annualized rate
of investigation of
suspected measles
case per 100,000 >=2 3.8 7.3 5.1 6.2 6 4.8 3.6 3.1 2.9 2.7 2.4
Non- measles febrile
Rash Rate >=2 2.6 2 3.8 3.9 2.1 2.3 1.9 2.4 3.2 2.1 1.4
Proportion of Woreda
with >=1 cases per
100,000 with a blood
sample (%) >=80 83 96 99 100 80 76 63 69 70 80 54
Proportion of
reported measles
cases with blood
specimen (%) >=80 100 100 96 99 91 42 100 100 100 100 100
Proportion of measles
IgM+ (%) <10 14 29 26 35 53 49 40 18 13.2 27 36

In 2020, a total of 1503 confirmed measles outbreaks measles outbreaks in 2020 compared to 125 in 2019,
were reported compared to 2255 in 2019 and 1204 and 55 in 2018. (see Table 7).
in 2018. A total of 108 woredas were affected by

22 Ethiopia National Expanded Program On Immunization

Table 9. Summary of Measles Outbreaks, by Year, Ethiopia, 2010 – 2020

Indicators 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
#of Measles 76 60 196 146 243 293 128 67 55 142 112
Outbreak
#of Woredas 59 51 143 125 192 242 113 61 55 125 108
Affected with
Measles Outbreaks
#Igm + cases from 309 248 945 623 1402 1567 690 315 241 792 531
the Outbreak
#EPI-linked cases 3092 1530 2582 3178 3982 9054 2159 1194 963 1363 972
#Total Confirmed 3201 1776 3527 3801 5384 10,621 2849 1509 1204 2155 1503
Outbreak cases

The measles incidence rate in the country used to be 20 per million population per year in Tigray to 76
varied from year to year, mainly affected by measles per million population per year in SNNPR and Addis
SIAs (Table). Measles incidence in 2019 was Ababa (Table 8). There is also wide variation in the
reported to be 40 per million population per year, measles incidence among zones (Fig. 10).
with wide variation among regions, ranging from

Table 10. Measles Incidence Rate by Region, Ethiopia, comparison between 2018 & 2020

Region Incidence Per 1,000,000 population

2018 2019 2020
Addis Ababa 7 76 27
Afar 12 24 23
Amhara 7 33 17
B/Gumuz 1 25 9
Dire Dawa 4 42 24
Gambella 165 50 2
Hareri 4 38 0
Oromia 1 40 21
SNNPR 6 39 19
Somali 93 76 19
Tigray 4 20 15
National 16 40 19

Comprehensive Multi-Year Plan (2021-2025) 23

In 2019, the most affected regions by measles Somali regions have been contributing of majority of
outbreaks were Oromia, SNNPR, Amhara, and the measles cases in the previous years.(see Fig 11)

1600
1510

1400 50
46
45
1200
40

1000 35

781 30 28
800 736
25 23
21
600
20
457
400 15
277 10
10
200 114
5

0 0
Oromia SNNPR Amhara Somali Addis Tigray Hareri D. Dawa Gambela B. Gumuz Afar

Figure 2. 7 Comparison of Confirmed Measles Cases by High and Low Contributing Regions, Ethiopia, Jan-Dec 2019

Larger proportion of measles cases occur in the gradual increase in the proportion of measles cases
age group below five years, though there has been in adults as shown in Fig. 12 below.

<5 5 to 10 11 to 15 >15

100
90 17% 16% 16% 15% 22%
25% 20% 27% 27%
80 11 % 41%
43%
Confirmed Measles Cases

14% 14% 16% 8%

70
15%
22 %
17% 9%
60 21%
24% 29% 23
% 23%
50 12% 11%
24 %
27% 25% 23%
40
17% 15%
30
20 45% 41% 45% 53% 47%
33%
33 %
33
% 40%
10 30% 31%
0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

n= 6196 4515 4619 6539 13311 17745 4579 1921 1512 3998 1944

Confirmed= Lab Confirmed + Epi linked + Clinically Compatible Cases

Figure 2. 8 Trend of Confirmed Measles Cases by age Distribution, 2010–2019, Ethiopia)

24 Ethiopia National Expanded Program On Immunization

2.4.1.3 Rubella Surveillance antibody in cases of rash illness where Measles
IgM antibody is negative. The incidence of rubella
The measles surveillance platform is also used to infection was unmasked for the first time in 2011.
identify rubella cases, , which includes laboratory The trend of confirmed rubella cases for the previous
testing for the detection of rubella-specific IgM 10 years is indicated in Fig.13 below.

Lab Confirmed Rubella Cases by Year, Ethiopia

2010 - 2020
900
812
800 775

700
652

600
No. of Rubella IgM+

500

400
329
310
300 266
213
200 174 184
130
95
100

0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Year

Figure 2.9 Lab confirmed Rubella Cases by Year, Ethiopia, 2010-2020

Children of age below 10 years account for majority geographic distribution of confirmed Rubella cases
(84%) of the confirmed Rubella cases. The age and is indicated in Figs 14.

<5 5 to 10 11 to 15 >15

100% 0%
0% 0% 7% 0% 7%
12% 13% 14%
90% 7% 12%
33% 13%
80% 40% 14%
47 %
70%
0% 36%
44%
% Rubella Caases

60% 80% 33% 44%

50% 43% 100%
40% 40%
30% 67%
50% 33 %
50%
20% 41% 37%
10% 29%
20 %
20 %

0% 0% 11%
Addis Ababa Afar Amhara B. Gumuz Gambela Oromia SNNPR Somali Tigray National

n= 31 3 10 5 5 16 16 7 2 95

Confirmed= Lab Confirmed + Epi linked + Clinically Compatible Cases

Figure 2.10 Age distribution of Confirmed Rubella Cases by Region, Ethiopia, Jan to Dec 2020

Comprehensive Multi-Year Plan (2021-2025) 25

2.4.1.4 Neonatal tetanus surveillance the success of MNTE, the country entered in to a
new phase called sustaining elimination which
The elimination of neonatal tetanus (NT), defined as requires:
a rate of <1 NT case/1000 live births in every district
in a country, has been a global goal since 1989 when ■ Continued strengthening of routine immunization
an estimated 800,000 deaths from NT occurred each activities for both pregnant women and children.
year. Elimination of maternal tetanus was added
to the program objectives in 2000 when UNICEF, ■ Maintaining and increasing access to clean
WHO and UNFPA renewed their commitment to NT deliveries
elimination, forming the Maternal and Neonatal ■ Ensuring reliable NT surveillance
Tetanus (MNT) Elimination Initiative. As MNT is
not an eradicable disease, the first milestone is ■ Introduction of school-based immunization,
to achieve MNT elimination in all countries, while where feasible
the second is to maintain elimination status in all
districts of countries that have achieved validation Ethiopia was validated for elimination of Maternal
status. Neonatal Tetanus (MNT) in June 2017. Sustaining
the MNT elimination through the recommended
In Ethiopia, efforts to reduce NNT began in 1980 strategies will be the major strategic direction in
with the start of the EPI program which included this strategic planning period.
TT immunization of women of reproductive age,
with more focus to pregnant women. This was 2.4.1.5 Paediatric Bacterial Meningitis/Hib
further strengthened by including NNT as one Surveillance
of the immediately reportable diseases and
enhancing case-based surveillance using the AFP Hib and HepB vaccines were introduced in the
surveillance network and infrastructure. AFP and routine immunization program in May 2007, while
measles activities integrated capacity building and Pneumococcal Conjugate Vaccine (PCV) was
sensitization on NNT surveillance for health workers introduced in 2011. Three hospitals, Tikur Anbessa
and community members. Hospital, (TAH), Yekatit 12 Hospital and Gondar
University Hospital, have been conducting sentinel
In April 2011, the government of Ethiopia concluded surveillance for pediatric bacterial meningitis
that the country had likely eliminated maternal and (PBM), since 2002, 2008 and 2009, respectively. The
neonatal tetanus as a public health problem and sites are tertiary-level hospitals, and the aim of the
requested a formal assessment by WHO. Considering surveillance is to provide information on the burden
the population size and traditional value towards of disease and determine disease epidemiology
neonatal death, there was an assumption that there based on genotypes and serotypes. The sites are
might be unreported cases of NNT, as nationally enrolling a significant number of cases; however,
the number of reported NNT cases was below the the level of performance indicators varies widely
acceptable number compared to the number of live among the three sentinel sites. Regular feedback
births in the country. Low awareness among health is provided from the national level to the sentinel
workers and the community about NNT as one of sites. Data is regularly analyzed and shared with the
the reportable diseases, its case definition and sentinel sites, EPHI, IST and AFRO.
reporting process has been a major gap. Following

26 Ethiopia National Expanded Program On Immunization

 1400
Number of Suspected PBM

1200
1000
800
cases

600 1166 1163

944 883 994
400 845
200
0
2015 2016 2017 2018 2019 2020
Year

Figure 2.11: Number of Suspected Pediatrics Bacterial Meningitis Cases per Year from 2015-2020

20
Number of Culture Confirmed PBM Cases

18
16
14
12
10 Nm
8 Spn
6 Hib
4
2
0
2015 2016 2017 2018 2019 2020
Year
Figure 2.12 Etiologies identified for PBM, 2015-2020, Ethiopia;
Figure 2. 12 Etiologies identified for PBM, 2015-2020, Ethiopia;
Note: etiologies areStreptococcus
Note: etiologies are HiB, HiB, Streptococcus pneumoniae
pneumoniae (Spn) and (Spn) andMeningitides
Neisseria Neisseria Meningitides
(Nm) (Nm)

Comprehensive Multi-Year Plan (2021-2025) 27

2.4.1.6 Rotavirus Surveillance Sentinel site coordinators and site members were
designated and trained to coordinate the day-to-
The FMOH continued to work in collaboration with day activities. Rotavirus vaccine was introduced
EPHI and WHO to monitor the epidemiological in November 2013. Rota Sentinel surveillance
impact after rotavirus vaccine introduction. is ongoing in referral hospitals where there are
Surveillance activities were initiated in selected teaching hospitals.
sentinel sites in 2007 at Black Lion Hospital with
further expansion to other two sites in Yekatit 12 and
Betezata Hospitals in 2008 and 2011, respectively.

Table 11. Rota Virus Positivity Rate, sentinel surveillance indicators, 2015-2020, Ethiopia

Indicators Target 2015 2016 2017 2018 2019 2020

# of <5 acute diarrhea
hospitalizations
reported >=80 301(126%) 210(88%) 180(75%) 225(94%) 353(148%) 208(87%)
% stool specimens
collected within 2 days
of admission >=90 100 100 100 100 100 100
% of collected stool
specimens that arrive at
laboratory for testing >=95 100 100 100 100 100 100
% of received
specimens that are
tested >=90 100 100 100 99.1 98.9 100
(%) ELISA Rotavirus 210 180 223 349 38
confirmed cases >=20% 301(100%) (100%) (100%) (99.1%) (98.9%) (18%)

2.4.2 Laboratory personnel are available. The measles laboratory

was accredited in September 2005. There are also
2.4.2.1 Polio Laboratory two regional laboratories in Amhara and SNNPR
(Hawassa) but do not do tests due to lack of
The national polio laboratory is located in the EPHI.
reagents, adequate sample comes from the regions
Since its establishment, the laboratory has scored
and other related problems.
an excellent proficiency test and onsite review
evaluation scores.
2.4.2.3 Rota Laboratory
2.4.2.2 Measles Laboratory
Rotavirus infection was determined by using
The measles national laboratory is in the same an antigen capture enzyme immunoassay (EIA;
premise with polio laboratory and all the necessary ProSpecTTM Rotavirus kit, Oxoid Ltd, United
resources such as equipment, reagents and trained Kingdom) at the national polio and measles laboratory

28 Ethiopia National Expanded Program On Immunization

of the Ethiopian Public Health Institute (EPHI). functioning end-to-end cold chain management
All positive samples were further characterized to ensure vaccines potency to the last mile, and
by molecular methods at the Rotavirus Regional ultimately to every person being immunized. iSC
Reference Laboratory (RRRL): SAMRC Diarrheal requires adequate, appropriate, and functional
Pathogens Research Unit, Department of Virology, cold chain and transportation infrastructures and
Sefako Makgatho Health Sciences University, well skilled human power, quality data to ensure
Pretoria, South Africa.The rota laboratory is in the availability of quality and potent vaccine at all level
same premise with polio and measles laboratory of the supply chain.
and all the necessary resources such as equipment,
reagents and trained personnel are available. The 2.5.1 Effective Vaccine Management
measles laboratory was participate on EQA and the
The Global EVM design helps countries achieve high
achievement were 100%.
standards of performance in immunization supply
chain. It also helps to best practices that need to be
2.4.2.4 Bacteriology Laboratory promoted, scaled up, and sustained at all levelsThe
Effective Vaccine Management (EVM) initiative is a
The three hospitals conduct sentinel surveillance for
corner stone for strong immunization supply chain.
pediatric bacterial meningitis (PBM): Tikur Anbessa
EVM is generally geared along with the six supply
Hospital, (TAH), Yekatit 12 Hospital and Gondar
chain essentials namely: system Design, Cold Chain
University Hospital, are still doing PBM detection
Equipment (CCE), Temperature monitoring & control
and treatment starting since their establishment at
(TMC), Distribution, Human Resource (HR) and Data;
the accredited bacteriology laboratory at EPHI. In
2019 and 2020 there is no culture confirmed case The MOH has conducted Effective Vaccine
of Neisseria Meningitides and the culture confirmed Management Assessments, (EVMA) in 2019, to
Streptococcus pneumonia decreased year to year. evaluate the performance and identify areas of
improvement. The assessment result showed an
2.5 Immunization Supply Chain improvement from the 2013 EVM cumulative score,
Management which was 65% to 70%.The assessment showed
The success of any immunization activity, whether an improvements in majority of the criteria except
routine, campaign, or VPDs emergency responses, for three indicators, E3 (storage capacity (i.e.
ultimately depends upon having the right product vaccine, dry supplies& transportation capacity)), E5
available in the right quantity at the right time and (maintenance of building, cold chain equipment and
place. Immunization supply chains (iSC) have a vaccine delivery vehicles) and E9 (MIS & supportive
unique attribute due to their dependency on a well- functions).

Comprehensive Multi-Year Plan (2021-2025) 29

 EVM Criteria Scores - Ethiopia
100%

90%

79% 80% 81%

80%
78%
76%
74%
70% 70% 69% 70% 70%

65% 65% 65% 66%

60% 51%
57% 60% 57% 58%
56%

50%

40%

30%

20%

10%

0%
Composite E1 E2 E3 E4 E5 E6 E7 E8 E9

evm_2013 evm_2019

Figure 2. 13 Assessment results EVMA 2013 & 2019 – Composite and Criteria score

Figure 35 below shows the performance by supply points (Woreda) and there is decline at service points
chain level for the two assessments conducted in (Health Facility) from 71% to 65%. Comparison of
2013 and 2019. The 2019 result shows that there the criteria scores for 2013 and 2019 assessments
has been an improvement in the composite scores at national and sub national levels shows significant
at the primary store (National) from 60% to 78% and improvement as the level progresses in all the
Sub-national level (Hub) from 64% to 74%, whereas criteria whereas the opposite is true for the Woreda
there is no change (63%) at the lowest distribution and health facility levels.

Performance per Supply Chain Level - EVM, Etiopia

100%
evm_2013

90% evm_2019

80%
78%
74%
71%
70% 70%

65% 63% 65%

64% 63%
60%
60%

50%

40%

30%

20%

10%

0%
Composite Score EPSA Hub Woreda HF

Figure 2. 14 EVM performance per supply chain level for 2013 and 2019

30 Ethiopia National Expanded Program On Immunization

 National level EVMA 2019 Result by criteria

National level EVMA 2019 Result by criteria

E1: Vaccine arrival

100%
92%
E9: IMS, support- 80% E2: Temperature
ive functions
60%

40%

E8: Vaccine 20% E3: Storage

management capacity
0%

E7: Distribution E4: Buildings, equipment

& transport

National E6: Stock

WHO management E5: Maintenance
Hub Leve EVMA 2019 result
Hub Leve EVMA 2019 result

63%
E2: Temperature
90%
80%
90%
70% E3: Storage capacity
59% 60%
E9: IMS, supportive 50%
functions 40%
30%
20%
10% 82%
84% 0% E4: Buildings, equipment
E8: Vaccine & transport
management

77%
E7: Distribution 72%
E5: Maintenance

Hub EVMA 2019 80%

E6: Stock management
Min WHO

Comprehensive Multi-Year Plan (2021-2025) 31

 Woreda level EVMA 2019 result

Woreda level EVMA 2019 result

71%
E2:
Temperature

48% 80% 76%

E9: IMS, 60% E3: Storage
supportive… capacity
40%
20%

77% 0% 71%
E8: Vaccine E4: Buildings,
management equipment…

65% 51%
E5:
E7:
Distribution Maintenance

57% Woreda EVMA 2019

E6: Stock Min WHO
management

HFHFlevel
levelEVMA
EVMA 2019
2019result
result

70%
E2: Temperature

45%
100% 76%
E9: IMS, supportive
functions 80% E3: Storage capacity

60%
40%
20% 74%
82%
E4: Buildings,
E8: Vaccine equipment & transport
management 0%

59% 56%
E7: Distribution
E5: Maintenance

HF EVMA 2019 50%

Min WHO E6: Stock management

Figure 2. 15 EVMA performance in supply chain level by EVM criteria 2019 EVMA

32 Ethiopia National Expanded Program On Immunization

Based on the 2019 EVMA result, continuous non-functional cold chain equipment. Because
improvement plan (cIP) is developed for the identified of the indicated (above) reasons, Ethiopia has
gaps with implementation period from 2021 to 2025. developed CCE Expansion and Replacement
Plan (2018-2020). EFSA (PSA) transition plan
2.5.2 Cold Chain Equipment Management was in advance stages in most hubs to reduce
the five tier system in to a mix of four/three-tier
The vaccine cold chain is not only an integral part,
system.
but the very backbone, of an immunization program.
It is a system for storing and transporting vaccines ■ All CCE procured and installed before 2013 are
at recommended temperatures from the point of going to be replaced taking into consideration
manufacture to the point of use, thus ensuring the 10-year lifespan of CCE. This will be
the potency and safety of vaccines throughout the complemented by the fact that all absorption
transport and storage phases. refrigerators will be phased out by 2022 from the
vaccine Supply Chain of the country irrespective
Ethiopia CCE Expansion and Replacement
of ages. If there are CCE procured after 2013 and
Plan (2018-2020) and implementation
not meeting the CCE technology requirement,
■ The cold-chain system has to be rehabilitated replacement of these kind of equipment will be
periodically and expanded to meet the changing also considered.
requirements of an immunization programme.
■ The new and underutilized vaccine introduction
Managers are encouraged to use this process
plan for the coming 5 years includes measles
to improve quality of service, increase efficiency
second doses (or MR), HPV, Td, MenA, HepB at
of the system and reduce operational costs. The
birth and Yellow Fever.
rehabilitation planning process should involve
an assessment of the impact of expected ■ Consideration is made to population projection
changes on the required capacity at each level for the coming 10 years to enable the programme
of the programme. Both static and outreach to meet its requirement in terms of NUVI plan
immunization service delivery depend on a and population increase in alignment with
reliable, adequate and functional cold chain the lifespan of cold-chain equipment which is
system. considered 10 years.
■ In the context of Ethiopia, equipment lifespan, ■ As vaccination campaign is one of key strategies
functional status, the shift from Kerosene that aim at increasing population immunity
refrigerators to electric and solar driven against vaccine-preventable diseases and
cold chain equipment, the expansion of the have the potential to constrain the cold chain
immunization services close to community, capacity, 25% additional storage capacity need
the introduction of new vaccines and other is considered for vaccination campaigns and
interventions such as campaigns were the key other interventions during estimation of the
reasons for the development of the cold chain storage capacity requirement.
rehabilitation and expansion plans. In addition,
there has been a growing demand for cold chain In 2017 onwards, the GAVI CCEOP project was
equipment in Ethiopia as a result of population commenced with total budget close to 27mUSD
growth, expansion of health services, and an to equip health facilities with optimal cold chain
increase in immunization coverage. Moreover, equipment
there is a continuous need to replace aging and

Comprehensive Multi-Year Plan (2021-2025) 33

In 2018, addressing access limitation to immunization temperatures of refrigerator trucks equipped with
service in four developing regional states: Somali, RTMD recently and using data for action will start
Afar, Benishangul-Gumuz & Gambella) and in 2019 soon.Through Gavi HSS & other funding sources,
covering regional disparity in equity and coverage the country procured over 8,134 Solar Direct Drive
among regions in pastoral areas of Agrarian refrigerators (SDDs) and installed over 99.8% of it to
Regions: Oromia: Borena , Guji, West Guji,, Bale); accommodate newly introduced vaccine, replacing
SNNPR: South Omo zone, Bench Maji Zone and the old and expanding immunization service to hard
in all rural District with less than 80% coverage. and difficult to reach areas. The SDG turnkey project
Accordingly, a total of 846 refrigerators were was initiated to procure 6000SDDs and equip
installed from the total 934 systems accounting for health post with optimal cold chain. The overall
91%. The remaining units are pending installation all implementation of this project is rated as 99%,
due to security and other unforeseen reasons. (only 59 refrigerators are pending installation due
to different reasons).These efforts bring up the total
The challenges with poor data quality of the national health post with cold chain equipment (optimal and
cold chain inventory data, delay in operational non-optimal) providing immunization service point
deployment plan development, procurement estimated to more than 50%.
process and installation and shortage of the budget
are the main challenges encountered through the Existing CCE at woreda cold stores will be re-
implementation both (SDG-PF & CCEOP) projects. positioned as needed and non-functional CCE will
On top of this, security situation in some part of the be repaired until woreda cold stores are bypassed
country is one of the pressing issue still ongoing and through EPSA’s supply chain strategy, at which point
affecting the timely installation and completion of the remaining CCE equipment will be relocated to
the projects. health facilities.

Since in 2013, the country procured and installed National Cold Chain Equipment Inventory
61 Cold rooms, 2 freezers were installed and as a
result cold storage capacity increased from 1,300 in National cold chain equipment inventory (CCEI) was
2013 to 4,248 cubic meters. In the last five years, conducted in 2020 with the objective of quantifying
over 27 cold rooms were regularly maintained (both and characterizing their variety, capacity and
corrective and preventive) at different hubs. Five functional status among HPs, HCs, Hospitals, and
new cold room’s installation at different EPSA hubs: administrative units throughout the country. The
(AA-Hana Mariam (2), AA- Jackros (1) Semera (1) survey also aimed to evaluate the cold chain storage
& Assosa (1) in 2019 as a result of new five cold capacity and distribution by the level in the health
room installation cold storage volume increased by system as well as to identify immediate and long-
462M3 gross. Re-location of cold rooms from RHB/ term requirements thereby meeting future EPI needs
Zonal HO to EPSA compound made in five sites According the CCEI survey data:
(Diredawa, Semera, Dessie, Nekemte & Assosa).
A total of 20,765refrigerators and freezers were
Monitoring of cold rooms temperature through found at 20, 797 different levels of the health
installing of Remote Temperature Monitoring structure from all regions of Ethiopia, summarized
devices (RTMDs) is being conducted to all EPSA as follows;
hubs, (except Negele hub). In addition, temperature
monitoring devices with GPS to monitor the

34 Ethiopia National Expanded Program On Immunization

Table 12. Model type and manufactures of equipment

Model Qty Percent (%) Manufacturer Qty Percent (%)

RCW 50EK 3577 17.2 Haier 3960 19.1
TCW 15R SDD 2552 12.3 Sibir 4068 19.6
HTC-40 SDD 2405 11.6 SunDanzer 1149 5.5
TCW 3000 AC 2085 10.0 Vestfrost 1060 5.1
V 170EK 2072 10.0 B.Medical system 2613 12.6
V 110EK 1844 8.9 Dometic/B.Medical system 5823 28.0
HTC-60 SDD 1113 5.4 Dulas 291 1.4
BFRV 55 SDD 1149 5.5 Electrolux 190 0.9
PR 265EK 812 3.9 Electrolux/Dometic 116 0.6
MK 304 474 2.3 Other 467 2.2
MK 404 319 1.5 Unknown 200 1.0
HBC-340 255 1.2 Zero 828 4.0
VC 200 SDD 208 1.0 Total 20765 100.0
Other 1592 7.7
Unknown 308 1.5
Total 20765 100.0

■ From the total 40,593 passive containers ■ From the total of 20,765 equipment
inventoried, 27,029 are vaccine carriers (VC) inventoried, 13,170 (63.4%) were functional,
and 13,564 cold boxes (CB) 6204 (29.9%) nonfunctional due to variety of
reasons, 836 (4.0%) obsolete and 555 (2.7%)
■ The national average of health facilities
uninstalled.
(hospitals and health centres) with functional
incinerators was reported to be only 26%

Comprehensive Multi-Year Plan (2021-2025) 35

Table 13. Functionality Status of the equipment by facility type
Functional Status
Facility Type Functional Non-functional Obsolete Uninstalled Total
N % N % N % N % N %
Comp./Speci./Referral 37 86.0% 3 7.0% 0 0.0% 3 7.0% 43 100.0%
Hospital
EPSA Centarl Store 18 90.0% 0 0.0% 1 5.0% 1 5.0% 20 100.0%
EPSA Hub 148 87.6% 11 6.5% 2 1.2% 8 4.7% 169 100.0%
General Hospital 116 72.0% 33 20.5% 7 4.3% 5 3.1% 161 100.0%
Health center 5032 59.4% 2798 33.0% 404 4.8% 233 2.8% 8467 100.0%
Health Post 6416 65.6% 2783 28.5% 315 3.2% 267 2.7% 9781 100.0%
Primary Hospital 288 73.7% 80 20.5% 15 3.8% 8 2.0% 391 100.0%
Woreda Vacine Store 1115 64.3% 496 28.6% 92 5.3% 30 1.7% 1733 100.0%
Total 13170 63.4% 6204 29.9% 836 4.0% 555 2.7% 20765 100.0%

Reason for non-functionality includes lack of spare part, power supply, lack of technicians etc.

Table 14. Reasons for the non-functionality of the equipment

Reasons for Non Functionality N Percent (%)

Other 139 2.2
Power 1730 27.9
SP & Technician 2106 33.9
Spare part 1371 22.1
Technician 801 12.9
Tool kit 57 0.9
Total 6204 100.0

2.5.3. Vaccine Direct Delivery Three EPSA hubs (Bahir Dar, Jimma and Mekele)
were selected to begin the transition by taking over
Since the beginning of the transition in 2014, EPSA storage and distribution of vaccines from RHBs and
has been engaged in a number of activities to ZHDs, and scaling up delivery to zones from all other
operationalize the transition of vaccines including hubs by 2015. The second phase was to bypass all
updating LMIS, carrying out system design and ZHDs and deliver vaccines from all EPSA hubs to
delivering vaccines directly to Woredas and Health Woreda Health Offices (WoHOs) by end of 2016. The
facilities. In addition, 20 refrigerated trucks were third phase which is currently under implementation
procured and deployed to the 17 ESPA hubs to is delivering vaccines to all WoHOs and accessible
increase the efficiency of vaccine distribution to the health facilities. The final phase is direct delivery to
last mile health facilities by bypassing WoHOs.

36 Ethiopia National Expanded Program On Immunization

Implementation of this initiative was possible Currently, EPSA has directly delivering vaccines to
through collaborative work between EPSA (Head a total of 1067 health facilities and 876 woreda
Office and Hubs), MOH, RHBs, ZHDs, WoHOs and health offices across all regions and the 2 city
development partners supporting vaccine supply administrations. The plan for the year 2012 E.C. was
chain. Furthermore, costing analysis has been done to deliver for a total of 1200 health facilities. This
for facility level distribution with multi stakeholder means the Agency has achieved 87.1% of the direct
analysis and dialogue made before starting the last delivery plan. There are hubs that achieved over
mile distribution. their plan.

198 382 101 57

99 36 50
28 17 65
13 21

909 1451 629 199

244 100 151
45 30 109
13 21
SNNP

Somali
Tigray

Dire Dawa
Sidama

Harari

Addis Ababa
Afar

Gambella
Amhara

Oromia

Benishangul

1 2 3 4 5 6 7 8 9 10 11 12
# of puplic health facilities # of Direct delivery to Health Facilities

Figure 2. 16 Regional distribution of health facilities accessed by direct delivery, 2020.

2.5.4 Injection safety and waste disposal ■ Auto-disable (AD) syringes are the preferred
type of injection equipment for administering
Injection safety is the safe handling of all injection vaccines. These are also used once and cannot
equipment, routine monitoring of the availability be re-used, because the plunger of the syringe
and use of safe injection equipment, and correct cannot be pulled back again once it has been
disposal of contaminated injection equipment. pushed forward to inject the vaccine.
A safe injection is one that results in no harm to
the recipient, the vaccinator, and the surrounding In addition, leak proof boxes are specifically designed
community. Starting from 2002 Ethiopia uses. to receive syringes with their needles attached
with minimal capacity of 100 syringes and should
■ Disposable, sterile, single-use syringes, and not be reused. The recommended waste disposal
needles, which are used once only and then method is incineration in all health facilities using
disposed of safely. They are used for mixing incinerators. However, burning and burial is also
freeze-dried vaccines (BCG and measles) with used in health facilities. Waste disposal for mOPV2
their diluents and will never be re-used. vaccine is centralized. mOPV2 is a vaccine used for

Comprehensive Multi-Year Plan (2021-2025) 37

polio outbreak response only. All empty, partial used All WICR (previous and new arrival) are equipped
and broken mOPV2 vials are collected and disposed with standby generators. To prevent power surge,
at national or sub national waste disposal facilities. more than 2000 voltage stabilizer procured and
distributed sites using electricity. Also for all WICRs
2.5.5 Vaccine, Supply and Quality big size voltage stabilizers procured distributed
In Ethiopia, the bulk of vaccine costs for new vaccines 2.5.6 Adverse Event following immunization (AEFI)
and underused vaccines are financed by GAVI, and the
government. Government pays co-financing for new The Ethiopian Food and Drug Authority (EFDA) is
vaccines while the cost of traditional vaccines (BCG, National Regulatory Authority in the country with
TT, and OPV) and injection materials are financed by the mandate to monitor the safety of all medical
the government, in addition the government pays products including vaccines. The regulatory
staff salaries. There are no significant problems at authority has been working to improve patient care
national level, but weak vaccine stock and inventory and safety in relation to the use of medicines and
management has been noted at woreda and service vaccines in collaboration with various stakeholders.
delivery levels. Vaccines used in national immunization programs
are considered safe and effective when used
Limitation of reliability and timelines of vaccine correctly. Vaccines are, however, not risk-free and
delivery and collection with absence of regular update adverse events will occasionally occur following
on vaccine storage space availability at center, hub vaccination.
and facility level, Shortage of means of transport at
all level, lack of computerized stock control system AEFI surveillance system focuses on vaccine safety
are some of the challenge for vaccine supply and and it utilizes tools such as guidelines and procedures
distribution. Weak temperature management during geared to assure public health protection through
storage and transportation, vaccine stores are not the use of vaccines with proven safety profile.
temperature mapped, weak and no calibration of The current system for monitoring drug safety
temperature monitoring devices, freeze indicators (pharmacovigilance) is being coordinated by the
are not used during transportation. There is also National Regulatory Authority (NRA) called Ethiopian
inadequate distribution capacity due to shortage of Food and drug authority). EFDA has been working to
refrigerator vehicles at EPSA level there is no self- improve patient care and safety in relation to the
sustained power reserve for refrigerated vehicles. use of medicines and other medical interventions in
collaboration with various stakeholders.
Equipping all 17 WICR, Remote Temperature
Monitoring Devices (RTMD) procured and 10 WICR An effective and well-functioning AEFI surveillance
were equipped with Fridge Fone and installation system will eventually boost trust, public confidence
with senior technician done. Generally, 17 CRs and will also help improve the quality of the
(cold rooms) have been installed with a remote immunization program in the long run. It is therefore
temperature monitoring devices and 10 RTMD in essential that all stakeholders like NIP, EFDA,
11 CRs locations are currently properly functioning. vaccine manufacturers, laboratories, healthcare
RTMD are installed in all cold room. As a result providers and development partners make concerted
vaccine store managers and supervisors of WICR are efforts to provide documented evidence through an
using installed RTMDs to monitor their respective effective AEFI surveillance system. This will ensure
WICR temperature remotely. the provision of best immunization services to the
community including effective monitoring and
response to AEFIs.

38 Ethiopia National Expanded Program On Immunization

In the past five years, the regulatory authority in dissemination of health education messages using
collaboration with other stakeholders has performed different media platforms including mass media,
the following major activities; electronic media, print media and community media
in Ethiopia country context. Regions also have
■ Preparation, revision and dissemination of AEFI similar units that coordinate all health promotion
surveillance tools such as the national AEFI and information dissemination activities in their
guideline, AEFI case reporting and investigation respective regions. Health facilities provide health
formats for healthcare providers education to both in-patients and outpatients. EPI
■ Established the national AEFI causality is one of the programs given priority in all these
assessment committee that evaluate and assign demand generation activities with the aim of
causality for serious AEFI reports increasing the knowledge and practice the target
communities in relation to their Health.
■ Provision and follow up of training of personnel
involved in AEFI surveillance. In this regard more 2.6.1 Advocacy
than 2000 health professionals were trained
MOH has been conducting advocacy activities
about AEFI.
throughout the country with a higher priority given to
■ Conducted supportive supervision of AEFI regions which had lower coverage of eligible target
surveillance activities to regions and health population. Launching events and press conferences
facilities were also conducted when introducing new
vaccines as part of advocacy to multi stakeholders.
■ Conducted active AEFI surveillance on HPV During the past cMYP, CSO engagement workshop
vaccine is selected primary schools in Addis was also conducted.
Ababa
Moreover, sensitization of media agencies was
■ Coordinated and conducted serious adverse done to engage them in strengthening immunization
event of the AEFI investigation and causality advocacy and communication activities. Engaging
assessment process of serious AEFIs during the media professionals, political leaders, religious
campaign immunization (19 serious AEFIs leaders and key influential persons has been done on
of measles vaccine and 1 AEFI of HPV) and a regular basis by disseminating core immunization
during routine immunization (2 serious AEFIs of messages to target populations.
Pentavalent vaccine).
For the cMYP 2021-2025, there is a need to develop
2.6. EPI Advocacy, social mobilization a national Demand Generation on Immunization
and program communication with multifaceted strategies including advocacy,
tailored demand generation, intensification of
Community engagement, communication, advocacy community engagement, media engagement,
and social mobilization play an important role in evidence generation and social mobilization plan of
generating demand, building confidence and trust in actions.
the immunization services among the communities.
MOH Ethiopia has made health structures reform 2.6.2 Community Engagement and Social
through incorporation of health promotion component Mobilization
in all health programs. This will positively benefit
health communication program for development and Community engagement and social mobilization
on immunization services was given high priority

Comprehensive Multi-Year Plan (2021-2025) 39

throughout cMYP 2016-2020 implementation. problem, or is shown to be unfounded, if the concern
Engagement of all stakeholders at all levels was persists it should be addressed through dialogue
strong with key messages and tailored trainings. In with the communities concerned.
addition to mainstream media use of social media
including Telegram, Facebook, Instagram and other National communication strategies will include
social media networks were critical in reaching ongoing risk–benefit communication on vaccine
target population for RI as well as SIAs. safety, both for the general population and for
specific target groups. This will include focus on
Social mobilization through community gathering the balance of risk and benefit, the benefits of
platforms, religious & community leaders and other vaccination to the individual and society and the
influential persons was implemented proactively. importance of reporting any AEFI that are observed.
Mapping of special populations such as refugees
and IDPs had been done but there is limited tailored 2.6.4. Challenges and gaps
strategies on reaching those population with
■ Lack of demand generation on immunization
immunization services.
services plan of action at the national and
2.6.3. Program Communication region levels

■ Poor attention from regional or lower level

2.6.3.1. Evidence Generation leadership on immunization communication

Although there were some studies available around ■ Absence of immunization communication officer
behavioral aspect of immunization practices during at regional/zonal and woreda levels
last cMYP, there is still limited evidence around
demand generation activities. Majority of the studies ■ Weak integration of communication activities
applied quantitative methodologies at regional with HEWs activities in some areas
or national level with limited focus on qualitative ■ Limited dedicated budget for demand
insight. Given the ethno-linguistic diversity of generation, communication and social
Ethiopia, there is a need to conduct behavior and mobilization interventions
social drivers around immunization practices in a
■ Limited researches that evaluate/assess social
contextualized manner.
and behavioural aspects of immunization
practices
2.6.3.2 Risk Communication
■ Though there is structure in some places
Risk /crisis communication includes the range of women development army is not functional in
communication capacities required through the some places , dissolving in some woreda/zones
preparedness, response and recovery phases of a ■ Increasing vaccine hesitancy among parents to
serious public health event to encourage informed bring children for immunization services
decision making, positive behavior change and the
■ Repeated interruption of pregnant women
maintenance of trust.
conferences
Ethiopia needs to develop locally-relevant ■ Decreasing commitment (increasing burnout)of
communication strategies for rapid response to health care providers including health extension
public concerns, including those relating to AEFI. workers
Whether a public concern reveals an underlying

40 Ethiopia National Expanded Program On Immunization

■ No team for risk communication or risk also provides technical and financial support to the
mitigation regions and ensures updating EPI implementation
■ Lack of risk communication guideline/strategy guideline, standardization of training manuals, job
at the national and regional levels aids and any related supplies. RHBs also provide
similar supports to the lower administration levels
■ Limited development and implementation and health facilities to implement planned activities.
tailored demand generation interventions in
the worst-off communities with high number of The Ethiopian National Immunization Technical
zero-dosed and under-immunized children Advisory Group (E-NITAG) has advisory roles and
provides evidence based technical recommendations
■ Limited engagement with Civil Society
on immunization including on new vaccine
Organizations on addressing vaccine hesitancy
introduction. It is an independent, advisory body
and demand related issues.
that provides transparency and credibility to the
2.7 Program Management decision-making process and contribute to building
public confidence in the vaccination programme. The
2.7.1 Planning Immunization program is coordinated by EPI task force
that is led by EPI case team manager. Developmental
The health sector strategic planning is guided by
partners’ program coordinators are actively engaged
the principles of the “one plan”, “one budget” and
and took their achievable assignments. Under the
“one report”. Every year Woreda-Based Health
EPI TF, there are three technical working groups
sector planning is prepared through a top-down
namely M & E, communication & advocacy and
and bottom-up approach. EPI is part of the WBHSP.
logistics & supply TWGs where all EPI partners are
Within the HSTP II, Immunization falls within the
members. M&E TWG is the main technical lead of
Maternal, Newborn and Child Health section.
the EPI program, planning and M&E through direct
Pentavalent 3, MCV1 and fully immunization was
communication with the ICC and E-NITAG. The
mentioned as an indicator for performance of the
core activities of the TWG include macro and micro
sector and general budget support. The last cMYP
-planning, selection of service delivery strategies,
2015-2020 was aligned with HSTP I, the Global
training, assessing country readiness, developing
Vaccine Action Plan (GVAP) and the Regional
tools for M&E, monitoring of the overall readiness
Strategic Plan for Immunization. Districts developed
levels of all components, and providing key evidence
detail EPI micro plan based on WBHSP every year
for E-NITAG, as needed.
and RHBs compile the EPI micro plan and develop
annual RI improvement plan. Despite a good The communication TWGs lead and coordinate
planning platform at all levels of the health system, efforts that will boost community acceptance of
there were challenges. The cMYP document has not Immunization and high-level advocacy. The core
been available for quick reference at lower level to activities under this TWG include, supporting
develop quality operation plan at lower level regions to achieve a high level of acceptance and
demand, design and development of communication
2.7.2 Administration and Coordination
and training materials.
The MCH directorate is the overall coordinating body
The logistics and supply TWG are responsible for
for the EPI activities at national level. It coordinates
planning all logistic needs including procurement,
EPI interagency coordinating committee (ICC) efforts
customs clearance, cold chain, distribution.
towards common national goals and targets. It

Comprehensive Multi-Year Plan (2021-2025) 41

Despite Strong ownership, planning and data verification based on selected indicators. In
implementation by the government with good responding the identified problem, immunization
coordination mechanism at FMoH level and data quality improvement plan was prepared in
existence of dedicated EPI unit at MOH at all levels 2018 based on data quality review and efforts have
(regional level), there is high shortage of human been made to improve the data quality through,
resource in number and quality at all level of the EPI securing tools, conducting RDQA/DQAs, staff
structure. capacity building on DHIS institutionalization and
implementation.
The immunization program also extended up to
service delivery level. HEWs delivering immunization However, critical challenges were observed on
service through static, outreach and mobile strategy immunization data management and use. According
in every health post/Keble, cold chain expansion to study by EHPI in 2018, the system assessment
and vaccine transition, direct delivery to woredas by showed that there were limited checking of quality
EPSA going on, DHIS_2 Implementation started all of report, absence of skilled staffs and no tracking
over the country and there is VPD Surveillance system databases, lack of sources document (28% did not
to inform EPI program for further improvement of the have sources document) and only around half of HFs
program. However, monitoring quality of service at had matched report with the source document.
session level were not conducted
Moreover, according to FMOH information revolution
2.7.3 Health Information system /Immunization document, cultural transformation on information
data Management use is still the most challenging part that are linked
to technical, organizational, and behavioral factors.
Ethiopia has been using health information generated Likewise, limited data triangulation practices among
by the District Health Information System (DHIS2) internal and external data sources, inadequate
deployed at all woredas and health facilities. Before accountability, lack of leadership and governance
DHIS2, e-HMIS and paper based HMIS were used to on information management are widely observed.
monitor EPI performance. The DHIS2 was primarily
aimed to produce quality health information that 2.7.4 Monitoring, Supervision and Evaluation
supports local evidence-based decision-making
for service quality improvement and ultimately to Monitoring
achieve desired health service outcomes. At health The immunization program is monitored on monthly
post levels, the Federal Ministry of Health (FMOH) basis with a total of 13 EPI related indicators.
implements the Community Health Information Most health facilities and woreda health offices
System (CHIS) which was later upgraded to utilized and updated immunization monitoring
e-CHIS and piloted in selected woredas alongside charts for monitoring and evaluating immunization
immunization registration books. e-CHIS comprise performances. In addition, performance review
of family folder pouch, integrated maternal and meetings have been conducted integrated with
childcare card, tally sheets and reporting formats. other MNCH services on a quarterly basis.However,
At health center and hospital levels, there is a use of GPS/GIS for geocoding the services delivery
standardized immunization register to capture points, locating and identifying zero doses as well
immunization information. as missed communities is limited. Besides, limited
Health Data Quality Review was conducted in software assisted data collection and analysis
2018 by focusing on system assessment and process has made monitoring process tedious.

42 Ethiopia National Expanded Program On Immunization

Similarly, lack of process monitoring indicators (like ■ Effective Vaccine Management Assessment
quality services delivery), lack of data disaggregated (EVMA) conducted in 2019 to identify the
by strategies (static, outreach and mobile), session strengths and weaknesses of the cold chain
interruption and quality monitoring practices, limited at all levels of the health system; the first was
use of locally amended coverage validation tools, conducted in 2013 and the second conducted
like RCS, inconsistent practices of RDQA/DQA and 2019,
limited actions on data quality discrepancies were ■ Within the last 5 years, Ethiopia Demographic
among the quantified challenges. and Health Survey (EDHS) was conducted in
Evaluation 2016 and 2019 to provide up-to-date estimates
of key demographic and health indicators,
Health sector annual review meeting (ARM) to
■ GAVI Joint Appraisal /Multi sector dialogue
which immunization program is part of, is conducted
(JA) meeting was conducted jointly with core
yearly at national level. In February 2020, the
and extended partners yearly
Ministry of Health (MoH) conducted integrated
post-introduction evaluation (PIE) of MCV2 and HPV ■ Joint Reporting form (JRF) for coverage
vaccines. The findings of the evaluation found that estimation were prepared annually
the high political commitment for the new vaccines’ Supervision
introduction, with broad stakeholder involvement to
be instrumental in the successful preparation and Capacity building through supportive supervision at
planning for both MCV2 and HPV vaccine. each level of health administrative level expected
to be conducted quarterly basis to the immediate
Similarly, comprehensive EPI/ vaccine-preventable lower level. In the last five years there were number
disease surveillance review was conducted and of supportive supervisions conducted integrated
evaluated country progress towards the global and with other MNCH programs in collaboration with
national targets; identify opportunities, gaps and partners. In 2012 EFY, the EPI was able to conduct
challenges in the immunization system to provide selected supportive supervision to poorly performing
evidence for the program’s strategic directions and regions based on low coverage after the country
priority activities. However, immunization coverage implemented the REC/PIRI approach.
survey and cMYP review have not been conducted
in the past five years. However there was a number of challenges observed
which includes irregularity of supportive supervision,
At national level the various evaluation activities limited EPI program specific supportive supervision
conducted include: & mentorship), getting the number of the supportive
supervisions conducted, inadequate culture of
■ EDHS survey from January 18, 2016, to June
providing feedback after supportive supervision
27, 2016, that provided immunization coverage
staff shortage, lack of transport, delayed funding
estimates at the national and regional levels
flow from the national to the regional and district
and for urban and rural areas,
level, data management with regards to timeliness,
■ Annual Performance Report (APR) was conducted accuracy, analysis and feedback at all levels.
and document prepared which represented the
yearly Health Sector Transformation Plan (HSTP)
performance, focused on the progress made
in the implementation of the health sector’s
annual plan

Comprehensive Multi-Year Plan (2021-2025) 43

2.8 Strengthening human and 2.8.2.2 In-service Training
institutional resources
Immunization is one of the most cost effective
2.8.1 Staffing public health programs that require frequent In-
service training in which the country is investing
Ethiopia has 273,601 heath work forces employed huge resources. The major training categories in
in public health facilities; of these 181,872 (66.5%) immunization include IIP, MLM, RED/REC, EVM
are health care workers and 91,723 (33.5%) are and Cold Chain maintenance. , In-service training
administrative and supporting staffs. Among system in Ethiopia is fragmented, has no regulation
health care workers, the three largest categories and course accreditation mechanism as well as
include Nurses 59,063 (21.59%) followed by never linked with license renewal. Moreover it also
Health Extension Workers 41,826 (15%) and 18,336 lacks adequate mentorship, digitalization of training
(6.71%) are Midwifery professionals. In addition to and training impact assessment mechanism. On the
this,, about 60,000 health workers employed in the other hand, the trainings conducted so far were not
private health sector. supported by need assessment resulting in unwise
use of human and financial resources. .
According to the National Human Resource for
Health Strategic Plan of Ethiopia; the overall EPI program training status (2016-2020),
health professionals to population ratio has Ethiopia.
increased from 0.84 per 1000 in 2010 to 1.5 per
1000 in 2016. However, there are high disparities Despite limited data on capacity building EPI focal
in health work force population ratio among regions and health workers across all levels, there were
indicating highest in Addis Ababa and Dire-dawa numbers of health care providers trained in the last
City Administrations, whereas the lowest are in five years by FMoH, RHBS and partners.
Gambella, Harari and Benishangul-Gumuz regions.
■ RED/C training for woreda health office and
there are challenges with regards to modern human
health facilities,
resource management includes; staff turnover,
high attrition rate, and weak HRIS tracking system ■ Integration of EPI training in the preserve EPI
secondary to low motivation. Despite the rapid curricula,
expansion of immunization program in its scope and ■ mid-level management training
type of antigens, the current immunization structure
■ immunization in practice
and staffing in Ethiopia is grossly inadequate and
not uniform among regions. ■ Effective vaccine management,
■ Vaccinology training for MoH staffs and
2.8.2 Capacity Building for EPI
Infectious disease experts,
2.8.2.1 Pre-service Training ■ cold chain management trainings
The pre service training in Ethiopia consisted of ■ Provide data quality self-assessment and
some EPI components in the curricula but not yet database management training.
materialized. Ministry has planned integrate EPI
2.8.3 Research and development
training in the pre service health curricula but was
not achieved due to different reasons. Immunization Agenda (IA) 2030 promotes countries
to participate in the development of new vaccines,

44 Ethiopia National Expanded Program On Immunization

accelerating innovation to improve programme were engaged in different scientific knowledge
performance, surveillance and quality of data. This improvement projects and new technologies
strategic direction was reaffirmed in the 2016 Addis development activities.
declaration on Universal Access to Immunization.
Even though African has the highest incidence of Various operational and implementation researches
mortality caused by infectious diseases, has limited focus on Immunization system were conducted in the
capacity to manufacture affordable and essential last five years. The research outputs which served
vaccines. as input to strengthen immunization program in
Ethiopia. These evaluations and researches include;
The challenges include in African vaccine EPI program reviews were also conducted to assess
development are; lack of adequate finances, skilled the introduction of the new vaccines, (PIE Post
manpower, limited research and institutional introduction assessment), coverage evaluation after
capacities. conduct go measles SIA, other includes serological
surveys, EVMA and VPD burden risk analysis.
Despite all these challenges, FMOH, EPHI, Armauer
Hansen Research Institute (AHRI) and Universities

2.9 Partnership and financial sustainability

2.9.1 National EPI Stakeholder Analysis

Stakeholders Behaviors we Their needs Institutional response

desire
Community Participation, Information on Community mobilization, ensure participation
engagement, services Access
and Ownership and utilize Quality and equitable service and information;
immunization ensure community trust and confidence
services
MOH, regional Policy and Implementation Put in place equitable and quality immunization
Governments; guideline of Policies, services; a strong M&E system and comprehensive
zonal and formulation, guidelines etc. capacity building mechanisms
woredas coordination, ensure equity &
administrations mobilize quality;
domestic and
interantional plan, implement,
resource for monitor, evaluate
immunization & report
ICC, NITAG, and Advise, approve, Verification Evidence-based decision making and guidance and
technical working and provide and reference, being proactive to respond to emergencies, adapt
groups guidance on guidance and new technologies, vaccines and systems, etc
immunization decision-making
program

Comprehensive Multi-Year Plan (2021-2025) 45

Stakeholders Behaviors we Their needs Institutional response
desire
Sector Ministries Intersectoral Evidence-based Collaboration,
(Education, collaboration, plans/ Reports
Women’s Affairs, strengthen advocacy and
Finance, etc.) national and Effective and
efficient use of integration
sub-national
political resources and
and social coordination
commitment to Technical support
immunization
Health Knowledgeable, Technical, policy Support and synergize to continuously assess
professional skilled, and support and the need and gaps in immunization program and
training institutes ethical health guidance, and recommend a better way of doing immunization
professionals execute research
trained on
immunization
Development Harmonized and Involve in Government leadership
Partners (donors, aligned planning,
implementing implementation, Transparency
Participation
partners) and M&E, aspire Efficient resource use
More on better health, and
financing disadvantaged Build financial management capacity and
Technical group sustainability
support and
System
strengthening
Local NGOs and Harmonization Involvement Advocacy, technical support,
CSOs/FBOs & aligned in planning,
Participation, implementation capacity building
Technical & M&E domestic resource mobilization
assistance; Participation
system
strengthening

46 Ethiopia National Expanded Program On Immunization

The Ministry of Health (MoH) has been implementing ■ The accounting and reporting should follow
the Health Sector Programs in collaboration with government procedures in compliance with the
development partners (DPs) in a more harmonized donor’s requirements.
and aligned approach. Given this, the Ministry has Channel 3: In this financing channel, DPs usually
been working towards further strengthening its carry out any procurement and pay the contractor
partnership through Partnership and Cooperation directly (through implementing partners).
directorates (PCD) to attain its vision, to see healthy, Government merely agrees to what is to be provided
productive, and prosperous Ethiopians. MOH through by the donor ensuring alignment with its priorities.
its PCD and other relevant directorates arranges the The government obtains the list of interventions and
fund flow into different channels. allocated finances from partners through resource
Channel 1 mapping and ensures its alignments during plan
developments.
■ Channel 1a (un-earmarked): Donor money
goes into the government’s (MOF) account and Health Pooled Fund: This fund was established
is disbursed through government procedures. in 2005 by five DPs to provide support to MoH. It
A typical example of funding that uses this fills a critical gap in capacity and is the first pooling
channel is the Promotion of Basic Services (PBS) arrangement in the health sector. It provides support
funding that donors support. in technical assistance, sector reviews, operational
research, and other activities at the MoH level. There
■ Channel 1b (earmarked): Donor money goes are several partners which support the immunization
into the govern ment (MOF) account and the program activities in Ethiopia including GAVI, WHO,
money is earmarked for specific use (consistent UNICEF, CDC, USAID, and BMGF.
with government priorities). This earmarked
fund is transferred to MoH tagged with a two- 2.9.2 GAVI support
figure code and sent to the region and zone/
woreda (with a location code). Ethiopia has benefited from GAVI support in relation
to New Vaccine Introduction Support (NVS), Health
■ The funds are reported on and accounted for
System Strengthening Support (HSS), Cold Chain
separately and are used to support activities
Equipment Optimization Platform Support (CCEOP),
agreed upon only, often according to its specific
PEF Targeted Country Assitance (TCA), PIRI, and
procurement and disbursement procedures.
CSO support in the last five years. The country
Channel 2: introduced two new vaccines into the routine
immunization program in the last five years; Human
■ Channel 2a (un-earmarked): This is funding Papillomavirus Vaccine (HPV) in the last quarter of
that goes into the health sector’s account 2018 and Measles Containing Vaccine second dose
directly and is spent at various administrative (MCV2) in February 2019. So far, 1.2 million 14-year-
levels of the health sector in line with the rules old girls and 3.3 million 15-23 months aged children
and regulations of GoE’s financial management were targeted for HPV and second dose of measles
system. vaccines respectively. In the last five years, Ethiopia
■ Channel 2b (earmarked): This is a project had switched tOPV to bOPV (2016), TT to Td (2020),
type of funding. Funds are provided directly to and 2 doses of PCV 10 to 4 doses of PCV13 (2020)
the health sector and managed and accounted vaccines, in line with global vaccine availability
for by the sector. This channel is mainly used by and epidemiological evidence of VPDs. Ethiopia is
vertical funds like GAVI and UN agencies. also one of the first countries to use the GAVI HSS

Comprehensive Multi-Year Plan (2021-2025) 47

support to strengthen its health system. The fund the immunization program. GAVI Targeted Country
was allocated to strengthening human resources Assistance (TCA) is also one support area provided
for the delivery of basic health services; to improve by GAVI to country immunization programs in their
supply, distribution, maintenance systems and efforts to improve coverage and reduce equity
to enhance the organization and management of barriers to immunization services. TCA is provided
health services delivery. by partner agencies including core partners (WHO,
UNICEF, CDC) and expanded partners. In the last
The Cold Chain Equipment Optimization Platform five years, core and expanded partners through
(CCEOP) was aimed to support the country with TCA support had planned and implemented key
improving the supply chain and contribute to efforts to prioritized activities and contributed significantly
strengthen the coverage and equity of immunization. to the overall achievements of the EPI program in
Because of the country’s effort, GAVI supported the Ethiopia.
scale up and sustainability of the supply chain for

Table: Budget Support from selected EPI Partners in the last 5 years

Budget source Type of Support Amount in USD

Government Co-financing 22,073,485.00
GAVI HSS 70,211,000.00
HSS-2 Quality 12,913,463.00
HPV 2,968, 334.00
MSD (MCV 2) 2,672, 270.40
Measles SIA 5,799,746.00
PCV Switch 827,032.00
CCEOP 13,177,093.00
CSO 3,320,000.00
PEF (TCA) 10,676,959.07
PIRI -
Total GAVI Support 116,925,293.07
SDG pool fund RI strengthening 6,718, 945.43
WHO-GPEI Polio 47,147,394.99
UNICEF AWP 12,000,000.00
Grand Total 182,791,633.49

The GAVI fund has brought a significant contribution by GAVI in Ethiopia for two subsequent years. GAVI
for strengthening immunization systems to CSO Support fund has learned partnership and
sustainably and equitably increase immunization networking among government agencies, PVOs/
coverage to meet national standards through PIRI NGOs, and community was vital to reach the
operationalization. Civil Society Organization (CSO) unreached communities and to avoid duplication of
support was also one of the few pilot areas provided efforts.

48 Ethiopia National Expanded Program On Immunization

2.9.3 Government Contribution the immunization program and the health system as
a whole. SDG pool fund is a fund where different
The Ethiopian government has been co-financing sources of budget support are managed to achieve
the immunization program with an average of 4.1 the SDG goals.
million USD annually for the last five years. Total
government co-financing contribution in this cMYP 2.9.5 Community participation
period remains at 18%. The government will
continue co-financing the immunization program in Effective community participation requires
a very organized and well-coordinated manner. partnership with communities through supportive
and coordinated actions. When communities
2.9.4 Other Donors: are involved as allies in planning, promoting,
implementing and monitoring services, they develop
Significant budget support has been in place from a stronger trust and ownership in the health
UNICEF for the routine immunization program service. They can be owners, users, financiers, and
through the annual work plan. At the same time, partners in health services. In Ethiopia, community
budget support for the polio eradication program participation was shown in many ways, for instance,
used to be channeled from the Global Polio during the expansion of health facilities some of the
Eradication Initiative (GPEI) through the WHO communities have contributed over 50% of the cost
country office. Besides, potential donors like USAID, of constructing health posts.
CDC, and BMGF have contributed a lot to strengthen

Comprehensive Multi-Year Plan (2021-2025) 49

50
EPI COMPONENT Strengths Weaknesses

Immunization ■ Coverage of antigens is increasing over time ■ Coverage is not at optimal level.
Service Delivery ■ Immunization System/structure available to ■ High dropouts and disparity persists among regions and
service delivery and the community level Woredas (wide equity gap by administrative localities,
■ The immunization service was provided residence, education, and wealth).
amid of COVID-19 pandemic and the impact ■ Weak integration of Immunization services with other
of pandemic was not significant Maternal, Neonatal and Child health and nutrition services
■ HPV introduced expanding age groups to leading to missed opportunities
immunization. ■ Interruption of vaccination sessions both in outreach and
■ Successful switch of vaccines PCV 10 to PCV static
13 and TT to TD ■ Interruptions of PIRI service due to funding gaps
■ Post Introduction Evaluation for newly ■ Some Health facilities not providing vaccination service
introduced vaccines ■ Lack of strategies to track and vaccinate mobile community
■ Conducting successful SIAs ■ Sub-optimal quality of EPI service provision, including age
■ Implementing cVDPV2 outbreak response invalid doses, particularly for MCV.
SIAs ■ Delayed new vaccines introduction (Men A, YF, Hep BBD,
■ Conducted many follow up and catch-up MR).
measles SIAs with coverage of above 95% ■ Poor private health facility engagement
■ Persistently missed children in hard to reach, pastoralist
and urban settings
■ Inconsistency in immunization coverage data across
different data sources and poor use of data for decision
making

Ethiopia National Expanded Program On Immunization

 EPI COMPONENT Strengths Weaknesses

Surveillance ■ Established strong Case and lab-based AFP ■ Sub-national AFP and measles surveillance gaps.
surveillance since the adoption of the GPEI. ■ Persistently low detection of EIV in national polio lab.
■ Achieved and sustained interruption of ■ Measles elimination targets not on track.
WPV transmission since January 2014 and ■ Unable to achieve adequate population immunity for
certified as WPV free country since 2017. Measles. .
■ Achieved majority of the Measles ■ Delayed outbreak notification in some cases leading to
surveillance performance indicators. delayed responses.
■ Validated for elimination of MNT ■ Weak VPD risk assessment, EPRP process and

Comprehensive Multi-Year Plan (2021-2025)

■ Existing PHEM structure and availability of implementation.
national disease specific guidelines. ■ Performance of the surveillance sentinel sites not as
■ Rapid detection, investigation and response expected
for VPD outbreaks, (conducting local ■ Weak monitoring and support
outbreak response vaccination campaigns,
and preventive SIAs, and case management

Immunization Supply ■ Adequate dry store for dry materials/ ■ Shortage of transport vehicle.
chain management consumables. ■ Delay of newly procured cold rooms installation,
■ The cold rooms are in good condition with ■ Lack of follow-up and monitoring of the written
functional standby generator, voltage maintenance plan implementation for cold chain
regulator and alarm systems and safety equipment.
cloths for central and most of the hubs. ■ Weak support (transport, budget, tool kits & monitoring)
■ Availability of continuous temperature utilization of the trained technicians (senior & mid-level)
monitoring system (central and hubs). ■ Lack of recording and reporting system for maintenance
■ Availability of distribution plan and a (CCE, including refrigerated trucks) activities
monitoring mechanism at the vaccine
storage facilities at national level.

51
52
EPI COMPONENT Strengths Weaknesses

Immunization Supply ■ Stock records designed to register wastage, ■ Poor spare parts management (planning, requesting,
chain management expire and heat exposure (VVM). (center and issuing and Stock management) - (Availability, storage and
hub) distribution).
■ Existence of legal framework, regulation and ■ There is no up-to-date/regular cold chain equipment
guidelines to monitor safety of medicines inventory system
and AEFI surveillances in the country ■ Irregularity in providing formal or on the job training for
■ Existence of national AEFI causality vaccine supply chain
assessment committee ■ Poor data quality and visibility at the lower level
■ Absence / turnover of trained cold chain technicians for
cold room maintenance and vaccine management at
national & EPSA at all levels
■ Poor implementation of annual work plan at all level
■ Poor vaccine stock management, no adherence to stock
level policy especially at woreda & health facility level
■ Absence of job aids (VVM& other CC PPM) & other training
manual related to vaccine supply chain management at
health facility level.
■ Lack of temperature monitoring/not using fridge tags/
freeze tag during transportation (if conditioning icepack
used).

Ethiopia National Expanded Program On Immunization

 EPI COMPONENT Strengths Weaknesses

Advocacy, ■ Revitalized the CTWG at National level ■ Poor leadership commitment at lower levels
communication& ■ High level Advocacies conducted at national ■ Inadequate Inter Personal Communication (IPC) skill among
Social mobilization and regional levels HCWs
and Risk ■ Averted disinformation, misconceptions and ■ Limited stakeholders engagement including CSOs at lower
communication rumours on HPV through extensive social level
mobilization and community conversations. ■ Extent of Immunization IEC materials utilization unknown
■ Availability of IEC materials, Brochures, job ■ No dedicated Communication HR structure at Subnational
aids with different languages level
■ Social mobilization & demand generation activities are

Comprehensive Multi-Year Plan (2021-2025)

■ Developed HPV risk/crises Communication
limited to risk/crises communication, NVI and SIAs
guideline and rolled out
■ Community engagement and demand generation to
■ Annual EPI Communication planning at immunization are not optimal especially in remote areas
national level ■ Weak monitoring and evaluation for communication
■ Use of various social media outlets for activities
social mobilization during HPV Vaccination, ■ Inadequate budget allocation for EPI Communication
NIDs and SIAs. activities
■ High Mainstream media engagement during ■ Absence of demand generation on immunization plan
social mobilization of HPV vaccinations, of action, tailored demand generation strategies and
NIDs and SIAs comprehensive risk communication plan
■ Limited research on vaccine acceptance and hesitancy
■ Lack of tailored demand generation strategy among the
special populations such as IDP, refugees and peri-urban
communities
■ Limited interventions addressing gender related barriers
around immunization practices
■ Lack of integration with other critical interventions such as
Early Childhood Development (ECD), nutrition, and maternal
and child health
■ Absence of EPI CTWG at regional and lower levels

53
54
EPI COMPONENT Strengths Weaknesses

Program ■ Strong EPI Coordination mechanism at ■ Low quality micro-planning, RED/C implementations:
Management FMoH level (Existence of functional ICC, (missing minorities, remote areas, slum areas, urban
NITAG, EPI Taskforce & TWGs providing periphery).
oversight and technical guidance to EPI). ■ Poor EPI data quality management as evidenced by huge
■ Dedicated EPI unit at MOH level discrepancies between admin coverage and conventional
■ Existence and the practice of having cMYP, estimates like WUENIC estimates, EPI coverage survey and
EPI Annual Work Plan and Woreda Based EDHS survey results.
Plan. ■ No well-structured, data pool and proper documentation as
■ Presence of functional DHIS tool data repository/storehouse
■ Absence of use of process monitoring indicators (quality
services delivery, coverage triangulation, data quality
varication session interruptions)
■ Limited technology assisted data management, monitoring,
supervision (geocoding, data collection and analytical
software)

Strengthening ■ Posting EPI focal persons at regional and ■ Inadequate human resources for EPI
human and zonal levels ■ There is no platform to track trained HWs
institutional ■ Conduct Training to build the capacities and ■ Trainings were conducted without need assessment
resources skills of EPI service providers Various TAs ■ High staff turn overs
have posted to strengthen HR in different ■ Lack of incentives and motivation
regions ■ No functional posts for e EPI coordinators at regional, zonal
levels
■ Pre service Curricula lacks basic immunization education.
■ Inadequate capacity of institutions to conduct operational
research to generate evidences

Ethiopia National Expanded Program On Immunization

 EPI COMPONENT Strengths Weaknesses

Partnership ■ Government commitment ■ Limited to bring onboard new partners

and financial ■ MOH has a dedicated directorate to handle ■ Lack of consistent mapping of international, national, or
Sustainable partnership local partners of EPI
■ Good relationship and coordination with ■ Suboptimal engagement of Public-Private Partnership
existing EPI partners such as GAVI, WHO,
UNICEF etc.
■ CSO proclamation is revised opening rooms
for increased CSO participation - 1113/2019

Comprehensive Multi-Year Plan (2021-2025)

55
Opportunities Threats

■ Existence of community platform(HEWS and ■ Rumors and misconceptions towards immunization

HDA) program and vaccines by the community / anti
■ Accessible mainstream as well as social vaccine activism /
media networks ■ Presence of mobile community, lack of access
■ Immunization a priority agenda by the to health services in remote areas and difficult
government topography in some communities.
■ Computer literacy and reluctant to use digital
■ Improving health care seeking behavior
technologies among the community
■ Sustained national economic development
■ No access to mobile network (for some area)
■ Improving basic infrastructure
■ Inadequate funding for Advocacy, social mobilization
■ Improved literacy rate particularly for and Crisis communication
female.
■ Dissatisfied public servant (Health workforce)
■ Expansion of Health Sciences Colleges
■ Inadequate pre service education quality
■ Existence of multi-EPI partners at national
■ External pull factor for health workers
and lower level
■ Lack of access to health services in remote areas and
■ Availability of new technologies such as
SDD refrigerators, temperature monitoring difficult topography in some communities.
Devices internet and electronic services in ■ Political un stability /conflicts Security problems in
the global and national levels which support many areas
quality and safety of the vaccines. ■ Natural disasters and health emergencies (drought,
flooding, locust infestation,Covid-19. etc).
■ Limited or Low predictability of donor funding

56 Ethiopia National Expanded Program On Immunization

 03
CHAPTER
Vision, Mission, Goals, Programme
Objectives, Strategic Approaches,
Key Activities, Indicators And
Milestones

3.1. Introduction 3.4. Goals of the cMYP (2021- 2025)

The National Immunization Program is one of The following four goals of cMYP of Ethiopia are set:
the most successful and cost effective programs
implemented in Ethiopia. The uniqueness of the ■ Reduce morbidity and mortality from vaccine-
NIP has been the innovativeness and adaptation preventable diseases for every one through the
it has gone through with the support of national life course.
and international partners. This comprehensive ■ Leave no one behind, by increasing universal
Multi-Year Plan (cMYP) for immunization covers the and equitable access and use of new and
years 2021-2025. The objectives and activities set existing vaccines.
forth in this plan provide the framework required to
■ Achieve vaccine-preventable diseases
meet the goals of reducing infant and child as well
elimination and eradication goals.
as adult morbidity and mortality associated with
vaccine -preventable diseases (VPD). While setting ■ Ensure good health and wellbeing for everyone
vision, mission, goals, program objectives, targets, by strengthening immunization with in primary
strategic approaches, key activities, indicators and health care and contribute to universal health
milestones; key considerations are made on the plan coverage and sustainable development.
development to be in line with country needs and 3.5 Program Objectives
plans as well as with the regional and global plans.
Ethiopia plans to introduce new vaccines into the Objective 1: Increase and sustain high
routine immunization schedule including Measles– vaccination coverage
Rubella vaccine, birth dose hepatitis B vaccine, IPV
second dose, Men A vaccine, Yellow Fever vaccine, ■ Pentavalent 1 coverage 100% nationally and
nOPV2 vaccine, COVID19 vaccine, and other new 98% in every district by 2025.
and/or underused vaccines to be determined in ■ Reach Pentavalent 3 coverage 98% nationally
during cMYP (2021-2025). and 95% and above in every district by 2025.
■ Reduce number of unimmunized children by
3.2. Vision
75% by 2025 from the 2020 baseline
A country where every eligible, everywhere, at ■ Reach MCV1 coverage 98% nationally and 95
every age, will be fully benefits from vaccines for % and above in every district.
good health and well-being.
■ Reach MCV2 coverage 93% nationally and 88%
3.3. Mission and above in every district.
■ Reach fully vaccination 90% national level
To save lives and protect people’s health by increasing
equitable and sustainable use of vaccines. and 85% in every district with full vaccination
coverage by 2025.

Comprehensive Multi-Year Plan (2021-2025) 57

■ Reduce DTP-HepB-Hib1(Penta 1)- DTP-HepB- ■ All polioviruses are laboratory-contained
Hib3 (Penta 3) dropout rate to 2% nationally and nationally by 2023
less than 5% in all districts by 2025. ■ Achieve and maintain the function and polio free
■ Reduce DTP-HepB-Hib1(Penta 1)- MCV1 dropout status mistermed in to national immunization
rate dropout rate to 2% nationally and less than and surveillance system
5% in all districts by 2025. Objective 3: Achieve and maintain Measles,
■ Reduce MCV1- MCV2 dropout rate dropout Rubella, and congenital rubella syndrome
rate to 5% nationally and less than 10% in all goals by 2025.
districts by 2025.
■ Conduct two Measles follow up SIAs and
■ Ensure availability of immunization service in all achieve ≥95% coverage by 2025.
HF (Hospitals, Health centres and Health posts)
by 2025. ■ Achieve and maintain measles incidence <1
cases per million populations
■ Introduce COVID 19 Vaccine, nOPV2 and
piloting of Hepatitis B birth dose by 2021, scale ■ Achieve surveillance performance targets: > 2
introduction Hepatitis B birth, and introduce MR, suspected measles case per 100,000 and non-
IPV2, Yellow fever, Men A vaccines by 2022. measles febrile rash illness rate ≥ 2/100,000
population per year.
Objective 2: Maintain polio free status,
achieve polio eradication, and fulfil the Objective 4: Attain and maintain elimination/
recommend standard control of other vaccine-preventable
diseases.
■ Maintain the quality of AFP surveillance at
national and subnational levels for national MNT elimination
polio eradication. Maintain maternal and neonatal tetanus elimination
■ Achieve 95% coverage routine bOPV annually in with NT less one per 1,000 live births.
high risk Zones/Districts by 2023.
Meningococcal meningitis Epidemics
■ Achieve 95% coverage two rounds bOPV SIAs elimination:
annually in high risk Zones/Districts.
■ Conduct catch up Men A mass vaccination
■ Introduce second dose of IPV in routine
campaign to close immunity gaps for the
immunization program
age cohorts born after the Mena vaccination
■ Achieve 95% coverage mOPV2/nOPV2 SIAs in campaigns and achieve ≥95% by 2022.
cVDPV2 outbreak in high risk areas
■ Introduce case based Meningococcal meningitis
■ Achieve and maintain all AFP surveillance surveillance in all woredas by 2023.
standard indicators minimum requirements by
2023 at nation and subnational levels.

58 Ethiopia National Expanded Program On Immunization

Elimination yellow Fever Epidemics Objective 6: Improve immunization supply
chain performance in line with introduction
■ Achieve yellow fever epidemics elimination by of new vaccines, population growth and
2025. coverage expansion plan and campaigns and
■ Conduct yellow fever preventive mass integration of other temperature sensitive
vaccination campaigns (phase by phase) and products like Oxytocin at all levels by 2025
achieve ≥95% by 2025,
■ Increase the cold storage capacity to reach 90%
■ Introduce case based yellow fever surveillance of demand by procuring appropriate cold chain
in all woredas in 2022. equipment and introducing new technologies by
■ Introduce routine/Phased mass vaccination 2025.
campaign of Yellow Fever vaccine by 2022. ■ Attain EVMA score of at least 80% by 2025and
Hepatitis B Control and elimination beyond at all level.
■ Realize on time and in full vaccine delivery
■ Reduce chronic HBV infection prevalence to <
(OTIF) at 90% of health facilities through
0.5 percent in children aged five years old by
implementation of last mile delivery by 2025.
2025.
Objective 7: Improve institutional and human
■ Introduce Hep B birth dose in the routine
capacity
immunization system by 2022
Objective 5: Expand cold storage capacity Human resource capacity buildings related
in line with introduction of new vaccines, interventions to be conducted by the end of
population growth and coverage expansion 2025
plan and campaigns at all levels by 2025
■ Conduct training based on need assessment
■ Increase the cold storage capacity to reach 90% tool findings
of demand by procuring appropriate cold chain ■ Link in service training(CPD) with promotion and
equipment and introducing new technologies by licensure
2025.
■ Assessing the existing carrucilu of pre service
■ Attain EVMA score of at least 80% by 2025and immunization education
beyond at all level.
■ Assessing the existing pre-school curriculum to
■ Realize on time and in full vaccine delivery (OTIF) include in service immunization education
at all woreda health office and health facilities
■ Establish and fully implement HIRIS data base.
through implementation of last mile delivery by
2025.

Comprehensive Multi-Year Plan (2021-2025) 59

Institutional capacity buildings for researches Objective 9: Improve partnership and financial
and development related interventions to be sustainability for immunization
conducted by the end of 2025
■ Implement one plan, one budget and one report
■ Plan full advanced research methodology approach on EPI program
studies to increase the capacity ■ Increase financial contributions of regional and
■ Conduct EPI related training impact assessment global partners for the EPI program
at all levels ■ Secure 100% of the required budget for EPI
■ Strengthen mentorship of health workers program
assigned for EPI. ■ Steadily increase domestic financial contribution
■ Conduct two EPI SARA for EPI program
■ Conduct ten operational research Objective 10: Strengthen coordination
Objective 8: Strengthen program monitoring and accountability through improved EPI
and evaluation management at all levels to successfully
deliver a robust immunization program and
■ Improve EPI data quality and attain the achieve planned targets.
acceptable level (within +10%) of data
■ Improved EPI management at all level through
discrepancies on immunization in all health
facilities and local use of immunization data for established and functional structures, policy,
quality improvement. and people in place for evidence-based decision
making.
■ Improve routine admin data quality with internal
■ Strengthen coordination platforms for
and external verification methods
immunization at all level
■ Introduce technology/application assisted and
■ Develop EPI related trainings database and
immunization focused supportive supervision
on regular bases. repository at all level
■ Develop regional and woreda level
■ Conduct EPI related assessment, evaluations
and operational researches implementation/operational plan aligned with
cMYP
■ Develop regional and woreda level
■ Introduce competency-based framework tool to
implementation/operational plan aligned with
cMYP improve EPI managers management capacity at
all level
■ Develop context specific bottom-up EPI micro-
plan at woreda and health facility level
■ Establish a system for data triangulation and
quality monitoring quarterly at national and sub
national levels by 2021 and beyond.

60 Ethiopia National Expanded Program On Immunization

Objective 11: Strengthen communication, 3.6 Strategic Approaches
advocacy, and demand generation for
immunization at all levels. The key approaches for implementation are
described below.
■ Increase awareness of the community on
immunization practices to 95% by 2025. Immunization for primary healthcare and
universal health coverage: To build effective,
■ Significant increase of demand, trust and efficient and resilient immunization program that
confidence in the immunization services among deliver high-quality immunization services as a part
the communities by 2025. of national primary healthcare systems aimed at
■ Communities with high number of zero-dosed and achieving universal and equitable health coverage.
under-immunized children from geographically
or socially hard to reach areas, conflict affected Outbreaks and Emergencies: Maintain and
areas, and urban-poor areas are reached with strengthen capacity to prepare for, prevent and
tailored immunization strategies for by using respond to vaccine-preventable disease outbreaks.
people centred design approach by 2025. Reach Every District (RED)/ Reach Every Child/
■ Engage Civil Society Organizations in the Community (REC) approach: Ensure all Woredas
immunization demand generation activities and health facilities developed bottom up micro
plans, conduct supportive supervision and review
■ Design, implement, monitor and evaluate
meeting, locally used data for decision making and
■ Train all national and sub-national level program action, reach target with appropriate strategy and
managers in the planning, implementation and engaging with the community.
monitoring and evaluation of immunization
communication activities by 2025. Integrating maternal, adolescent, child health
and nutrition services to immunization program
■ Build interpersonal communication skills of
health workers in all health facilities by 2025 Immunization services often provide the only reliable
with a focus on integrated The First 1000 Days routine contacts with health services for mothers
(immunization, ECD, nutrition, maternal and and their infants. The importance of integration,
child health) approach. both in health systems in general and within
■ Conduct at least two research to assess, monitor immunization programs more specifically, has been
and evaluate the utilization of immunization growing, and this is reflected in a broad range of
communication interventions including global policies and strategies. Immunization service
behaviour and social drivers of immunization delivery serve as a platform for providing other
practices by 2025. priority public health interventions; other priority
programs, in turn, serve as a platform for delivering
■ Reduce gender related barriers around
immunization service as well. Routine immunization
immunization practices by applying gender-
has a long history of integration several services
sensitive demand generation activities at all
such as vitamin A supplementation, growth
levels by the end of 2025
monitoring, deworming or insecticide-treated
■ Integrate with other critical social and behaviour bed nets. There is also considerable evidence of
change interventions on ECD, nutrition, maternal positive health and nutrition outcomes resulting
and child health with immunization demand from integrating nutrition services into other health
generation activities by end of 2022. interventions. Thus, nutrition specific interventions

Comprehensive Multi-Year Plan (2021-2025) 61

like Growth monitoring and promotion, Vitamin Improving immunization services in urban
Supplementation, deworming, screening, IYCF areas: Developing innovative strategies for urban
counselling and maternal nutrition counselling vaccination will be one important focus areas in the
need to be integrated with routine immunization country, along with devising strategies to specific
services; supplementary immunization events, such populations like slum areas, outskirts, big buildings,
as national immunization days (NIDs), measles, urban migrants, street populations.
tetanus toxoid (TT) and yellow fever campaigns; For
example, WHO recommends that if routine coverage Reducing Missed Opportunities for
with vitamin A supplements is less than 80%, Vaccination (MOV): Reducing missed
then vitamin A supplements should be included opportunities for vaccination (MOV) is a strategy to
with supplementary immunization activities and it increase immunization coverage by making better
supports to reach high proportion of children that use of existing vaccination sites. Efforts will be
are not reached by routine services and they reach done to reduce the MOV through designing tailored
children above one year of age. strategies.

Integration avoids missed opportunities of maternal, Population movements: Migration, pastoralist

adolescents and youth health services. Integration communities, and cross-border population
of maternal, adolescent and nutrition services with movements can result in large communities of
immunization program has paramount importance unprotected individuals at risk of infection. It is
in establishing and sustaining effective service vital to design tailored strategies to address these
provision through integration. With this regard, the populations.
following maternal, adolescent and youth, child Conflict and instability: Civil conflict, resulting in
health and nutrition services are recommended to IPDs and refugees, can rapidly lead to loss of health
be integrated with immunization services. service infrastructure and shortages of trained
Life-course approach: Consider Vaccination health workers, often for extended periods, thereby
beyond infancy, with a life course approach for disrupting delivery of immunization services. It is
target groups of population. vital to design tailored strategies to address these
populations.
Leave no one behind: Leave no one behind by
increasing equitable access of new and existing Improving vaccine supply, safety and
vaccines. regulation: Efforts will be undertaken to improve
vaccine supply, safety, regulation and sustainability
Equity and Access: Focus will be given to identify of vaccines functional cold chain system.
and address low levels of coverage among the
poorest and most disadvantaged individuals; and Sustainable immunization financing:
actively seeking out zero dose and under-immunized Sustainable immunization financing mechanisms
target population and develop locally tailored and will be sought from government, domestic, and
context-specific interventions and strategies to external resources. The country will ensure a
address inequalities. clear pathway to programmatic and financial self-
sustainability for immunization service and program

62 Ethiopia National Expanded Program On Immunization

with increasing efforts to establish national budget Accelerating innovation and research: Robust
lines, allocation, and disbursing funds. research agenda offers new opportunities to meet
future challenges on immunization.
Strengthen institutional and human capacity:
The EPI structure and function need to revisit its Improve monitoring and data quality: The
structure and capacity based on the current and quality of immunization, vaccine and surveillance
future country context on immunization evolving data will be regularly monitored and used for action.
context. As one critical action, pre-service and Process indicators like different strategies, micro
in-service vaccinology training/capacity building plan availability, session implementation, vaccine
activities will be in place based on need. wastage and related indicators will be monitored.

Planning and coordination: The forward Public private partnership: The MOH will work
ambitious immunization strategic plan, the existing with private facilities that provide immunization by
and new coordination mechanisms like the ICC, the capacity building, ensuring quality of immunization,
taskforce, the technical working groups, and the cold chain standardization and reporting.
NITAG need to be strengthen at all levels.
COVID19 precaution and infection prevention:
Enhancing partnership and collaboration for While planning, implementing and close out of
immunization: Partnership and collaboration for vaccination sessions; ensure COVID19 prevention
immunization will be expanded within the country, precautions (physical distancing, one-way client
continental and international immunization partners. flow, ventilation, handwashing washing/sanitizer,
wear facemask and properly contain vaccine
Create demand, and gain/Sustain trust: wastes).
Development and implementation of integrated
communication plan for immunization and address
any mistrust among different interest group and
maintain the trust of the community.

Comprehensive Multi-Year Plan (2021-2025) 63

 3.7 Anticipated Coverage Targets

64
Indicators Base year Expected Targets
coverage coverage
m-EDHS 2019
2019 2020 2021 2022 2023 2024 2025
Total Population 99,603,376 101,767,684 102,193,064 104,850,083 107,576,186 110,373,166 113,242,869
Live Births (3.36%) 3,346,673 3,419,394 3,433,687 3,522,963 3,614,560 3,708,538 3,804,960
Infants’ deaths (43/1000 4,282,945 4,274,243 4,189,916 4,194,003 4,195,471 4,194,180 4,076,743.28
in mini EDHS 2019
Surviving infants (3.16%) 3,147,467 3,215,859 3,229,301 3,313,263 3,399,407 3,487,792 3,578,475
12-23 months old (2.5%) 2,490,084 2,544,192 2,554,827 2,621,252 2,689,405 2,759,329 2,831,072
9-13 old female pop (7%) 6,972,236 7,123,738 7,153,514 7,339,506 7,530,333 7,726,122 7,927,001
Pregnant women (3.36%) 3,346,673 3,419,394 3,433,687 3,522,963 3,614,560 3,708,538 3,804,960
Target population BCG 2,443,072 2,667,127.46 3,055,981.38 3,205,896.15 3,397,686.25 3,560,196.86 3,728,861.18
BCG coverage 73% 78% 89% 91% 94% 96% 98%
Target population OPV3 1,888,480.01 2,154,625.41 2,615,733.66 2,816,273.24 3,025,472.64 3,208,768.69 3,399,550.92
OPV3 coverage 60% 67% 81% 85% 89% 92% 95%
Target IPV vaccinated 2,041,471 2,154,625.41 2,615,733.66 2,816,273.24 3,025,472.64 3,208,768.69 3,327,981.43
IPV Coverage 61.0% 67.0% 81% 85% 89% 92% 93%
Target population 1,919,955 2,154,625.41 2,615,733.66 2,816,273.24 3,025,472.64 3,208,768.69 3,399,550.92

Penta 3
Penta 3 coverage 61.0% 67.0% 81% 85% 89% 92% 95%
Target population 2392075 257268705 2874078 3015069 3195443 3348280 3506905
(Penta 1)
Penta 1 coverage 76 80 89% 91% 94% 96% 98%

Ethiopia National Expanded Program On Immunization

 Indicators Base year Expected Targets
coverage coverage
m-EDHS 2019
2019 2020 2021 2022 2023 2024 2025
Target population3rd dose 1,490,274 2,154,625.41 2,615,733.66 2,816,273.24 3,025,472.64 3,208,768.69 3,399,550.92
of PCV
3rd dose PCV Coverage 61.0% 67.0% 81% 85% 89% 92% 95%
Target population 1st 1856734 257268705 2874078 3015069 3195443 3348280 3506905
dose of PCV
1st dose PCV Coverage 76 80 89% 91% 94% 96% 98%

Comprehensive Multi-Year Plan (2021-2025)

Target pop vaccinated 1,384,885.34 1,768,722 2,260,511 2,518,080 2,753,520 2,929,745 3,113,273
with 2nd dose of MCV
vaccinated
Coverage 2nd dose of 44% 55% 70% 76% 81% 84% 87%
MCV
Target pop vaccinated 1,857,005 2,090,308 2,583,441 2,783,141 2,991,479 3,139,013 3,327,981
with1st dose of MCV
1st dose of MCV coverage 59% 65% 80% 84% 88% 90% 93%
Target pop for 2nd dose of 909,067 2,379,736 2,874,078 3,015,069 3,195,443 3,348,280 3,506,905
Rota vaccinated
Coverage 2nd dose of 61.0% 74.0% 81% 85% 89% 92% 95%
Rota
Target pop for 1st dose of 1132608 257,268,705 2,874,078 3,015,069 3,195,443 3,348,280 3,506,905
Rota vaccine
1st dose of Rota vaccine 76 80 89% 91% 94% 96% 98%
coverage
Pregnant women - 2,735,515 3,055,981 3,205,896 3,397,686 3,560,197 3,728,861
vaccinated with
TT+(PAB)/TD
TT+ coverage (PAB)/Td 80% 89% 91% 94% 96% 98%

65
66
Indicators Base year Expected Targets
coverage coverage
m-EDHS 2019
2019 2020 2021 2022 2023 2024 2025
Annual Penta Dropout 20.2 16 8 6 5 4 3
rate
Annual Measles Dropout 23.2 19 9 7 7 6 5
rate 1
Annual MCV1-MCV2 15 10 8 7 6 6
Dropout rate 1
Men A 0 0 - - 2,991,479 3,139,013 3,327,981
Men A Coverage 0 0 0% 0% 88% 90% 93%
Yellow Fever 0 0 0 2,650,610 2,889,496 3,139,013 3,327,981
Yellow Fever Coverage 0 0 0 80% 85% 90% 93%
HPV1Performance 1,147,431 1,172,364 1,177,264 1,220,455 1,252,187 1,297,988 1,331,736
HPV1 Coverage 96% 96% 97% 97% 98% 98%
HPV2 Performance - 1,013,606 1,071,801 1,117,282 1,164,405 1,207,924 1,304,558
HPV 2Coverage 83% 87% 89% 90% 91% 96%
Target Hep B Birth dose 14621 2924059 3108521 3300599 3500564
Coverage 80% 83% 86% 89% 92%
Target COVID 19 vaccine 0 0 20,438,613 52,425,042 16,136,428 11,037,317 5,662,143
Coverage from total 0 0 20% 50% 15% 10% 5%
population
Coverage from target 0 0 80% 85% 90% 93% 95%
Target fully Vaccinated 1,353,411 1,607,929 1,776,115 2,153,621 2,549,556 2,790,234 3,041,703
Fully vaccinated 43.0% 50.0% 55.0% 65.0% 75.0% 80.0% 85.0%

Ethiopia National Expanded Program On Immunization

 National priority, Objectives and Milestones, AFRO Regional and Global Goals

Global/ AFRO
NATIONAL PRIORITIES NIP OBJECTIVES NIP MILESTONES ORDER OF PRIORITY
REGIONAL GOALS

■ To vaccinate 89% of
Routine Immunization ■ To achieve 98% Penta 1 coverage nationally
children with Penta 1 in
Coverage and equity and 98% in every district by 2025.
2021; 91% in 2022; 94%
■ To achieve 95% Penta 3 coverage nationally
in 2023; 96% in 2024 and
■ Low coverage and 95% and above in every district by 2025.
98% in 2025
with high disparity ■ To achieve 93% MCV 1 coverage nationally
■ To vaccinate 81% of
among regions and and 88% and above in every district by 2025.
children with Penta 3 in
Woredas. (Penta To achieve 87% MCV 2 coverage nationally

Comprehensive Multi-Year Plan (2021-2025)

■
2021; 85% of children in
1=76%; Penta and 86% and above in every district by 2025. HSTP targets
2022: 89% in 2023; 92%
3=61%; MCV1=59% ■ Reduce DTP-HepB-Hib1(Penta-1)- DTP-HepB-
in 2024 and 95% in 2025.
and MCV2=50%) Hib3 (Penta-3) dropout rate to 3% nationally ■ Increase
■ To reduce Penta 1 to
■ High dropouts and less than 5% in all districts by 2025. pentavalent 3
Penta 3 DoR to 8% in
of RI (Penta 1 to ■ Reduce DTP-HepB-Hib1(Penta-1)- MCV1 coverage from 61%
2021; to 6% in 2022; to
Penta3=20.2% dropout rate dropout rate to 5% nationally to 85%
5% in 2023; to 4% in
and Penta 1 to and less than 7% in all districts by 2025. ■ Increase MCV1
2024 and to 3% in 2025
MCV1=23.2%) ■ Reduce MCV1-MCV2 dropout rate dropout coverage from 59%
■ To reduce Penta 1 to
■ Some public rate to 6% nationally and less than 10% in all to 83%
MCV1 DoR to 9% in 2021;
Hospitals and HCs districts by 2025.
to 7% in 2022; to 7% in
do not provide EPI ■ Reduce proportion of woredas with less than
2023; to 6% in 2024 and
service. 80% penta 3 coverage to zero
to 5% in 2025
■ Delayed new ■ Ensure availability of immunization service in
■ To introduce MR vaccine
vaccines introduction all HF (Hospitals, Health centres and Health
in 2024; Men A in 2024;
(Men A, YF, Hep posts) by 2025.
YF in 2024 and Hep BBD
BBD, MR). ■ To introduce Men A, YF, Hep BBD, MR
in 2022
vaccines

67
68
SIAs and NIP OBJECTIVES NIP MILESTONES Global/ AFRO REGIONAL GOALS ORDER OF
Surveillance PRIORITY
Polio Preventive ■ Achieve >95% SIAs coverage in ■ Two rounds SIA annually with ■ Interrupt transmission of all One
and outbreak all districts all through 2024 coverage >95%. wild polioviruses ( WPV).
response SIAs ■ Achieve and maintain the ■ Mobilize additional funds to ■ Ensure sensitive
function and polio free status ■ bridge funding gaps poliovirus surveillance
mistermed in to national ■ Monitor quality of SIAs through integration
immunization system ■ Receive polio funded assets with comprehensive
phase by phase, vaccinepreventable diseases
■ Incept Polio lab in the national (VPD) ad communicable
health system diseases surveillance system
■ Certify eradication of WPV
■ Contain all polioviruses

Measles SIAs ■ Conduct two Measles follow ■ Conduct follow up measles SIA ■ Eliminate measles One
up SIAs and achieve ≥95% ■ Improve quality of measles SIAs
coverage by 2025. and monitor performance
Maternal and ■ Sustain MNT road map ■ Considering school Td ■ Maintain MNT elimination One
Neonatal Tetanus ■ ■ (<1/1,0000LB it is also proxy
SIAs indicator of MT)
Meningitis A ■ Prevent Meningococcal ■ Conduct catch up Men A mass ■ Eliminate Meningococcal One
vaccination Meningitis epidemic till 2025 vaccination campaign by 2022 Meningitis by 2030 (global
campaign and beyond ■ Men A introduced into routine Target)
immunization
Polio ■ Achieve AFP surveillance ■ AFP surveillance maintained in ■ Sustain polio free (both W Two
performance indicator targets in all Woredas with government and vDPV)
all Woredas and environmental ownership, AFP surveillance ■ Support the polio eradication
surveillance in select areas. indicators achieved. program
■ Expand the environmental sites ■ Expand the environmental sites
to be collected twice per month to be collected twice per month
for a period of 6 months after for a period of 6 months after

Ethiopia National Expanded Program On Immunization

the last OPV campaign. the last OPV campaign.
 SIAs and NIP OBJECTIVES NIP MILESTONES Global/ AFRO REGIONAL GOALS ORDER OF
Surveillance PRIORITY
Measles and ■ Attain measles incidence <5 ■ Conduct measles outbreak ■ Eliminate Measles by 2023 Two
Rubella cases per million population response among vulnerable ■ The key global objective of
■ Achieve measles surveillance population and in affected areas CRS surveillance is to provide
performance indicator targets in ■ Improve quality of measles SIAs data in support of rubella
all Woredas. and monitor performance elimination in five of six WHO
■ Strengthen the national polio ■ communicated with surveillance regions
and measles laboratory in staffs to notify the outbreaks
molecular techniques ■ Initiated the CRS surveillance
■ strengthen the CRS Sentinel

Comprehensive Multi-Year Plan (2021-2025)

sites
Maternal and ■ Achieve MNT surveillance ■ MNT surveillance maintained ■ MNT surveillance Two
Neonatal Tetanus performance indicator targets in in all Woredas with government maintained in all Woredas
Surveillance all Woredas. ownership, measles MNT with government ownership,
indicators achieved. ■ Measles MNT indicators
achieved.
■ MNT case management
improved
■ HWs sensitized/trained on
MNT
Bacterial Men A ■ Establish casebased meningitis ■ Men A introduced into routine ■ Eliminate Meningococcal Two
A surveillance by 2022 immunization Meningitis by 2030 (global
Target)
New Vaccines ■ Monitor new vaccines ■ Case based surveillance
surveillance introduction established

69
70
NATIONAL PRIORITIES NIP OBJECTIVES NIP MILESTONES Global/AFRO Order of
Immunization Supply chain goals priority
Inadequate capacity and weak Improve optimal CC capacity through By 2025 all planned CCE installed
cold chain maintenance, Sub deployment& installation of CCE.
optimal CCE By 2023 CCE maintenance system established.
Establish cold chain maintenance system.
Poor temperature monitoring By 2023 Temperature monitoring system
system Establish temperature monitoring at established and implemented in all vaccine
storage and transportation storage & transportation sites
Poor cold chain inventory and Establish Data base for CCEI By 2025, national automated CCEI management
maintenance management system established
system
Low EVMA score nationally Capacity building of focal persons 2023 EVM score achieved >80% EVM score >80%

Conduct periodic EVMA

Develop improvement plan

Strengthen Regular performance

monitoring
Low EVM score at lower Capacity building of focal persons 2023, 90% of HFs scored>80% EVM score EVM score >80%
distribution and health facility
level Regular performance monitoring
Poor vaccine stock monitoring Revitalize real time stock monitoring By 2025, 100% of vaccine storage sites order/
system and Enhance end to end vaccine monitor stock status electronically.
data visibility
By 2023, 95% of sites no vaccine stock outs
Incomplete last mile vaccine Conduct last mile vaccine delivery By 2025, 90% of HC& Hosp received vaccine from
delivery EPSA hub
Vaccine Supply Computerized vaccine stock management Computerized stock mx established on 2022
in all districts and direct delivery of
weak vaccine stock vaccines to HFs by 2025
management and distribution
system

Ethiopia National Expanded Program On Immunization

 NATIONAL PRIORITIES NIP OBJECTIVES NIP MILESTONES Global/AFRO ORDER
REGIONAL GOALS
Demand generation, communication, advocacy, social mobilization and program communications
Inadequate sub-national level To build the capacity By 2022, communication focal person at regional 3
capacity on communication of sub-national level level and/or EPI focal person at all level are trained
for immunization in the planning, on communication for immunization to improve
implementation and their capacity in the planning and coordination
monitoring and evaluation of demand generation and communication for
of communication for immunization activities.
immunization activities by
2022

Comprehensive Multi-Year Plan (2021-2025)

Low level of commitment To increase the involvement Through 2021to 2025, a series of advocacy 3
or support of political and of political and decision meetings, workshops and visits are conducted to
decision makers as well as makers as well as other ensure the commitment, engagement and support
other important stakeholders important stakeholders by political leaders, heads of sector offices, CSOs
in immunization at all level including CSOs in and community leaders for the immunization
immunization program at all program
level by 2022
Poor social mobilization and To improve the participation By 2022, the HDA/WDA and social mobilization 3
community engagement of HDA/WDA and social committees are established and/or revitalized for
on immunization demand mobilization committees by social mobilization and community engagement on
activities at grass root level 2022 immunization demand generation activities at the
community level
Inadequate interpersonal To improve the interpersonal By 2023, at least one health worker or HEW per 3
communication skills for communication skills, one health facility is trained on interpersonal
vaccine communication particularly on vaccine communication skills with a focus on vaccine
among health workers communication, of health communication
workers including HEW by
2023

71
72
NATIONAL PRIORITIES NIP OBJECTIVES NIP MILESTONES Global/AFRO ORDER
REGIONAL GOALS
Lack of immunization demand To develop a budgeted By 2022, National Immunization Demand 3
generation plan of action at National Immunization Generation Plan of Action developed and
the national and sub-national Demand Generation Plan of implementation initiated
level Action by 2022
Limited strategies which are To develop, implement, By 2025, at least five tailored immunization demand 3
tailored for the communities monitor and evaluate strategies have been developed, implemented,
with high number of zero- tailored immunization monitored and evaluated for the socially/
dosed and under-immunized demand strategies by 2024 geographically hard to reach communities by using
children people-centered approach
Lack of specific interventions To mainstream gender- By 2025, communication materials, messages and 3
addressing gender related sensitiveness in every activities developed for the immunization practices
barriers to seek immunization immunization messages and are gender-sensitive
services activities by 2025
Lack of awareness on the To increase awareness By 2023, standardized, produced and disseminated 3
importance of immunization of the community on the communication materials on immunization in at
and the schedule among the importance of immunization least five local languages
community members which to 95% by 2025
result from the shortage
of job aids and other IEC
materials on immunization for
awareness raising
Weak involvement of media To strengthen relationship, By 2022, national, regional and community 3
in immunization messages engagement, capacity and media agencies sustain their engagement in the
dissemination involvement of different immunization demand generation activities with
media agencies in a high media coverage around immunization
immunization activities/events such as African Vaccination Week,
World Polio Day, etc. and support dissemination of
program by 2022 immunization messages to the community via their
media channels

Ethiopia National Expanded Program On Immunization

 NATIONAL PRIORITIES NIP OBJECTIVES NIP MILESTONES Global/AFRO ORDER
REGIONAL GOALS
Limited monitoring activities To conduct regular Regular monitoring of immunization demand 3
on immunization demand monitoring communication generation activities is conducted throughout 2021-
generation activities at the activities throughout 2021 2025 at all levels
national and sub-national to 2025
levels

Limited availability of To undertake assessment By 2023, at least one research or assessment 3

evidence, research and and/or research around around behavior and social drivers of immunization
assessment on immunization behavior and social drivers practices is conducted

Comprehensive Multi-Year Plan (2021-2025)

practices of immunization practices
by using qualitative and
quantitative methodologies
by 2023
Lack of integration of other To integrate key behaviors By 2022, key behaviors and messages around ECD,
critical interventions such as around ECD, nutrition, nutrition, maternal and child health are integrated
ECD, nutrition, maternal and maternal and child health into the immunization demand generation activities
child health messages into immunization
demand generation
interventions by 2022.

73
74
NATIONAL PRIORITIES OBJECTIVES MILESTONES Global/ AFRO ORDER OF
Program management REGIONAL PRIORITY
GOALS
Immunization data quality Improve EPI data quality and attain 90% HFs attain Penta 3 data discrepancy of +10% between all countries
and use at all level the acceptable level (within +10%) of registration book and data on DHIS2 by 2025 collect quality
data discrepancies on immunization immunization 1
in all health facilities and local use data though
of immunization data for quality building local
improvement. capacity to use
Improve routine admin data quality with Routine data quality verified at all level with internal innovation
internal and external verification methods mechanisms (eg. though quality improvement team,
performance monitoring team, etc monthly at PHCU and
quarterly at woredas) and use of local coverage validation
tools

Routine data from various sources verified and triangulated

including convenience coverage assessment
Technology-assisted Introduce technology/application assisted Immunization focused program focused Supportive supervision 2
program supervision, regular and immunization focused supportive done by user friendly apps in all woredas regularly at all level
program monitoring and supervision on regular bases.
evaluation at lower level
EPI coordination at all level Strengthen coordination platforms for EPI coordination platform established/revitalized in all zones 2
immunization at all level and woredas

Institutionalize EPI TOR by 2022

All countries have a functional NITAG or are part of a local

regional functional NITAG (GVAP)

All woredas have EPI coordination platform

Ethiopia National Expanded Program On Immunization

 NATIONAL PRIORITIES OBJECTIVES MILESTONES Global/ AFRO ORDER OF
Program management REGIONAL PRIORITY
GOALS
Systematic program Conduct EPI related assessment, Midterm review done by 2023 and terminal evaluation of 2
monitoring and evaluation evaluations and operational researches cMYP 2025
(cMYP review, coverage
survey, sero-survey, and One immunization coverage survey
other operational research) Two operational researches done
Document capacity building Develop EPI related trainings database Consolidated EPI related training database developed BY 2022 1
activities in immunization and repository at all level
program The databased used at regional, zonal and woreda level -

Comprehensive Multi-Year Plan (2021-2025)

PI/health related training consolidating and monitoring
databases developed by
Context specific operational Develop regional and woreda level All regions and woredas have regional implementation plan 3
plan/micro plan at lower implementation/operational plan aligned aligned with cMYP
level and regional and with cMYP
woreda operational plan All woredas and PHUs have context specific bottom-up micro
plan
Management, accountability Introduce competency-based framework Competency-based management capacity building to EPI
and operational capacity of tool to improve EPI managers managers introduced at all level
the EPI program management capacity at all level

75
76
NATIONAL PRIORITIES OBJECTIVES MILESTONES Global/ AFRO ORDER OF
(Strengthening human and REGIONAL GOALS PRIORITY
institutional resources)
Absence posts in the structure Improve staffing pattern to Review the exiting EPI structure by 2021
for EPI coordinators at national, include EPI managers and
regional and zonal levels coordinators post at national and Advocacy for senior management of the
regional levels ministry by 2022

Create EPI manger post at Federal level and

regional coordinators by 2023 and zonal
coordinators by 2024
There is no platform to track Improve Health sector human Launch iHRIS by the end of 2021, scale up
trained HWs resource information system 2022

Establish data base system to Establish and fully implement HIRIS data
trach trainees base by the end of 2023.

Ethiopia National Expanded Program On Immunization

 NATIONAL PRIORITIES OBJECTIVES MILESTONES Global/ AFRO ORDER OF
(Strengthening human and REGIONAL GOALS PRIORITY
institutional resources)
Inadequate health work force Improve health workers capacity Conduct training based on need assessment
Capacity by conducting need based tool findings by end of 2021
trainings
Link in service training(CPD) with promotion
Improve health work staffs and licensure from 2021-2025
turnover through incentives and
motivations Assessing the existing curricula of pre
service immunization education by 2021

Comprehensive Multi-Year Plan (2021-2025)

Revise pre service curricula to
include immunization education Curricula revision plan alignment with
stakeholders by 2022 ,finalize by end of
2022 and revise curricula by the end of
2023Increase training access for frontline
health workers, health managers and focal
persons by the end of 2025

Incorporate EPI program in Pre-service

education curricula by the end of 2025

Conduct two training impact assessment by

the end of 2025

Revise the existing EPI Health workforce

structure by the end of 2022

Establish mentorship system to

immunization service by the end of 2022

Conduct full implementation of mentorship

activities by the end of 2025

77
78
NATIONAL PRIORITIES OBJECTIVES MILESTONES Global/ AFRO ORDER OF
(Strengthening human and REGIONAL GOALS PRIORITY
institutional resources)
Inadequate capacity of Enhance the capacity of Plan full advanced research methodology
institutions to conduct institutions to conduct research studies to increase the capacity in 2021-
operational research on EPI through training and financial 2022
support
Build partnership with donors to mobilize
technical and financial supports from 2022-
2023
Establish EPI training center of Initiate discussion with WHO Afro IST/inter
excellency country support by 2022

Advocate with government to establish the

excellency centers by 2022
initiate discussion for local Conduct feasibility studies to assess local
vaccine production capacity in production of the country by 2021-2022
Ethiopia.
Sharing the findings with appropriate
Authorities

Ethiopia National Expanded Program On Immunization

 National priority NIP Objectives NIP Milestones Afro /regional/global ORDER OF
PRIORITIES
(Partnership
and financial
sustainability)
Enhance local and Engage and sustain EPI ■ One plan, one budget and one ■ Aliened plans, integrated
global partnership in partners throughout report on EPI program implementation and joint monitoring
EPI program program planning, and supervision.
■ Standardized, comprehensive and
implementation and accessible immunization ■ Regionally, globally, Standardized,
monitoring comprehensive acceptable up to date
■ Increase financial contributions of
immunization
local, regional and global for the

Comprehensive Multi-Year Plan (2021-2025)

EPI program ■ Regionally, globally, Regionally, globally,
vaccination
Secure the required Secure the required ■ Mobilize 100% of the required ■ Equitable, accessible, and effective
resources to funds for EPI program costs for the EPI program vaccine at all level.
implement the cMYP ■ Steadily increase domestic
financial contribution for EPI
program

79
 3.8 Planning by immunization system component

80
Service Delivery and New Vaccine Introduction

NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025

■ To achieve 98% Penta 1 coverage nationally and ■ RED/REC approach Conduct bottleneck assessment and context X X X X X
at least 95% in every district by 2025. implementation in every specific micro planning workshops in all
district and kebeles districts and PHCUs with the involvement of
■ To achieve 95% Penta 3 coverage nationally and
95% and above in every district by 2025. community.
Conduct house to house registration of X X X X X
■ To achieve 93% MCV 1 coverage nationally and
target groups
90% and above in every district by 2025.
Conduct RED/C strategy evaluation X
■ To achieve 87% MCV 2 coverage nationally and
85% and above in every district by 2025. ■ Plan to reach all kebeles at Implement routine immunization X X X X X
■ To achieve 85% fully immunization coverage least four times per year in improvement roadmap in zones with large
nationally and 80% in every district by 2025. difficult to reach areas and number of unimmunized children and regions
areas with large number of require special support
■ Reduce DTP-HepB-Hib1(Penta 1)- DTP-HepB-Hib3 unvaccinated children using
(Penta 3) dropout rate to 3% nationally and less HWs and HEWS
than 5% in all districts by 2025.
■ Capacity building for EPI Training of HWs and EPI managers on RED/C X X X X X
■ Reduce DTP-HepB-Hib1(Penta 1)- MCV1 dropout managers and health strategy, MLM, IIP, and IRT
rate to 5% nationally and less than 7% in all workers
districts by 2025. ■ Design and implement Organize and deploy mobile health teams X X X X X
■ Reduce MCV1-MCV2 dropout rate dropout rate to context specific and for pastoralist and other hard to reach
6% nationally and less than 10% in all districts by appropriate strategy for populations
2025. pastoralist and urban areas PIRI implementation in hard to reach districts X X X X X
■ Reduce proportion of woredas with less than 80% (training, service delivery, supportive
Penta 3 coverage to zero supervision, and review meeting)
Conduct assessment on implementation X
■ Ensure availability of immunization service in all
status and outcome of PIRI
HF (Hospitals, Health centers and Health posts) by
2025. Implementation of tailored strategy to X X X X X
address unreached segments of urban
community
■ Intensify defaulter tracing Defaulter tracing using HDAs/Community X X X X X
through strengthening volunteers
available community
platforms and structures

Ethiopia National Expanded Program On Immunization

 NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025

■ Regular supportive Conduct supportive supervision at all level X X X X X

supervision and program Conduct performance review meeting at all X X X X X
monitoring level
■ Learn, document and Documentation of lessons and best practices X X X X X
share experience and share through different platforms

■ Incorporation of Incorporate immunization services in X X X X X

immunization in the emergency preparedness plans and activities
emergency preparedness
and response plans

Comprehensive Multi-Year Plan (2021-2025)

■ Prepare and implement Develop catch up vaccination X
catch-up plan to address implementation guideline
population in areas with Conduct catch up vaccination X X X X X
prolonged interruption of
immunization service due
to conflict, IDP, drought and
other emergency affected
areas.
■ Utilization of second year Sensitization of HWs and EPI program X
platform to improve MCV1 managers on second year of life platform for
and MCV2 coverages RI strengthening

■ Integration of EPI with other Circular for all regions to monitor integration X X X X X
services to reduce missed of immunization service with other Maternal,
opportunity Neonatal and Child health services
Integration of immunization service with X X X X X
other Maternal, Neonatal and Child health
services
■ Avail vaccination service Delivery of vaccination service on daily basis X X X X X
whenever and wherever by all health facilities
needed Monitor outreach sessions are conducted as X X X X X
per the plan

■ Private HFs engagement in Sensitization of private HFs (HWs and X

RI service Managers) on engagement of PHFs on EPI
service delivery,

81
82
NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025

■ Introduce COVID-19 Vaccine, nOPV2 and piloting ■ leadership strengthening for Apply for MR, IPV2, Mena A, Hep BBD and X X
of Hepatitis B birth dose by 2021, introduce MR new vaccine introduction Yellow Fever vaccine introduction plan
and IPV2, scale introduction of Hepatitis B birth Strengthen new vaccine introduction X X X X X
■ Capacity building on new
dose, Yellow fever, Men A vaccine by 2022. vaccine introduction at all taskforce
levels Training of health workers and EPI program X X X X X
■ Advocacy and consensus managers
building Introduce IPV2 X
■ Expansion of Cold chain Introduce MR X
Storage space
■ Evaluate vaccine Introduce Men A X
management practices Introduce YF X
■ Revision of monitoring tools COVID-19 and other emergency

Expand PFSA cold rooms X X X

Train EPI managers and health workers from X X

each HF on new vaccines
Evaluate programmatic impact of new X
vaccines introduction

Ethiopia National Expanded Program On Immunization

 Supplementary Immunization Activities (SIAs) and Surveillance
NATIONAL STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
OBJECTIVE
Supplementary Immunization Activities (SIAs)
Polio ■ Improve quality of polio SIAs and Conduct two rounds bOPV SIAs annually in selected risk X X X
monitor performance areas.
Achieve >95% SIAs
■ Integrate polio functions and Conduct mOPV2 SIA as outbreak response in cVDPV2 X X X X X
coverage in all districts
assets in to the national health affected and high risk areas.
through 2024 and
sustain polio free system phase by phase Map and Mobilize additional funds to bridge funding X X X X X
status. gaps.
Obtain polio vehicle and transition fund from partner X X X X X

Comprehensive Multi-Year Plan (2021-2025)

Mainstream polio functions in health system
Measles ■ Improve implementation capacity Revise the m-easles elimination document X
Improve quality SIAs Conduct follow up measles SIA for 6-59 months age X X
Achieve >95% Measles ■
children and monitor performance.
coverage in the follow-
up SIAs and outbreak
Conduct measles reactive vaccination for vulnerability X X X X X
response, 2021 all
reduction in affected population and areas
through 2025
MTN Consider school Td vaccination ■ Microplanning X X X X X

Maintain MNT ■ resource mobilization for operation

elimination ■ logistic and supply

(<1/1,0000LB it is also ■ coordination and partnership with partners with

proxy indicator for MT education sectors
elimination)

Men A Catch-up Men A vaccine Catch-up Men A SIA by 2022 in susceptible population X X X

Prevent meningococcal
meningitis outbreaks
all through , 2021 to
025

83
84
NATIONAL STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
OBJECTIVE
II. Surveillance and Accelerated Disease Control
AFP ■ Strengthen and monitor case and ■ Follow-up assessment and regular Supervision X X X X X
lab-based AFP surveillance and
Achieve AFP achieve performance indicator
surveillance targets in all Woredas
performance indicators
■ Expand environmental surveillance
targets in all Woredas
sites ■ Monitoring and data harmonization with AFP X X X X X
and environmental
surveillance in selected ■ Integrate VDP surveillance in the surveillance indictor
areas. context of COVID 19 pandemic
response
■ Emphasis to enhancing
government ownership of AFP ■ Regions and partners orientation and training X X X X
surveillance activities health workers regarding AFP surveillance in the
context of COVID-19.

Ethiopia National Expanded Program On Immunization

 NATIONAL STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
OBJECTIVE
Measles: ■ Strengthen case and lab- ■ Follow up assessment and Regular X X X X X

Achieve measles
based measles surveillance Supervision
surveillance integrated with rubella
performance indicator to achieve performance
targets in all Woredas indicators in all Woredas,
with emphasis to enhancing
government ownership.
■ Mobilize additional funds
■ Monitoring and data harmonization with X X X X X
to bridge funding gaps to

Comprehensive Multi-Year Plan (2021-2025)

measles surveillance indictor.
MNT surveillance: sustain measles case-based
surveillance.
Achieve MNT
surveillance ■ Ensure continuity of measles
performance indicator case-based surveillance
targets in all Woredas during the COVID 19
Pandemic.
■ Ensure continuity of Td ■ Regions and partners orientation and X X X X
vaccination and MNT training health workers regarding AFP
surveillance during the surveillance in the context of COVID-19
COVID 19 Pandemic X X
■ Revise the MNTE sustainability roadmap/
plan Strengthen MNT surveillance
■ Capacity building to improve
■ through universal sensitization of health X X X X X
MNTE performance
workers and community awareness
■ Consider school Td creation
vaccination
■ Ensure continuity of Td vaccination and
■ Program mainstreaming X X X X X
MNT surveillance during the COVID 19
Pandemic

85
86
NATIONAL STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
OBJECTIVE
Pediatrics bacterial Upgrade/strengthen the coordination between ■ Arrange regular forum between X X X X X
meningitis: Men A case based & lab-based surveillance two parties
system with Central /Regional laboratories
Establish case- ■ Conduct joint supportive
based Meningitis A
surveillance by 2022
supervision
■ Create Orientation/training
opportunities

Laboratory
Polio Lab: Expand ■ Sewage samples collected ■ Coordination meeting with the site X X X X X
environmental twice per month for a period coordinators
sampling sites of AFP
of 6 months after the last ■ Capacity building of surveillance officers
OPV campaign. and subnational lab team member about
■ Initiation of molecular test CRS
for measles and Strengthen
the CRS sentential sites

Ethiopia National Expanded Program On Immunization

 Immunization Supply Chain
Objectives Strategies Activities 2021 2022 2023 2024 2025
Pilot test third party logistics, ■ Assess availability of third partly logistics who can be able to X X X X
outsourcing of vaccine provide the service.
distribution to the last mile and
■ Advocate and discuss the possibility of outsourcing.
bimonthly vaccine distribution
Computerized vaccine by integrating with the IPLS. ■ Implement outsourcing on last mile delivery for pilot sites
stock and inventory
■ Review the cold chain capacity of health facilities and select those
management in all
who have sufficient storage capacity to stock for two months of
districts and direct
delivery of vaccines to stock
HFs by 2025

Comprehensive Multi-Year Plan (2021-2025)

Integrating the management of ■ Assess the feasibility of integrating the management (storage and X X X X X
non-EPI keep cool items with distribution) non-EPI Keep cool items at all levels
EPI
■ Piloting the integration non EPI keep cool items management with
EPI from national to the service delivery point.
Conduct operational research ■ Mobilize resource to conduct operational research on actual X X X X X
on selected iSCM elements. vaccine wastages rates
■ Conduct operational research to underhand the actual wastage
rates (Opened and unopened vial wastages) of vaccines at all
■ Advocate logistics data use for decision making at all levels

87
88
Objectives Strategies Activities 2021 2022 2023 2024 2025
■ Conduct capacity building X X X
activities.
■ Maintain temp monitoring ■ Establish state of the art cold chain maintenance workshops/
devices and formats facilities and training centers at new and existing institutions,
availability and quality. (such as in Debremarkos, Jimma, Gondor and Addis Ababa
university, Tegbareid TVET, etc) and others.
■ Make temperature
monitoring components a
performance indicator
■ Conducting periodic temperature monitoring studies and conduct X X
calibration:
Ensure storage and
■ Map the cold rooms and refrigerated vehicles temp /new and
transportation equipment
maintain a standard existing

Improve the Cold chain temperature ■ Conduct calibration periodically /for new and after repair
management works for cold rooms and refrigerated vehicles.
■ Establish mechanisms to monitor temperature during transport by
procuring and installing of RTMDs
Establish mechanisms to ■ Establish formal temperature reviewing team X X X X X
maintain temperature record
■ Establish reporting and feedback system in hard/soft copy on
traces and reviewed
temperature monitoring and schedule periodic temperature review
exercise (at least once per month) at all level

■ Establish recording and reporting system for maintenance (CCE, X X X X

including refrigerated trucks) activities
Improve data generation and
utilization for cold chain and ■ Establish spare parts inventory management system X X
maintenance activities
■ Establish updatable cold chain equipment inventory system using X
web based inventory tools, at levels.

Ethiopia National Expanded Program On Immunization

 Objectives Strategies Activities 2021 2022 2023 2024 2025
Monitoring and fulfilling Prepare schedule for distribution of vaccine from the issuing store to X X X X X
backorders hold appropriate the each receiving store
stock at each level according to
min-max level Record the number of deliveries. collection by issuing and receiving X X X X X
stores
Improve last mile
vaccine delivery
Ensure implementation of SOPs Prepare JOBAID illustrating packages X X X X X

Advocate to use cool/chill water pack X X X X X

Temperature monitoring and
recording Monitor the recording of VVM status during delivery to different levels X X X X X

Comprehensive Multi-Year Plan (2021-2025)

Revitalize VITAS/mBrana to ■ Estimate non EPI keep cool items cold chain space needed X X X X X
incorporate the necessary
■ Exercise logistics data triangulation with other program data
supply chain parameter
sources
Revitalize real time ■ Develop transition of governance on mBrana and VITAS from JSI
stock monitoring to EPSA and MOH.
system Conduct operational research

Conduct data triangulation and operational research on selected iSCM

elements such as vaccine wastage rate

89
 Advocacy, social mobilization and program communication

90
NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
Increase demand, knowledge, ■ Multi-faceted demand Update, print and distribute immunization X X X X
attitude and practices of the generation strategies including communication materials and tool for HEW by
community on immunization services advocacy, social mobilization, 2022.
utilization at least 5% from the community engagement,
baseline by 2025. tailored interventions and risk Develop National Demand Generation on X X
communication to eliminate Immunization Plan of Action and Comprehensive
rumours and misconceptions immunization risk communication guideline
around vaccination and to
Ensure HEW have planned community dialogue on X X X X X
build trust in the immunization
immunization annually
services
Establish social media pages for immunization X x x x x
communication by 2021
Four TV and Radio spots on routine immunization X X X X X
annually.
TV and radio dialogs on immunization annually X X X X X
Hotline services on immunization communication X X X X X
Short SMS messages 2X annually X X X X X
Sensitize and Utilize town criers and social X X X X x
mobilizers for immunization communication
Develop messages on AEFI communication X X
Harmonize, develop and distribute messages(TV X X X X X
spot, radio spot, IEC/BCC materials etc) for
new vaccine introductions, SIAs and routine
immunizations
Develop SMS messages and communicate X X X X X
on vaccine-preventable diseases surveillance
annually.

Ethiopia National Expanded Program On Immunization

 NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
Conduct baseline immunization communication X X
survey
end line immunization communication survey X
Train all Sub-national level Improve the monitoring and Develop immunization communication planning,
immunization program experts evaluation practice of subnational monitoring and evaluation training material for
in the planning, implementation level EPI program experts EPI program experts
and monitoring and evaluation Train immunization program experts on planning, X X X
of immunization communication monitoring and evaluation of immunization
activities by 2025. communication.

Comprehensive Multi-Year Plan (2021-2025)

Promote and advocate for ■ Promote partnership and Develop manual for immunization advocacy X x
multisectoral involvement in conduct high level advocacy
meetings particularly in poor National and subnational immunization advocacy X X X X X
immunization Communication performing regions workshops
Sensitize and engage mainstream media X X
community on immunization communication.
■ Establish regional Draft regional immunization CTWG TOR and X X X X X
immunization CTWG support regions to establish the TWG

91
92
NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
Improve IPC skills of health workers ■ Improve health workers’ Develop IPC training manual for health workers X X
in 75% of health facilities by 2025. interpersonal communication
Conduct IPC skills trainings for health workers X X X X
capacity
Conduct two Researches to assess ■ Monitor and evaluate Conduct baseline assessment on immunization X X
immunization communication utilization of immunization communication outcomes by using Behavior and
intervention outcomes communication interventions Social Drivers (BeSD) tools for immunization
Conduct IEC/BCC material distribution auditing X X

Conduct end line assessment on immunization X

communication intervention
Develop, implement, monitor and Tailored immunization demand Conduct rapid inquiry around behavior and social X X
evaluate tailored immunization strategies by using people centered drivers of immunization practices among the
marginalized communities
demand strategies for urban-poor approach
and marginalized communities by Develop tailored immunization demand strategies X X
for the marginalized communities including
2024 activities addressing gender related barriers
Implementation, monitoring, documenting and X X X X
evaluation of tailored immunization demand
generation strategies

Ethiopia National Expanded Program On Immunization

 Program management
NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
Ensure/secure recording tools (immunization register,
X X X X X
cards...)
Improve EPI data quality Intensify data quality improvement Provide data Analysis, DHIS2 application and data quality
tools and technics through X X X X X
and attain the acceptable assessment (DQA) trainings
level (within +10%) of data addressing technical, behavioral
Advocate standardized immunization registration book into
discrepancies on immunization and organizational barriers X X X X X
part of CHIS tools to use at HP levels and use
in all health facilities and local
Support e-CHIS implementation including in developing
use of immunization data for X X X X X
regional states

Comprehensive Multi-Year Plan (2021-2025)

quality improvement. Build a body of evidence around
Conduct data quality and use improvement TWG regular
successful data quality, data use, X X X X X
■ Improve routine admin meetings at all level including QIT
data quality with internal and digitization interventions
Pilot electronic immunization register (EIR), identify lesson
and external verification (e-CHIS, EIR, Data Entry Level X X X X
learned and scale up
methods Validations, Data Quality Apps….)
Introduce locally applicable coverage validation tools X X X X X
Introduce data triangulation method to ensure data quality
X X X X X
(eg. from supply and program data)
EPI monthly reviews and EPI performance monitoring in all
X X X X X
PHCUs and quarterly in all districts using DHIS2II.
Introduce technology/application Setup the ODK infrastructure and conduct training on ODK
Ensure availability and access to X
assisted and immunization use
ODK and other similar applications
focused supportive supervision Conduct integrated and/or EPI specific systematic
for supervisory visit X X X X X
on regular bases. supervision using ODK or other similar applications

93
94
NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
Strengthen coordination Ensure engagement at highest level
Continue collaborating with E-NITAG X X X X X
platforms for immunization at of immunization program
all level Establish/revitalize immunization/child survival TWG/TF at
X X X X X
reginal, zonal and woreda level
Designate responsible person for
coordination

Develop/update the TOR of the TWG/TF X

Actively engage national and
regional stakeholders to strengthen
TWG/TFs
Conduct midterm cMYP evaluation X
Conduct data quality and other immunization
Identify resources for evaluation implementation focused operational research and x X
Conduct EPI related assessment, assessment and researches implement study outcome recommendations
evaluations and operational
Conduct national immunization coverage survey X
researches
Develop EPI related trainings Create awareness among all Develop EPI data base for documenting trainings of health
X
database and repository at all stakeholders about the need for the workers on immunization related topics
level database

Document consistently all EPI related trainings on the

Assign responsible person for data X X X X X
database at all level
reposition

Ethiopia National Expanded Program On Immunization

 NATIONAL OBJECTIVE STRATEGY KEY ACTIVITIES 2021 2022 2023 2024 2025
Develop regional and woreda Distribute cMYP to all regions (in soft or hardcopy as
level implementation/ needed)
operational plan aligned with All regions develop EPI operational/implementation plan in
cMYP alignment with cMYP and national operational plan
Ensure cMYP is availability and X
used at all level

Share developed EPI operational/implementation plan

to the next higher level for verification, follow up and X X X X X
feedback
Develop context specific bottom- All woredas and PHUCs develop context specific bottom-up

Comprehensive Multi-Year Plan (2021-2025)

up EPI micro-plan at woreda and Training/orientation on bottom up X X X X X
microplan
health facility level microplanning
All RHBs compile microplans developed by woredas/zones
X X X X X
Collect and collet MP developed at and provide feedback and support to the woredas/zones
woreda level to regional level At woreda level, during development of woreda base
X X X X
planning ensure to align with MP
Introduce WHO/CDC competency-based training for
regional and national level EPI program managers/ X
Introduce competency-based personnel
framework tool to improve EPI
Monitor the progress of implementation on based on
managers management capacity Assign responsible to rollout X X X
competency-based framework for EPI
at all level competency framework

Introduce e-learning platform in immunization program for

X X X X X
capacity building activities

95
 Strengthening human and institutional resources

96
Human Resource for immunization 2021 2022 2023 2024 2025
Objectives Strategies
Core Activities
Improve health ■ conducting need Conduct training based on need assessment tool findings by end of 2021 50 60 65 70 51%to
workers capacity based trainings, 80%
■ Conduct two training impact assessment by the end of 2025
■ Increase training access for frontline health workers, health managers
and focal persons by the end of 2025
■ Improve skills and practice of Health workers on EPI; Increase vaccine
management knowledge among health workers from current score of
51%to 80% as measured by EVMA by 2025
■ Achieve MLM training in 80% of districts by 2025
■ To achieve IIP training for >90% of front line HWs who are providing
immunization services
■ Achieve RED/REC training for > 90% HWs working in EPI
■ Achieve data management training (EDQS) for 80% HWs working in
EPI
■ Achieve training on VPD surveillance for 80% HWs working in
vaccine-preventable disease surveillance.
■ Strengthen EPI program training in pre-service education to 50% of
health teaching colleges.
■ Increase training access for frontline health workers, health managers
and focal persons by the end of 2025
■ Initiate vaccinology course training
■ incentives and ■ Link in service training(CPD) with promotion and licensure from 2021- X x
Improve health motivations and 2025
work staffs include pre service
turnover
■ curricula for

Ethiopia National Expanded Program On Immunization

 Human Resource for immunization 2021 2022 2023 2024 2025
Objectives Strategies
Core Activities
■ Curricula revision plan alignment with stakeholders by 2022, X X X x x

■ Incorporate EPI program in Pre-service education curricula by the end X

of 2025
■ Initiate vaccinology course X X

Improve Health Implement integrated Establish and fully implement HIRIS data base by the end of 2023. X
sector human health information
X X X x x
resource system(iHRIS)

Comprehensive Multi-Year Plan (2021-2025)

information
system
Improve staffing Review the exiting EPI structure by 2021 X Xx X x x
pattern to structure of EPI senior management of the ministry by 2022 X x x
include EPI Create EPI manger post at Federal level and regional coordinators by 2023 X X X x x
managers and and zonal coordinators by 2024
coordinators High level communication
X X X x x
post at national and Advocacy
and regional
levels

Enhance the Plan full advanced research methodology studies to increase the capacity X
capacity of in 2021-2022
Strengthen partnership
institutions Build partnership with donors to mobilize technical and financial supports X X X x x
and cooperation
to conduct from 2022-2023
research
Establish EPI Cooperation Strengthen Initiate discussion with WHO Afro IST/inter country support by 2022 X X x x x
training center Advocate with government to establish the excellency centers by 2022 X X x x x
of excellency

97
98
Human Resource for immunization 2021 2022 2023 2024 2025
Objectives Strategies
Core Activities
Initiate Conduct feasibility studies to assess local production of the country by
discussion for Strengthen partnership 2021-2022
local vaccine and cooperation Sharing the findings with appropriate Authorities
production Conducting mentorship to training centers of excellency
capacity in Strengthen mentorship
Ethiopia.
X
Develop improvement plan

Strengthen Regular Advocate with partners to conduct EVMA at regional and zonal levels to x
performance monitoring develop continues improvement plan following EVMA

Ethiopia National Expanded Program On Immunization

 Partnership and financial Sustainable
National Objective Strategy Key Activities Year
2021 2022 2023 2024 2025

Engage and sustain EPI ■ Facilitate joint planning meeting and share X X X X X
partners throughout the plan with government, partners and
Develop and strengthen joint stakeholders
the program planning,
annual planning, implementation, ■ Conduct joint supervision at all levels (National, X X X X X
implementation and
monitoring and evaluation Regional, and zonal)
monitoring
■ Advocating and sharing the CMYP for potential X X X X X

Comprehensive Multi-Year Plan (2021-2025)

donors
■ Regular follow-up on the progress of the CMYP X X X X X
implementation

X X X X X

Secure the required funds for Engage the community members, ■ Create flexible and open platform to different X X X X X
EPI program partners, officials, and other partners to take part in the CMYP activities/
objectives.
stakeholders in facilitation,
administration and coordination of ■ Mobilize community X X X X X
the vaccines delivery.
■ Map available resource mapping within the X X X X X
community, partners and stakeholders
■ Increase local authorities’ participation X X X X X

99
 04 Costing, Financing and
CHAPTER Financing Gaps

4.1 Macroeconomic Information

The macroeconomic information was included for The 2020 GDP per capita, 1,116 USD taken from
the purposes of placing the costing and financing cMYP 2016 to 2020 as baseline and assumed to
information in to context. increase by a minimum of 9.1% annually.

Macroeconomic information, current and projected, Ethiopia

MACROECONOMIC INDICATORS 2020 2021 2022 2023 2024 2025

GDP per capita 1116 1218 1328 1449 1581 1725

Total Health Expenditures per capita 9.46 11.04 12.87 15.02 17.52 20.44
(THE per capita) in USD

Government Health Expenditures (GHE %) 11.6 12.1 12.7 13.2 13.8 14.5
Data extrapolated from cMYP 2016 to 2020 with similar assumption

4.2 Methodology for costing the cMYP GDP growth based on WHO/NHA database; and
Disease Programme activity standards.
The cMYP 2021-2025 costed using OneHealth
Tool (OHT). This tool is built on six health system 4.2.1: Costing Assumptions
building blocks, drawing upon the WHO framework
on health systems that include health workforce, Targets were set using the available evidences from
infrastructure, logistics and supply chain, health the EPI surveys such as EDHS, WUNIC estimates,
information system, health systems financing, routine DHIS_2 administrative data and expert
leadership and governance. OHT is a policy opinions. Inputs for the tool were completed
projection-modeling tool that allows users to create through series of consultative workshops with EPI
short- and medium-term plans for scaling up health partners, program experts and stakeholders. List of
services. It is used for health planning, costing and priority Immunization interventions were identifies
budgeting with a focus on integrating planning and and prioritized prior to entry to OneHealth Tool for
financial space analysis. The tool is also organized costing and Target setting. Then the tool generated
into three components: health systems, health overall program cost and Targets considering existing
services delivery, and impact module. The tool interventions and no additional investments such as
comprises different country specific default data infrastructure expansion. The costing and Target
like; Baseline situation analysis (Epidemiology, assumptions are designed to be linked to cv000
Demography, current coverage, etc…); Intervention live births, Infant Mortality from 47 to 36/1000 live
standards (drug and supply cost per average case births and Under Five Mortality from 59 to 44/1000
based on WHO treatment guidelines + international live births in line with the HSTP II.
Vaccine prices from UNICEF, MSH and IDA, estimated
The cost implications for the proposed program
personnel type & time required); Expenditures &
activities and how they are related to the available

100 Ethiopia National Expanded Program On Immunization

financing for respective categories of the program injection equipment are based on unit expenditure
is highlighted in this section. Implementing this on different personnel cadres working in EPI at the
multiyear plan will require increasing costs over the different levels of the system and the numbers of
cMYP 2021-2025 periods. The major increases in personnel, adjusted for by time spent on EPI related
program costs are driven mainly by: activities. The cost and time spent on supervision,
and outreach activities were included for the
■ New Vaccine Introduction
different cadres of staff at the different level of the
■ Supplemental Immunization activities and VPD system. The unit expenditures based on Government
outbreak response Vaccinations gross wages. The quantities available and needed
■ Increase in target population and age group for the duration of the cMYP were included. Time
spent on EPI estimated by input of the different level
■ Need to expand cold chain capacity and
of staff at different levels.
rehabilitation
4.3 Costing of cMYP 20221-2025 4.3.3 Cold Chain Equipment Procurement and
Maintenance
The overall EPI Program cost for the cMYP 2021-
2025 including NVIs and SIAs is estimated to be Ethiopia developed a multi-year cold chain
1,165,091,340. The cost by intervention types are rehabilitation plan and the requirements of the
narrated section by section and indicated in the cold chain equipment considered the current gap,
table as follows. replacement of the over aged cold chain equipment
and the new health facilities to be constructed,
4.3.1 Vaccines and Injection Equipment construction of additional cold rooms at national and
sub-national level, and procurement of spare parts,
The costs are function of the unit prices for refrigerated trucks and cold chain monitoring tools.
individual vaccines, with quantities determined To replace old equipment, furnish all new health
by the target population, which is adjusted for by facilities, fill the current gap and procure spare parts
coverage and wastage objectives. The prices based and cover the maintenance, procure additional cold
on information from GAVI/UNICEF supply division. rooms a total of 28,678,667.30 USD will be needed
For the period of five years a total of 300,590,940.44 for the period of five years.
USD will be needed for the routine vaccines and
injection materials. For this cMYP period, new 4.3.4 Operational Costs for Campaigns
vaccine introduction plan includes HepB birth dose,
Men A, COVID-19 Vaccine, Yellow fever and IPV2 Polio supplementary immunization activities will be
with the total vaccine and supplies estimated cost of conducted twice a year at national level. Ethiopia
496,415,192.99 USD required for the cMYP period. is also a priority country for measles control and
neonatal tetanus elimination. Measles follow-
4.3.2 Personnel Costs (EPI specific and shared) up through supplementary immunization will be
conducted every 2 to 3 years covering children 9
Over the period of 2021 to 2025, the total to 59months and bOPV preventive campaign every
programme cost is 167,355,728.7USD and this cost year, Men A catch up campaign once, COVID-19
includes costs of program specific HR, capacity response vaccination, nOPV2 response campaign
building, supportive supervision, communication every year and Yellow fever reactive vaccination
and community engagement, operational cost to phase by phase. The total cost estimated to conduct
reach HTR, transportation cost, CCE and spare part the planned supplemental immunization activities is
costs. The cost estimates as with vaccines and 166,228,917.84USD

Comprehensive Multi-Year Plan (2021-2025) 101

 Costs for the different cMYP components (shared and EPI specific)

102
FUTURE BUDGET REQUIREMENTS
EXPENDITURES
COST CATEGORY
IN 2020 2021 2022 2023 2024 2025 TOTAL 2021-2025

Vaccines (routine only) 71,132,478.60 49,073,644.4 53,612,482.75 58,482,660.03 63,349,704.08 68,300,685.21 292,819,176.5

Injection supplies 3,656,140.30 1,284,061.9 1,412,596.8 1,557,331.7 1,689,290.1 1,828,483.5 7,771,763.9

Program Specific HR 36,000.00 36,000.00 36,000.00 36,000.00 36,000.00 36,000.00 180,000.00

Training 433,126.08 4,719,628 6,912,203.00 4,710,713.00 6,802,713.00 0 23,145,257

General Programme
12,000.00 32,310.00 12,000.00 12,000.00 12,000.00 0 68,310.00
management
Supervision 2,925,982.00 3,069,382.00 3,165,382.00 3,165,382.00 3,165,382.00 0 12,565,528.00
Communication, IEC/social
970,067.50 2,575,968.50 6,542,657.86 2,574,968.50 5,689,657.86 50,000.00 17,433,252.72
mobilization
Operational Cost to reach
HTR, Transport, CCE, Spare 28,031,749.00 28,274,165.00 28,417,481.00 28,543,393.00 28,728,342.00 0 113,963,381.00
part
VPD Surveillance 689,954.30 832,816.57 981,292.39 1,135,142.39 1,294,067.14 1,458,573.88 5,701,892.37

Supply Chain 375,946.30 7,440,654.00 6,365,753.00 6,571,570.00 7,924,744.00 28,678,667.30

NVI with Injection Supplies 65,492,828.65 210,087,610.35 89,446,087.7 75,346,354.94 56,042,311.3 496,415,192.99
Campaigns with Injection
482,862.1 40548544.59 56,790,621.57 36,412,207.03 31,994,682.54 166,228,917.83
Supplies
EPI Operational Research - - - 120,000.00 - 120,000.00

Total 107,887,497.78 156,249,613.429 359,168,904.716 252,940,052.895 229,097,288.165 167,635,480.4528 1,165,091,339.659

Ethiopia National Expanded Program On Immunization

4.3.5. Financial Sustainability

According to the National Health Accounts to increase Immunization financing both for routine
2016/17, the Government contribution to the immunization and New Vaccine Introductions in the
Total Heath Expenditure has increased from 30% next five years strategic cMYP (2021-2025). The
to 32%. Ethiopia has been covering the cost of increase in the share of the government contribution
traditional Vaccines and sharing the cost of NVIs to Health is encouraging, as this pushes the Health
in the past cMYP period. The MOH is committed Sector towards more financial sustainability

Comprehensive Multi-Year Plan (2021-2025) 103

 05 Implementation, Monitoring
CHAPTER and Evaluation

5.1 Implementation 5.2 Monitoring and Evaluation

The cMYP, once developed and approved by To properly monitor the implementation of cMYP
all ICC members, will need to be printed and and evaluate the output/outcome, a robust M&E
largely disseminated to national and sub national plan will be developed and used. Regular monitoring
government bodies, development partners and and periodic evaluation will be carried out using
implementers at district level. The cMYP will different mechanisms. Annual and mid-year reviews
serve both as a management and advocacy tool will be planned and carried-out as main mechanism
for the MOH /EPI and development partners to to monitor progress made toward the planned
better understand their involvement while making objectives, identify the strengthen and weaknesses
decision to support the immunization program. To and update the plan as needed. A feedback will
operationalize the cMYP, an operational plan needs always be provided to EPI focal points at all levels.
to be developed. This will be done every year, with
much attention focused on the year’s objectives
and strategies as indicated in cMYP. Each year’s
operational plan will have detail activities with
required resources and indicators to monitor and
evaluate the implementation status and output/
outcome of the intervention. It also supports districts
to develop RED micro-plan.

104 Ethiopia National Expanded Program On Immunization

 Frequency Baseline Targets
Immunization System
Suggested Indicators of Source of data
Subcomponent EDHS
reporting 2021 2022 2023 2024 2025
2019/2020
Penta 1 immunization coverage Monthly DHIS-2 and Survey 76% 89% 91% 94% 96% 98%
Access Percent of public health facilities
Annually DHIS-2 and SARA 81% 100% 100% 100% 100% 100%
providing routine immunization service
Penta 3 immunization coverage Monthly DHIS-2 and Survey 61% 81% 85% 89% 92% 95%
MCV1 immunization coverage Monthly DHIS-2 and Survey 59% 80% 84% 88% 90% 93%
MCV2 immunization coverage Monthly DHIS-2 and Survey 55% 70% 76% 81% 84% 87%
Routine coverage
Proportion of Woredas with >=95% of
Monthly DHIS-2 and Survey 81% 85% 90% 92% 94% 95%
Utilization

Comprehensive Multi-Year Plan (2021-2025)

Penta 3 coverage
National Penta 1–Penta 3 drop-out rate Monthly DHIS-2 and Survey 20% 8% 6% 5% 4% 3%
National Penta 1–MCV1 drop-out rate Monthly DHIS-2 and Survey 23% 9% 7% 7% 6% 5%
Percentage of districts with drop-out
Monthly DHIS-2 and Survey 70% 77% 82% 86% 89% 90%
rate Penta 1– Penta 3 = < 5%
EDHS vaccination
Penta 1 Percentage gap between
coverage and
lowest– highest socio-economic Annually 36% 38% 40% 43% 46% 50%
inequality trend
Equity quintile
analysis
EDHS vaccination
Penta 3 Percentage gap between
coverage and
lowest– highest socio-economic Annually 34% 36% 38% 41% 44% 48%
inequality trend
quintile
analysis
Proportion of children screened for
Integration vaccination status at under five OPD Monthly DHIS-2 NA 50% 65% 70% 76% 80%
and linked for immunization service
Percentage of new vaccines introduced
from targeted new vaccine for Vaccine
New vaccines Annually NA 33 67 0 0 0
introduction (Men A, Yellow fever, MR, introduction report
HeB birth dose, IPV 2, COVID 19)

105
 Frequency Baseline Targets

106
Immunization System
Suggested Indicators of Source of data
Subcomponent EDHS
reporting 2021 2022 2023 2024 2025
2019/2020
Number of Measles SIAs conducted
every two SIAs admin and
from targeted catch-up measles NA 0 1 0 1 0
year survey report
Measles vaccination camping in the 5 year.
Percentage of children vaccinated every two SIAs admin and
NA 0 95% 0 95% 0
during the Measles SIAs year survey report
Number of bOPV SIAs conducted
SIAs admin and
from targeted preventive vaccination Bi-Annually NA 2 2 2 2 2
survey report
Polio campaign in the 5 year.
Percentage of children vaccinated SIAs admin and
Bi-Annually NA 95% 95% 95% 95% 95%
during the bOPV preventive SIAs survey report
SIAs
Number of Men A catchup SIAs
SIAs admin and
conducted from targeted vaccination Annually NA 0 1 0 0 0
survey report
Men A campaign in the 5 year.
Percentage of children vaccinated SIAs admin and
Annually NA 0 95% 0 0 0
during the Men A catch-up SIAs survey report
Number of yellow fever catch-up SIAs
SIAs admin and
conducted from targeted vaccination Annually NA 0 1 0 0 0
survey report
Yellow fever campaign in the 5 year.
Percentage of children vaccinated SIAs admin and
Annually NA 0 95% 0 0 0
during the yellow fever catch-up SIAs survey report

Ethiopia National Expanded Program On Immunization

 Frequency Baseline Targets
Immunization System
Suggested Indicators of Source of data
Subcomponent EDHS
reporting 2021 2022 2023 2024 2025
2019/2020
Annual plan
Availability of communication plan Annually NA 1 1 1 1 1
document
Percent of mother/caretaker who once in the 5
Knowledge KAP report 76.7% 85%
knows about vaccination services years
Percent of mother/caretaker who
Communication and once in the 5
Attitude perceive immunization protects a child KAP report 72.3% 83%
demand generation years
from disease
Percent of mothers/caretakers who

Comprehensive Multi-Year Plan (2021-2025)

have received timely vaccination for once in the 5
Practice KAP report 67.6% 80%
their child or willing to take their child years
for vaccination
Proportion of health facilities without
Availability Monthly VRF/mBrana 90% 92% 94% 95%
stockout of any vaccine
Proportion of vaccine storage points EVM self-
Immunization supply Quality Annually 70% 72% 75% 80% 80% 80%
with EVM score >80% assessment
chain
Web based/
Proportion of vaccine storage points
Efficiency Annually Physical annual 50% 55% 80% 83% 85% 86%
with adequate cold chain capacity
inventory

107
Reference

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companion document to the Global Vaccine Action Plan (GVAP).

3. Immunization Agenda 203: A Global Strategy To Leave No One Behind National, draft four, April 2020. 4.
WHO: National Immunization Strategy - Guidance Document (final draft), May 2020.

4. WHO: WHO-UNICEF Guidelines for Comprehensive Multi-Year Planning for Immunization, Update
September 2013.

5. WHO: Guide for the Development of National Immunization Policies in the African Region (draft), July
2016.

6. WHO Regional Office for Africa, 2015: Regional Strategic Plan for Immunization 2014-2020.

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March 2017.

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9. Gavi 5.0: The Alliance’s 2021 2025 strategy.

10. World Health Organization 2018: A practical handbook for planning, implementing, and strengthening
vaccination in the second year of life.

11. World Health Organization 2018: Establishing and strengthening immunization in the second year of life
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12. World Health Organization 2017: Planning Guide to Reduce Missed Opportunities for Vaccination. 14.
Urban Immunization Toolkit. New York: United Nations Children’s Fund; 2018: Urban Immunization A tool
kit for those planning to address inequitable immunization coverage in the urban context, September
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13. World Health Organization 2018: Working together an integration resource guide for immunization
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14. Services Availability and Readiness Assessment (SARA); Ethiopian Public Health Institute, ETHIOPIA,
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108 Ethiopia National Expanded Program On Immunization

Federal Ministry of Health
Addis Ababa | 2021